Addictive Behaviors 142 (2023) 107667

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Addictive Behaviors
journal homepage: www.elsevier.com/locate/addictbeh

Prevalence of cannabis use disorder among individuals using medical

cannabis at admission to inpatient treatment for substance use disorders
Marie N.S Gendy a, b, c, Radia Taisir c, Sarah Sousa c, Jean Costello c, Brian Rush c, d,
Jason W. Busse e, f, James Mackillop a, b, c, f, g, *
a
Peter Boris Centre for Addictions Research, McMaster University & St. Joseph’s Healthcare Hamilton, Hamilton, ON, Canada
b
Department of Psychiatry and Behavioral Neurosciences, McMaster University, Hamilton, Ontario, Canada
c
Homewood Research Institute, Guelph, ON, Canada
d
Center for Addiction and Mental Health, Toronto, ON, Canada
e
Department of Anesthesia, Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
f
Michael G. DeGroote Centre for Medicinal Cannabis Research, McMaster University & St. Joseph’s Healthcare Hamilton, Canada
g
Department of Psychology, Neuroscience, and Behavior, McMaster University, Hamilton, Canada

A R T I C L E I N F O A B S T R A C T

Keywords: Introduction: Cannabis is used for medical and recreational purposes and may result in cannabis use disorder
Cannabis (CUD). This study explored the prevalence of cannabis use disorder and other psychiatric comorbidities among
Cannabis use disorder inpatients undergoing treatment for substance use disorder who reported medical cannabis use at admission.
Medical cannabis
Methods: We assessed CUD and other substance use disorders based on DSM-5 symptoms, anxiety with the
Recreational cannabis
Substance use disorders
Generalized Anxiety Disorder scale (GAD-7), depression with the Patient Health Questionnaire (PHQ-9), and
Addiction treatment post-traumatic stress disorder with the PTSD Checklist for DSM-5 (PCL-5). We compared the prevalence of CUD
and other psychiatric comorbidities between inpatients who endorsed the use of cannabis for medical purposes
only vs those endorsing use for medical and recreational purposes.
Results: Among 125 inpatients, 42% reported medical use only, and 58% reported medical and recreational use
(dual motives). For CUD, 28% of Medical-Only and 51% of Dual-Use motives patients met the diagnostic criteria
for CUD (p = 0.016). High psychiatric comorbidities were present: 79% and 81% screened positive for an anxiety
disorder, 60% and 61% screened positive for depression, and 66% and 57% screened positive for PTSD for the
Medical-Only and Dual-Use inpatients, respectively.
Conclusions: Many treatment-seeking individuals with substance use disorder who report medical cannabis use
meet criteria for CUD, particularly those reporting concurrent recreational use.

1. Introduction National Academies of Science, Engineering, and Medicine proposed

In Canada, patients were granted legal access to cannabis for medical
purposes in 2001 by the Medical Marijuana Access Regulations (Ware &
Ziemianski, 2015). During the last five years, the number of individuals
using cannabis for medical purposes has tripled; cannabis is now widely
authorized for numerous psychological and physical conditions (Baron,
2015; Yarnell, 2015). While some countries permit cannabis for specific
medical conditions, Canadian patients can obtain cannabis for medical
purposes for any condition with physician authorization (Ng et al.,
2021).
In 2018, the Canadian Clinical Practice Guideline and the US
limited indications for authorizing cannabis for medical purposes,
including chemotherapy-induced nausea and vomiting, neuropathic and
palliative pain, and multiple sclerosis-induced spasticities (Allan et al.,
2018; Groce, 2018; National Academies of Sciences, Engineering, and
Medicine, 2017). These guidelines were based on the most robust sci­
entific evidence at the time, aiming to limit the wide usage of medical
cannabis given the mixed evidence for efficacy. Further, a recent in­
ternational guideline had a weak recommendation for using non-inhaled
medical cannabis or cannabinoids for people living with chronic cancer
or non-cancer pain in addition to standard care (Busse et al., 2021).
One population of particular interest in medical cannabis use is

* Corresponding author at: Peter Boris Centre for Addictions Research, Department of Psychiatry and Behavioral Neurosciences, McMaster University & St.
Joseph’s Healthcare Hamilton, Hamilton, ON L8P 3P2, Canada
E-mail address: jmackill@mcmaster.ca (J. Mackillop).

