Sedentary Work Exerting up to 10 pounds (4.5 kg) of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and other sedentary criteria are met.

Light Work Exerting up to 20 pounds (9.1 kg) of force occasionally and/or up to 10 pounds (4.5 kg) of force frequently, and/or negligible amount of force constantly to move objects. Physical demand requirements are in excess of those for Sedentary Work. Light Work usually requires walking or standing to a significant degree. However, if the use of the arm and/or leg controls requires exertion of forces greater than that for Sedentary Work and the worker sits most the time, the job is rated Light Work.

Medium Work Exerting up to 50 (22.7 kg) pounds of force occasionally, and/or up to 25 pounds (11.3 kg) of force frequently, and/or up to 10 pounds (4.5 kg) of forces constantly to move objects.

Heavy Work Exerting up to 100 pounds (45.4 kg) of force occasionally, and/or up to 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Very Heavy Work Exerting in excess of 100 pounds (45.4 kg) of force occasionally, and/or in excess of 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Job Classification

In most duration tables, five job classifications are displayed. These job classifications are based on the amount of physical effort required to perform the work. The classifications correspond to the Strength Factor classifications described in the United States Department of Labor's Dictionary of Occupational Titles. The following definitions are quoted directly from that publication.

Sedentary Work Exerting up to 10 pounds (4.5 kg) of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and other sedentary criteria are met.

Light Work Exerting up to 20 pounds (9.1 kg) of force occasionally and/or up to 10 pounds (4.5 kg) of force frequently, and/or negligible amount of force constantly to move objects. Physical demand requirements are in excess of those for Sedentary Work. Light Work usually requires walking or standing to a significant degree. However, if the use of the arm and/or leg controls requires exertion of forces greater than that for Sedentary Work and the worker sits most the time, the job is rated Light Work.

Medium Work Exerting up to 50 (22.7 kg) pounds of force occasionally, and/or up to 25 pounds (11.3 kg) of force frequently, and/or up to 10 pounds (4.5 kg) of forces constantly to move objects.

Heavy Work Exerting up to 100 pounds (45.4 kg) of force occasionally, and/or up to 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Very Heavy Work Exerting in excess of 100 pounds (45.4 kg) of force occasionally, and/or in excess of 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Cannabis Use Disorder


Related Terms

  • Marijuana Abuse
  • Marijuana Addiction
  • Marijuana Dependence

Differential Diagnosis

Specialists

  • Clinical Psychologist
  • Occupational Therapist
  • Psychiatrist

Comorbid Conditions

Factors Influencing Duration

The length of disability is influenced by the duration and severity of cannabis dependence/cannabis use disorder, the presence or absence of chronic physical consequences of cannabis use, any underlying mental illness, other substance abuse, the individual's motivation to change, the individual's social support system, the appropriateness of the treatment choice, compliance with treatment, and the adequacy of ongoing care.

Medical Codes

ICD-9-CM:
304.30 - Cannabis Dependence; Unspecified
304.31 - Cannabis Dependence; Continuous
304.32 - Cannabis Dependence; Episodic
304.33 - Cannabis Dependence; in Remission
305.20 - Cannabis Abuse; Unspecified
305.21 - Cannabis Abuse; Continuous
305.22 - Cannabis Abuse; Episodic
305.23 - Cannabis Abuse; in Remission

Overview

Marijuana, the main focus of cannabis use disorder, is made from the dried leaves, tops, and stems of the Cannabis sativa plant. Hashish is derived from the dried, resinous exudate that seeps from the plant. In both, the psychoactive ingredient is delta-9-tetrahydrocannabinol (THC). Marijuana is usually smoked in the form of loosely rolled cigarettes or in pipes but may also be taken orally in food or tea. The effects of marijuana last 2 to 4 hours when smoked and 5 to 12 hours when taken orally. Marijuana dependence/cannabis use disorder develops over an extended period, with gradually increasing frequency and amount of use.

