Standard diagnostic criteria both overestimate and underestimate cannabis use disorder in chronic pain patients

Among 187 chronic pain patients prescribed medical cannabis, CUD prevalence was 29.9% using standard DSM-5 criteria, 13.9% when tolerance and withdrawal items were removed, and just 2.1% when positive items attributable to pain relief were excluded. Meanwhile, physicians identified abuse in only 1 patient, suggesting substantial underestimation from the clinical side.

Cross-sectional study using anonymous questionnaires and urine testing in 187 consecutive patients attending 3 German pain centers in 2021. DSM-5 criteria scored three ways: all criteria, without tolerance/withdrawal, and without pain-relief-motivated behaviors.

The DSM-5 was not designed to diagnose substance use disorders in patients using a substance therapeutically. This study demonstrates how the diagnostic framework can produce dramatically different prevalence estimates depending on how criteria are interpreted.

As medical cannabis prescriptions increase globally, the lack of appropriate diagnostic tools for identifying problematic use in therapeutic contexts becomes a growing clinical gap. Adapting or replacing DSM-5 criteria for this population is overdue.

Cross-sectional design at German pain centers may not generalize internationally. Anonymous questionnaire format prevented linking individual responses to clinical records. The adjusted scoring method has not been validated independently.