https://doi.org/10.1016/j.addbeh.2023.107667
Received 15 July 2022; Received in revised form 28 December 2022; Accepted 14 February 2023
Available online 17 February 2023
0306-4603/© 2023 Elsevier Ltd. All rights reserved.
M. N.S Gendy et al.
individuals diagnosed with substance use disorder (SUD). The reason is
an increasing interest in using cannabis as a potential treatment for
opioid use disorder (OUD) (Hurd et al., 2019), alcohol use disorder
(AUD) (Turna et al., 2019), and even cannabis use disorder (CUD) itself
(Rømer Thomsen et al., 2022). Individuals with SUDs also report ther­
apeutic use of cannabis for anxiety, depression, and sleep problems
(Kosiba et al., 2019; Sexton et al., 2016; Sznitman et al., 2020). Despite
the potential therapeutic benefits of medical cannabis, regular use may
lead to the development of CUD, especially among those with SUD.
Therefore, caution for recommending medical cannabis in SUD treat­
ment settings is warranted.
Moreover, it is not unusual for individuals to report medical and
recreational cannabis use, i.e., “dual motives use” (Turna et al., 2020).
Individuals reporting dual motives for cannabis use endorse more
problematic cannabis and other substance use behaviors and psychiatric
problems than those who use cannabis for medical-only purposes
(Rotermann & Pagé, 2018). Despite a lack of scientific support, those
reporting dual-use also endorse using cannabis to manage underlying
psychiatric conditions. Further, US studies reported that those who
report medical and recreational cannabis use also prefer cannabis
products with higher tetrahydrocannabinol (THC) content (Morean &
Lederman, 2019). However, no studies have examined CUD in in­
dividuals with SUDs reporting medical cannabis in SUD clinical settings.
Therefore, the current analysis aimed to explore the prevalence of
CUD and other psychiatric illnesses among individuals who reported
cannabis for medical purposes only vs dual cannabis use in an inpatient
SUD population. Based on previously observed differences, we hypoth­
esized that CUD criteria endorsement would differ between the Medical-
Only and the Dual-Use groups.
2. Methods
2.1. Participants
Participants were admitted to an inpatient addiction medicine ser­
vice (AMS) located in a large mental health and addictions treatment
center in southwestern Ontario, Canada, between April 2018 and
December 2019. At the time of data collection, this AMS offered two
streams of programming: a 35-day group-based treatment for adults
aged 19+ with alcohol and SUD and specialized programming (56 days
in length) for patients with concurrent PTSD. In both cases, program­
ming was based on an abstinence-based approach to recovery informed
by 12-step facilitation therapy and provided by a multidisciplinary team
comprised of physicians with certifications in addiction medicine and
registered addiction counsellors. All patients entering the AMS
completed an electronic questionnaire as part of routine assessment
practices that collected data on demographic characteristics, substance
use and psychiatric symptoms, including anxiety, depression, and PTSD.
Pre-admission medical cannabis use was assessed but medical canabis
was not part of the treatment program. For this study, data were
accessed retrospectively. All ethical research approvals were obtained
from the Regional Centre for Excellence, Research Ethics Board in
Guelph, Ontario, Canada (protocol #19–8).
2.2. Psychiatric questionnaires/measures
We assessed self-reported SUD symptoms using the items of the
Psychoactive Substance Use Module from the International Classifica­
tion for Diagnosis (ICD)–10 Symptom Checklist for Mental Disorders
(Janca et al., 1994), in addition to other items of SUD according to the
Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition
(DSM-5) (Roehr, 2013). Total scores range from 0 to 11, with self-
reported response options for each symptom of either ‘yes’ or ‘no.’
Substances include cannabis, alcohol, cocaine, other stimulants, heroin,
hallucinogens, inhalants, sedatives, prescription sleep aids, and other