Individuals may consider themselves more insightful or knowledgeable when intoxicated, but both memory and concentration are impaired. Some individuals experience anxiety and panic rather than euphoria and relaxation. Long-term use can lead to mild forms of depression, anxiety (which may be severe), irritability, physical and mental lethargy, apathy, and the inability to feel pleasure during activities that are normally pleasurable (anhedonia).

Marijuana and its active ingredient THC can be used medicinally for treating nausea, vomiting, chronic pain, and glaucoma. Marijuana can also be used as an anti-anxiety agent, muscle relaxant, appetite stimulant, and anticonvulsant. It is often used in individuals receiving chemotherapy when traditional medicine fails to control symptoms. In the US, many states prohibit cannabis use. However, a number of states have legalized marijuana's use for certain medical conditions, with a few legalizing the recreational use of cannabis. In other states, the use of marijuana is under legal review or there are medical and/or decriminalization possession laws.

In the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR), the section Cannabis-Related Disorders includes Cannabis Use Disorders (Cannabis Dependence, and Cannabis Abuse), Cannabis-Induced Disorders (Cannabis Intoxication [specify if: With Perceptual Disturbances], Cannabis Intoxication Delirium, Cannabis-Induced Psychotic Disorder [With Delusions, or With Hallucinations], Cannabis-Induced Anxiety Disorder, and Cannabis-Related Disorder NOS.

In the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), the section Cannabis-Related Disorders includes Cannabis Use Disorder, Cannabis Intoxication, Cannabis Withdrawal, Other Cannabis-Induced Disorders, and Unspecified Cannabis-Related Disorder.

Note: For the substance/medication-induced disorders approach established by the DSM-IV-TR, and the DSM-5, please see the following topics: Substance/Medication-Induced Anxiety Disorder, Substance/Medication-Induced Bipolar and Related Disorder, Substance/Medication-Induced Depressive Disorder, Substance/Medication-Induced Major or Mild Neurocognitive Disorder, Substance/Medication-Induced Obsessive-Compulsive and Related Disorder, Substance/Medication-Induced Psychotic Disorder, Substance/Medication-Induced Sexual Dysfunction, and Substance/Medication-Induced Sleep Disorder.

Incidence and Prevalence: Marijuana is the most commonly used illicit drug in the US. Surveys show that at least one-third of the US population, or about 70 million individuals, have used marijuana at least once, with individuals under 35 reporting most frequent usage. An estimated 5% of individuals report marijuana abuse or dependence at some time during their lifetime. About 2% to 3% use marijuana daily or nearly daily. Usage appears to be growing among individuals aged 12 to 17. It is estimated that there are 250 million users of marijuana or hashish in the world, making this the most common illicit drug used worldwide. Incidence is independent of race but varies based on cultural attitudes toward the drug.

According the DSM-5, the prevalence of cannabis use disorder has increased among adults and adolescents during the past decade. The 12-month prevalence of cannabis use disorder (abuse and dependence (DSM-IV-TR) rates combined) is about 3.4% among 12- to 17-year-olds and 1.5% among adults age 18 years and older. Rates are greater among males than females. Twelve-month prevalence rates of cannabis use disorder among adults decrease with age. For 12- to 17-year-olds, 12-month prevalence rates are highest among Native American and Alaska Natives (7.1%), followed by Hispanics (4.1%), whites (3.4%), African Americans (2.7%), and Asian Americans and Pacific Islanders (0.9%); for adults, the prevalence is also highest among Native Americans and Alaska Natives (3.4%), followed by African Americans (1.8%), whites (1.4%), Hispanics (1.2%), and Asian and Pacific Islanders (1.2%) (DSM-5).

Source: Medical Disability Advisor



Causation and Known Risk Factors

In the US, adolescents have a higher risk of experimentation with marijuana use than any other age group, although substantial abuse is found in all racial, ethnic, sex, socioeconomic, and age groups. More men than women are abusers. Cultural attitudes toward marijuana have a strong influence on use. Individuals with psychiatric disorders are at very high risk for marijuana abuse.