substances not listed in the checklist. The frequency of any substance use
2
Addictive Behaviors 142 (2023) 107667
was also calculated. Any substance use for a participant is calculated as
follows: No use = 0; any frequency of use = 1.
Only nine symptoms of the 11 total were included in the analyses,
excluding Item#10 (tolerance) and #11(withdrawal symptoms) for the
cannabis use disorder to avoid over-inflating the prevalence of CUD
among medical users (Barnhill, 2013; Roehr, 2013). This is consistent
with the recommended practice for diagnosing of opioid use disorder
among individuals prescribed opioids, as tolerance and withdrawal may
be features of the substance use even when consumed as recommended.
Those with mild severity endorsed 2 to 3 criteria, moderate severity
reported 4 to 5 criteria, and severe severity reported more than five
criteria (Grant et al., 2015).
Regarding cannabis use: each participant was asked the following
question: “During the past 3 months (or 90 days) before you came to
Homewood, how often, if at all, did you use cannabis (any form [e.g.,
marijuana, hashish, hash oil, edible marijuana]; prescription or non-
prescription)?”, The participant had to respond by a “Yes” or “No.” Then
the participants were also asked about their frequency of non-
prescription cannabis use and their frequency of prescription cannabis
use. We used the terms ‘recreational’ for “non-prescription” and “med­
ical” for “prescription” cannabis use.
We assessed anxiety using the Generalized Anxiety Disorder scale
(GAD-7) (Spitzer et al., 2006), a reliable measure for anxiety symptoms.
This scale evaluates seven anxiety symptoms scored from 0 (not at all) to
3 (nearly every day) in the past two weeks. We used a cut-off score of
nine or above (Levitt et al., 2021). The Patient Health Questionnaire
(PHQ-9) (Fann et al., 2009; Spitzer et al., 1999) was used to assess for
symptoms of depression. This scale evaluates nine symptoms scored
from 0 (not at all) to 3 (nearly every day) in the past two weeks. We used
a cut-off score of 16 or above (Levitt et al., 2021). The Posttraumatic
Stress Disorder (PTSD) Symptom was assessed using the PTSD Checklist
(PCL-5) (de Lima Osório et al., 2017), which evaluates the presence of
twenty symptoms ranging from 0 (not often) to 4 (extremely) in the past
two weeks. We used a cut-off of 42 or above (Levitt et al., 2021).
Readiness to change cannabis, and other substance use was assessed
using the readiness ruler tool. It is scored from 1 to 10, where 1 is not
ready, and 10 is already trying to change (Hesse, 2006).
2.3. Statistical analyses
We generated frequencies for all collected data and checked for
differences between inpatients that declared only medical use of
cannabis vs those who reported both recreational and medical use. We
used a t-test (for unequal variances, the Welch approximation to the
degrees of freedom was used) for continuous variables, Wilcoxon rank
sum test for non-normal variables, and a chi-squared test for categorical
variables unless there were ≤5 observations in any cell. For categorical
variables having <5 observations, we used Fisher’s exact test. Wilcoxon
rank sum test was used to detect differences in CUD item endorsement
between groups. We used ANCOVA to check whether there is any dif­
ference in mental health variables between groups after adjusting for
age. We also used ANCOVA to compare the mean CUD severity between
the CUD groups using age as a covariate. The CUD severity val­
ues range from 0 to 3 (“none” to “severe”). All the analyses were done
using R 4.2.0 (R Core Team, 2022; R Studio Team, 2022), and we set our
threshold for statistical significance at p < 0.05.
3. Results
3.1. Participants
60.4% of the Medical-Only use group and 66.7% in the Dual-Use
group were admitted to the addiction-only stream, while 39.6% from
the Medical-Only group and 33.3% of the Dual-Use group were from the
concurrent PTSD stream.
The total number of patients reporting cannabis use was (n = 746),
M. N.S Gendy et al. Addictive Behaviors 142 (2023) 107667