Source: Medical Disability Advisor



Diagnosis

History: History should include information about the pattern of past use as well as regular use in the most recent 12-month period.

Individuals intoxicated from marijuana exhibit maladaptive behavioral or psychological changes, impaired motor coordination, and social withdrawal. Initially, individuals may experience a "high" feeling followed by euphoria with inappropriate laughter and grandiosity, sedation, lethargy, short-term memory impairment, difficulty with complex mental processes, distorted sensory perceptions, impaired motor performance, a sensation of slowed time, and impaired judgment (DSM-IV-TR). There may also be increased appetite.

With increased marijuana use, the individual may report changes in cognitive functioning (memory and recall deficits or decreased speed of learning), psychological functioning (anxiety, panic attacks, or mood disorders), behavioral functioning (legal, financial, or relational issues), and/or physiological functioning (weight gain, sinusitis, bronchitis, or chronic cough). Both an individual and a family history for any substance abuse/dependence and other psychiatric disorders or treatments should be obtained. The specifiers applied to a diagnosis of cannabis dependence are: with physiological dependence, without physiological dependence, early full remission, early partial remission, sustained full remission, sustained partial remission, and in a controlled environment (DSM-IV-TR).

Individuals with cannabis use disorder have a problematic pattern of cannabis use leading to clinically significant impairment or distress, as manifested by 2 or more (as specified in the DSM-5) or at least 3 (as specified in the DSM-IV-TR) of the following, occurring within a one-year period: (1) cannabis is often taken in larger amounts or over a longer period than was intended; (2) there is a persistent desire or failed efforts to reduce or control cannabis use; (3) much time is spent in activities necessary to obtain cannabis, use cannabis, or recover from its effects; (4) there is craving (a strong desire or urge to use cannabis); (5) there is recurrent cannabis use that results in a failure to fulfill major role obligations at work, school, or home; (6) there is continued cannabis use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of cannabis; (7) the individual gives up or reduces important social, occupational, or recreational activities because of cannabis use; 8) there is recurrent cannabis use when it is physically hazardous; (8) the individual continues cannabis use despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by cannabis; (9) there is tolerance (a need for markedly increased amounts of cannabis to achieve intoxication or desired effect, or a markedly diminished effect with continued use of the same amount of cannabis); (10) there is withdrawal syndrome for cannabis (see below); (11) the individual takes cannabis (or a closely related substance) to relieve or avoid withdrawal symptoms.

It is necessary to specify the current severity: mild (presence of 2-3 symptoms), moderate (4-5 symptoms), or severe (6 or more symptoms). During recovery, it is necessary to specify if the cannabis use disorder is in early remission or sustained remission, as well as if the individual is in a controlled environment where access to cannabis is restricted (DSM-5).

Withdrawal syndrome for cannabis appears after cessation of heavy and prolonged cannabis use and consists of at least 3 of the following: irritability, anger, or aggression; nervousness or anxiety; sleep difficulty (insomnia, disturbing dreams); decreased appetite or weight loss; restlessness; depressed mood; and one or more of the following physical symptoms, with significant discomfort: abdominal pain, shakiness/tremors, sweating, fever, chills, or headache. The signs or symptoms develop within a week after the cessation of cannabis use; cause clinically significant distress or impairment in social, occupational, or other important areas of functioning; are not attributable to another medical condition; and are not better accounted for by another mental disorder, including intoxication or withdrawal from another substance (DSM-5).

Psychological or physical problems associated with compulsive use of cannabis should prompt a diagnosis of cannabis dependence rather than cannabis abuse (DSM-IV-TR).

Physical exam: The psychoactive effects of marijuana intoxication coexist with at least two of the following signs (developing within 2 hours of cannabis use): reddening of the lining of the eye (conjunctival injection), dry mouth, and increased heart rate (tachycardia) (DSM-IV-TR).