among which 83% (n = 621) participants reported recreational-only use reasons, 21% reported using cannabis for medical purposes more than
of cannabis. This group was excluded from the current study as the focus recreational use, and 60% reported similar use. The mean CUD score
was on the 17% (n = 125) of patients reporting cannabis use for medical was significantly higher (t = 3.1505, p-value = 0.002) in the Dual-Use
purposes and/or recreational cannabis use. There was no significant group (mean = 2.6, SD = 2.8) compared to the Medical-Only use
difference between both treatment streams (χ2 = 0.287, p = 0.592). group (mean = 1.3, SD = 2.0).
Among 125 participants who reported cannabis for medical pur­ There was a significant difference in the number of criteria for CUD
poses, 53 (68% male) reported their cannabis use as Medical-Only. In endorsement between groups. Participants in the Medical-Only group
comparison, 72 participants (72% male) reported Dual-Use (i.e., medi­ did not endorse all the nine criteria of CUD, as shown in Fig. 1. The mean
cal and recreational). The mean (SD) age of those in the Medical-Only (SD) number of endorsed CUD criteria was [1.28 (1.96) and 2.62 (2.81);
group was significantly different from those in the Dual-Use group W = 2476, p = 0.003] for Medical-Only and Dual-Use, respectively.
[41.3 (10.7) vs 37 (10.5), respectively]. More of those in the Dual-Use Half of the Dual-Use group (51.4%) endorsed mild to severe CUD,
group (16%) were unemployed compared to those in the Medical-Only while 28.4% of the Medical-Only use group endorsed CUD (Table 2).
use group (8%). While more of those in the Medical-Only use group Also, there was a significant difference in CUD severity in both groups,
were married (56.5%) compared to those in the Dual-Use group (39%). where a higher percentage of participants in the Dual-Use group showed
However, both groups had no statistically significant differences in sex, mild to severe CUD (Fisher’s exact test p = 0.045), as shown in Table 2.
education, employment, race, or sexual orientation (Table 1). ANCOVA for CUD severity showed a significant difference between
groups after adjusting for age: [mean (SE) = 0.489 (0.142) and 0.959
3.2. Cannabis use and CUD characteristics (0.121); F (1,122) = 6.206, p = 0.014] for Medical-Only and Dual-Use
group, respectively.
In the subgroup comprised of dual cannabis use, 19.4% reported The endorsement of different CUD criteria is illustrated in Fig. 2. The
using recreational cannabis more frequently than cannabis for medical percentage of subjects responding “Yes” to each item differed in both
groups. The percentage of subjects endorsing the following criteria was
significantly higher in the Dual-Use group as follows: “use more than
Table 1
intended” (χ 2 = 9.629, p = 0.002), “having social or interpersonal
Descriptive demographics for Medical-Only and Dual-Use (i.e., medical and
recreational) cannabis use groups.
problems because of cannabis use” (Fisher’s Exact p-value = 0.016), and
“using cannabis in hazardous situations” (χ 2 ¼ 5.085, p-value = 0.024),
Demographics
Medical- Dual-Use p-value Effect
respectively.
1
Only (Med + Rec) Size 2
(n = 53) (n = 72)
3.3. Other SUD characteristics
Characteristics % (n) or Mean (SD)
Sex 0.748 0.047
Details regarding the use of psychoactive substances are shown in
Female 32.08 (17) 27.8 (20)
Male 67.92 (36) 72.2 (52) Table 3. The percentage of participants using cocaine/stimulants and
hallucinogens was significantly higher in the Dual-Use group. Further,
Age 0.115 0.244 more than two-thirds of participants showed symptoms of mild to severe
<30 years 17.0 (9) 29.2 (21) AUD in the Medical-Only and Dual-Use groups (68% and 66%, respec­
30 to 39 years 30.2 (16) 29.2 (21)
40 to 49 years 24.5(13) 29.2 (21)
tively) with no significant difference.
50 to 59 years 24.5 (13) 8.3 (6)
≥60 years 3.8 (2) 4.2 (3)
Mean (SD), years 41.3 (10.7) 37.0 (10.5) 0.026 0.408
3.4. Psychiatric comorbidities