Objective signs may also include increased blood pressure, loss of motor coordination (ataxia), sinusitis, bronchitis, emphysema, or pulmonary dysplasia. Psychiatric examination may reveal schizophrenic symptoms or panic reactions. Diagnosis is often complicated by concomitant use of alcohol, tobacco, and other illicit drugs.

Tests: A polydrug screen, preferably of urine, can generally identify cannabinoid metabolites. However, these metabolites can be seen up to 4 weeks after use, so the test cannot establish current use or intoxication. A urine polydrug screen should be ordered to detect whether the individual is using drugs other than marijuana and should always be confirmed by a second test because a positive test may result in serious consequences for the individual. Blood tests may show decreased levels of testosterone and luteinizing hormone. Acute cannabinoid use causes diffuse slowing of background activity as seen on an electroencephalogram (EEG) with rapid eye movement (REM) suppression. Pulmonary function tests may show decreased measures of lung function.

Note: It must be kept in mind that just because a physical diagnosis cannot be established as the cause of the presenting symptomatology, it does not necessarily mean that the cause is a mental one. That is to say that the presence of medically unexplained symptomatology does not necessarily establish the presence of a psychiatric condition. The first step in identifying the presence of a mental disorder is excluding the presence of malingering and/or of factitious disorder. Although factitious disorder is conscious and purposeful, it is classified as a psychiatric disorder. The strong need for this step is especially true whenever there is a medicolegal context associated with the presenting problem(s). Additionally, using DSM-5 and/or ICD-9-CM or ICD-10-CM, the clinician will find that many presentations fail to fit completely within the boundaries of a single mental disorder. There are systematic ways to go about making psychiatric diagnoses, however.

Source: Medical Disability Advisor



Treatment

According to the DSM-IV-TR, substance dependence recovery occurs in four phases: an acute phase that focuses on alleviating symptoms of withdrawal, a 1-month period of abstinence during which the individual focuses on changing behaviors, an early remission phase that can last up to 12 months, and a sustained remission phase that lasts as long as the individual does not meet any of the diagnostic criteria for substance dependence or abuse. Individuals who remain steadily in sustained remission may eventually be evaluated as being in full recovery.

Cannabis withdrawal symptoms rarely require inpatient monitoring or pharmacological treatment. In severe cases of cannabis-induced anxiety or panic, anti-anxiety drugs may be used. Antipsychotic drugs are occasionally needed to treat protracted cannabis-induced psychosis. If cannabis was used to alleviate symptoms of depression or anxiety, appropriate antidepressants or anti-anxiety drugs should be considered as substitution therapy. Detoxification is not necessary.

Treatment for the 1-month abstinence and early remission phases may include education on physical, emotional, and mental aspects of addiction and recovery; identification of stressors and stress management skills; improved coping skills; assertiveness training; relaxation training; and lifestyle management changes. When drug abuse is a symptom of chronic anxiety, depression, or feelings of anxiety rather than being the primary problem, psychotherapy may be helpful. Psychotherapy should focus on the reasons for the drug abuse. Family therapy is often indicated. Behavior therapy teaches ways other than drug abuse to reduce anxiety.

In addition to professional treatment, many individuals participate in self-help groups, such as Narcotics Anonymous (NA) or Rational Recovery. The long-term support that self-help groups provide can be crucial in preventing relapse. The combination of a psychiatric illness with substance abuse (dual diagnosis) can complicate the treatment of both the chemical dependency and the psychiatric illness.

Source: Medical Disability Advisor



Prognosis

The most reliable predictor of treatment outcome, regardless of treatment strategy, is the individual's readiness to change. Recovery is not an easy process and first, second, or later attempts at recovery may be followed by relapse. This cycling from recovery back through relapse to dependence or abuse/cannabis use disorder is common. Outpatient therapy and counseling are becoming more common and may enable the individual to continue working. Generally, the individual is more successful if social patterns and relationships change along with abstinence from marijuana use.

Many individuals who seek treatment for excessive, prolonged use of marijuana respond to treatment and remain in remission from cannabis dependence/cannabis use disorder, especially when adequate social support systems are in place. However, a significant number of individuals experience at least one relapse after treatment. Some individuals never seek treatment and/or never stop usage. As mentioned, support groups (e.g., Alcoholics Anonymous, Narcotics Anonymous, Rational Recovery), family support, and social support all contribute to the individual's success in recovery.

Source: Medical Disability Advisor



Complications

Paradoxical anxiety, panic, and paranoid reactions to acute intoxication have been reported. Long-term effects of using marijuana include decreased testosterone levels for men, which can result in a lower sperm count, and increased testosterone levels for women, which can possibly affect reproductive functioning. Regular marijuana use can lead to chronic weight gain, a slightly weakened immune system, or respiratory problems such as sinusitis, pharyngitis, bronchitis, emphysema, and abnormal lung tissue cells (pulmonary dysplasia).

Source: Medical Disability Advisor



Ability to Work (Return to Work Considerations)

Marijuana abuse has been shown to slow reaction times and alter the perception of time passing. For these reasons, temporary work accommodations may include reducing or eliminating activities in which the safety of self or others is contingent upon a constant and/or high level of alertness, such as driving a motor vehicle, operating complex machinery, or handling dangerous chemicals; introducing the individual to new or stressful situations gradually under individually appropriate supervision; allowing some flexibility in scheduling to attend therapy appointments (which normally should occur during the employee's personal time); promoting planned, proactive management of identified problem areas; and offering timely feedback on job performance issues. It will be helpful if accommodations are documented in a written plan designed to promote a timely and safe transition back to full work productivity.

The individual should avoid exposure to situations where intoxicants are available, such as pharmacies or establishments that serve alcohol.

Source: Medical Disability Advisor



Maximum Medical Improvement

MMI is expected at 6 months of treatment or less.

Note: MMI is estimated under the assumption that the vagaries involved in psychiatric diagnoses have been taken into consideration.

Source: Medical Disability Advisor



Failure to Recover

If an individual fails to recover within the expected maximum duration period, the reader may wish to consider the following questions to better understand the specifics of an individual's medical case.

Regarding diagnosis:

  • Was a comprehensive assessment, including detailed history of past and present substance use, general medical and psychiatric history, prior psychiatric treatments with outcomes, and family and social history, completed on individual? If not, what areas were omitted?
  • Would missing information affect the current treatment plan?
  • What changes should now be made?
  • Have all underlying medical disorders been identified?
  • Have underlying psychiatric disorders been identified?

Regarding treatment:

  • Because marijuana can often be used intermittently without causing noticeable social or psychological dysfunction or addiction, what brought individual to treatment in the first place?
  • Is treatment aimed at psychotherapy and behavioral therapy plus regular attendance at a support group, such as Narcotics Anonymous?
  • If marijuana abuse is a symptom of underlying depression or anxiety rather than the primary problem, would anxiolytics or antidepressants be helpful?

Regarding prognosis:

  • Is individual currently involved in a support group (e.g., Narcotics or Alcoholics Anonymous)?
  • What other support system does individual have in place? Family? Friends? Social? Is the individual receiving the external support and motivation necessary to continue in treatment beyond the initial stages?
  • Because addicts need to think about developing new relationships and rebuilding their lives, does individual have the needed tools, skills, and encouragement to move ahead with his or her life?

Source: Medical Disability Advisor



References

Cited

Diagnostic and Statistical Manual of Mental Disorders (DSM-5). 5th ed. American Psychiatric Association, 2013.

Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR). 4th ed. Washington, DC: American Psychiatric Association, 2000.

Source: Medical Disability Advisor






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