Education 0.497 0.106 Both groups reported high proportions of those who screened posi­
At least some college/ 66.0 (35) 54.2 (39) tive for each condition: 60.4% and 61.1% of the Medical-Only and the
university
Dual-Use groups, respectively, screened positive for depression (PHQ-9
Technical/trade school 7.5 (4) 8.3 (6)
High school or less 26.4 (14) 34.7 (25) ≥ 16). 79.2% and 80.6% of the Medical-Only and Dual-Use groups
Missing – 2.8 (2) screened positive for anxiety (GAD-7 ≥ 9). Regarding PTSD, 66% and
Employment 0.249 0.149 56.9% of the Medical-Only and Dual-Use groups screened positive (PCL-
Employed 58.5 (31) 62.5 (45) 5 ≥ 42). For all the measures, there was no significant difference be­
Unemployed 15.1 (8) 22.2 (16)
tween groups; (p > 0.05). In addition, there was no significant difference
Unknown/Other 26.4 (14) 15.3 (11)
Marital Status 0.075 0.176 in means of any psychiatric comorbidities between groups after con­
Married or partnered 56.6 (30) 38.9 (28) trolling for age, as shown in Table 4.
Single, divorced, separated, 43.4 61.1 (44)
widowed. (23)
4. Discussion
Race 0.938 0.028
White 73.6 (39) 79.2 (57) This study aimed at characterizing medical and dual recreational
Other 20.8 (11) 19.4 (14) cannabis use and the prevalence of CUD, other SUDs, and comorbidities
Missing 5.7 (3) 1.4 (1)
in a sample of inpatients undergoing treatment for SUD who reported
Sexual Orientation 1.000 0.001
Heterosexual 77.4 (41) 79.2 (57) recent medical cannabis use at admission. In this sample, 28.3% of those
Other 18.9 (10) 19.4 (14) who reported Medical-Only use of cannabis and 51.4% of those with
Missing 3.8 (2) 5.7 (1) Dual-Use screened positive for CUD. Participants in the Medical-Only
1
t-test was performed for age (continuous); χ 2 -test/Fisher’s was performed for cannabis use group were significantly older. However, no significant
the rest of the variables; the category ‘Missing’ was not included during the test. differences existed between the two groups regarding sex, marital status,
2
Cohen’s d was used to calculate the effect size for age (continuous); For the rest education, employment, or race. More than two-thirds of participants in
of the variables, Cohen’s w was used. Cohen’s d is interpreted as small (0.2), both groups endorsed severe AUD criteria. The Dual-Use group showed
medium (0.5), and large (0.8); Cohen’s w is interpreted as small (0.10 to <0.30), polysubstance use, mainly, cocaine/stimulants and hallucinogens,
medium (0.30 to <0.50), and large (≥0.50); (Cohen, 2013). compared to the Medical-Only group. It was shown that those who
endorsed dual motives endorsed more problematic cannabis and other

3
M. N.S Gendy et al. Addictive Behaviors 142 (2023) 107667

Fig. 1. Number of items of CUD endorsement for Medical-Only and Dual groups.

cannabis is not yet well-understood. The results of a survey done among

Table 2
Canadian university students (n = 4000) who used cannabis for various
Cannabis use and CUD characteristics for Medical-Only and Dual-Use groups.
reasons, such as anxiety, depression, sleep problems, and pain, showed
Medical- Dual- p- Effect Size that 85% of those who reported medical use also reported recreational
Only Use value1 2
motives to use cannabis (Smith et al., 2019). The same study showed
that 13.6% of the Medical-Only use group endorsed different criteria for
Characteristics Percentage
CUD. In another survey of > 300 patients using medical cannabis for
Cannabis Use Disorder 0.016 0.232
Status
pain and mental conditions, more than half of the sample reported dual
CUD Negative <2 71.7 48.6 use motives (Morean & Lederman, 2019). Further, community partici­
CUD Positive =>2 28.3 51.4 pants in a Dual-Use group reported daily use of cannabis with a pref­
CUD Severity 0.045 0.254 erence for products with high THC content (Turna et al., 2020).
None 71.7 48.6
Individuals with dual motives also reported that their primary drive to
Mild 16.9 20.8
Moderate 5.7 13.9 use cannabis was to treat psychiatric conditions that are not yet sup­
Severe 5.7 16.7 ported scientifically (Rotermann & Pagé, 2018).
Frequency of use of 0.657 0.140 Some explanations of this observed dual motives use are that
Cannabis advertising, marketing, and availabilities may influence social norms.
1 = Once a month or less 15.1 13.9
often
For instance, it was found that exposure to extensive medicinal cannabis
2 = Once a week 7.5 9.7 advertisements has been associated with higher rates of cannabis use
3 = Multiple times weekly 20.8 16.7 and adverse health outcomes in adolescents (D’Amico et al., 2018).
4 = Once a day 17.0 9.7 Another possibility is the misperception that cannabis is safe and does
5 = Multiple times daily 39.6 50.0
not cause dependence or withdrawal symptoms, even though one in ten
1
χ 2 -test/Fisher’s test was performed for all the variables. persons who use cannabis regularly and one-third of individuals who use
2
Cohen’s w was used to calculate the effect size and interpreted as: small cannabis daily develop CUD (Connor et al., 2021). Further, some clini­
(0.10 to <0.30), medium (0.30 to <0.50), and large (≥0.50) (Cohen, 2013). cians note that patients may be misrepresenting their motives when
seeking medical authorization for cannabis prescriptions (Ziemianski
substance use behaviors than individuals using cannabis for Medical- et al., 2015). In a survey circulated among Canadian physicians, it was
Only reasons (Rotermann & Pagé, 2018; Turna et al., 2020). reported that for 65% of patients requesting medical cannabis, the pri­
Both groups reported high percentages of comorbid psychiatric mary motivation was recreational use (Ziemianski et al., 2015).
conditions, anxiety, depression, and PTSD, with no significant difference Medical cannabis authorization is not considered a first-line treat­
between groups. A meta-analysis of longitudinal studies showed an ment for medical or psychological conditions. Therefore, its use for
increased risk of depression in subjects with heavy and continuous many conditions lacking scientific support should be limited (Hill,
cannabis use (Lev-Ran et al., 2014). Moreover, a medication trial for 302 2015). Moreover, a recent international guideline was developed
adults showed a longitudinal relationship between cannabis use reduc­ through a panel including patients, clinicians, and methodologists. This
tion and improvements in symptoms of anxiety, depression, and sleep panel had a weak recommendation of using non-inhaled medical
disturbance (Hser et al., 2017). However, a national survey showed that Cannabis or cannabinoids for people living with chronic cancer or non-
cannabis use and CUD were not associated with increased risks of most cancer pain in addition to the standard care based on a robust evidence
anxiety disorders (Feingold et al., 2016). The same study showed that body of benefits versus harms (Busse et al., 2021). Further, side effects
most anxiety disorders were not associated with an increased risk of and health risks related to continuous and chronic cannabis use should
CUD except for patients with panic disorder that showed initiation of be discussed with patients before prescribing, for example, potential
cannabis use as self-medication (Feingold et al., 2016). In our study, the consequences such as memory, driving, motor coordination and judge­
questionnaires did not include information regarding the onset of anx­ ment impairments. High doses of THC use can cause paranoid ideation
iety and depression. Therefore, it is unclear if anxiety and depression and other psychotic symptoms. For young adults, studies have suggested
were motives for cannabis use or the consequences of prolonged use. structural changes in the nucleus accumbens and amygdala in the
The overlap between the recreational and dual motives use of developing brain (Gilman et al., 2014). The regular use of cannabis also

4
M. N.S Gendy et al. Addictive Behaviors 142 (2023) 107667

Fig. 2. Percentage of participants endorsing CUD criteria in both Medical-Only and Dual-Use groups.*: Significant difference (p < 0.05).

Table 3 Table 4
Percentage of participants reporting substance use in the Medical-Only and Clinical comorbidities in Medical-Only and Dual-Use groups.
Dual-Use groups1. Variable Medical CUD Dual CUD Test statistic, p- Effect
Substance Medical- Dual- Test Statistics, p- Effect (n = 53) (n = 72) value Size1
Only Use value Size2
Depression Mean = 16.5, Mean = 16.7, F(1,121) = 0.001
PHQ-9 SE = 0.798, SE = 0.687, 0.067, p = 0.797
Alcohol 84.6 88.9 χ2 = 0.184, p = 0.668 0.063 CI = CI =
Stimulants þ 34.0 54.2 χ2 = 4.242, p-value 0.200 (14.9,18.0) (15.4,18.1)
Cocaine = 0.039 PHQ ≥ 16 60.4% 61.1% χ2 = 0.000, p =
Opioids 20.8 34.7 χ2 = 2.263, p = 0. 0.152 1.000
0.133 Anxiety GAD- Mean = 14.4, Mean = 13.6, F(1,121) = 0.005
Stimulants 17.0 31.9 χ2 = 2.846, p = 0.092 0.169 7 SE = 0.746, SE = 0.643, 0.645, p = 0.423
Sleep Aids 13.2 15.3 0.029 CI = (12.9, CI = (12.3,
χ2 = 0.005, p = 0.946
15.8) 14.8)
Sedatives 20.8 22.2 χ2 = 0.000, p = 1.000 0.018
GAD ≥ 9 79.2% 80.6% χ2 = 0.012, p =
E-cigarettes 13.2 19.7 χ2 = 0.510, p = 0.475 0.086
0.912
Tobacco 73.6 75.0 χ2 = 0.000, p = 1.000 0.016
PTSD Mean = 46.6, Mean = 44.0, F(1,121) = 0.004
Hallucinogens 3.8 18.3 Fisher’s exact p- 0.220
PCL-5 SE = 2.65, SE = 2.29, 0.538, p = 0.465
value = 0.023
CI = (41.4, CI = (39.5,
1
Any substance use for a participant is calculated as follows: No use = 0; any 51.9) 48.5)
frequency of use = 1. PCL ≥ 42 66.0% 56.9% χ2 = 0.565, p =
2
Cohen’s w was used to calculate the effect size and interpreted as: small 0.452
(0.10 to <0.30), medium (0.30 to <0.50), and large (≥0.50) (Cohen, 2013). 1
Effect size is measured by partial eta squared (η2p ). η2 is interpreted as small
(0.01), medium (0.06), and large (0.14). η2p is also interpreted as η2 .
increases the risk of anxiety, depression, and psychosis, which should be
considered before prescribing cannabis for patients with these pre-
existing conditions to avoid worsening their symptoms (Crippa et al.,
comorbid with SUDs, such as anxiety, depression, and PTSD (Kosiba
2009; Moore et al., 2007; Patton et al., 2002).
et al., 2019; Sexton et al., 2016; Sznitman et al., 2020), although evi­
There have not been enough studies examining CUD endorsement in
dence of efficacy for these conditions is scant. Further, medical cannabis
individuals diagnosed with SUD reporting cannabis use, whether for
products could be problematic in addiction settings due to their psy­
medical-only reasons or with dual motives use. One recent RCT on 186
choactive properties, especially those with high THC concentrations.
participants seeking medical cannabis for various conditions showed an
This work has some limitations, for instance, using self-report as­
increased CUD endorsement after 12 weeks, with an improvement in
sessments that did not have collateral biomarkers or clinical interviews.
self-reported sleep and no significant improvement in pain, anxiety, or
Another limitation is the design of the study, which was cross-sectional;
depression (Gilman et al., 2022). Therefore, our study and other similar
the study sample was drawn from inpatient files and cannot be repre­
studies focusing on CUD criteria in individuals using cannabis for
sentative of the Canadian population. Further, the limited size of each
medical reasons or having dual motives of use are critical to explore the
group limited the statistical power of comparisons. Lastly, information
possibility of iatrogenic SUD (i.e., CUD that follows from initial autho­
about clinical diagnosis and details regarding the form of and the rea­
rized use for a medical purpose). Individuals diagnosed with SUD and
sons for the need for medical cannabis and which substance was the
using cannabis for medical-only or dual-use reasons may be particularly
primary reason for treatment was not available.
vulnerable to developing CUD. The reason could be their continued use
of cannabis to alleviate various psychiatric conditions commonly

5
M. N.S Gendy et al.
5. Conclusions
In sum, individuals undergoing inpatient treatment for SUD who
report medical cannabis use present with relatively high rates of CUD,
disproportionately affecting patients that endorse both medical and
recreational use. Indeed, one-third of the Medical-Only and one-half of
the Dual-Use use groups endorsed clinically significant symptoms of
CUD. Acknowledging a number of limitations, these results nonetheless
support the need to further understand CUD among individuals with
SUDs who are using medical cannabis.
Funding:
This work was supported by charitable donations to Homewood
Research Institute, a registered charity in Canada, the Peter Boris Chair
in Addictions Research, and a Tier 1 Canada Research Chair in Trans­
lational Addiction Research.
CRediT authorship contribution statement
Marie N.S Gendy: Conceptualization, Writing – original draft.
Radia Taisir: Formal analysis. Sarah Sousa: Writing – review & editing.
Jean Costello: Writing – review & editing. Brian Rush: Writing – re­
view & editing. Jason W. Busse: Writing – review & editing. James
Mackillop: Supervision, Writing – review & editing.
Declaration of Competing Interest
JM is a principal in Beam Diagnostics, Inc., and a consultant to
Clairvoyant Therapeutics, Inc. The remaining authors declare that they
have no known competing financial interests or personal relationships
that could have appeared to influence the work reported in this paper.
Data availability
Data will be made available on request.
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