NCPIC - National Cannabis Prevention and Information Centre

2: Cannabis withdrawal syndrome: GP information

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Clinical studies over the last decade have produced evidence for a ‘cannabis withdrawal syndrome’. The proportion of clients reporting cannabis withdrawal in treatment studies has ranged from 50-95%. The following symptoms are the most commonly experienced:

The clinical consequences of cannabis withdrawal

Cannabis withdrawal symptoms can adversely affect quit attempts with some users reporting using cannabis or other drugs to relieve symptoms.

Although this syndrome does not appear to include major medical or psychiatric consequences, its severity appears comparable to tobacco withdrawal.

Severity and length of symptoms

Most symptoms peak 2-6 days after cessation. The symptoms that take longer (some weeks) to subside include sleep disturbances (including disturbing nightmares) and mood disturbances such as irritability. It should be noted that many cannabis users use other drugs such as tobacco and alcohol. If the patient is also giving up tobacco, nicotine replacement therapy may also be recommended.

Pharmacotherapy for cannabis withdrawal

A number of small human laboratory studies on potential pharmacotherapies for cannabis dependence have appeared in the literature. Buproprion, divalproex, lofexidine, naltrexone, nefazadone, mirtazapine, lithium and oral THC have been explored but none have an adequate evidence-base. Some agents such as buproprion and divalproex exacerbate withdrawal symptoms.

There is support for further testing of agonist (THC) approaches and their use in combination with other medications such as lofexidine. Antagonist therapies have yet to receive adequate attention, however, both cannabinoid and opioid antagonists appear to warrant more study.

The cannabis antagonist Rimonobant, has been removed from the US market as a result of adverse events including suicidal ideation.

In summary, there are currently no evidence-based pharmacotherapy treatments for cannabis withdrawal. It should also be noted that anti-depressants may exacerbate symptoms of cannabis withdrawal.

Symptom-focused approach

There is no evidence for symptoms-focused treatment of withdrawal management. Despite the lack of evidence, it may be appropriate to prescribe short-acting benzodiazepines for withdrawal-related anxiety.

Caution
  • prescription of benzodiazepine is not recommended for adolescents. Consultation with specialist services is recommended
  • any prescription of benzodiazapines should be short-acting, no more than 7 days’ supply and monitored carefully

Psychosocial interventions (non-pharmacological approaches) are highly recommended for cannabis withdrawal management. There is growing evidence for psychosocial interventions generally, and the risks are considered minimal. Areas that have a strong evidence-base generally include sleep hygiene, progressive muscle relaxation, meditation, exercise and family support.

Psycho-education of withdrawal symptoms

Psycho-education about withdrawal symptoms is important for patients to help with managing expectations.

Consider giving the patient: What's the deal on quitting? A do-it-yourself guide to quitting cannabis booklet.

Referral to inpatient management of cannabis withdrawal may be warranted where the individual has:

  • repeatedly failed attempts to abstain
  • has experienced exacerbation of mental health disorders while undergoing withdrawal
  • has no social support

Concurrent tobacco use

For clients who smoke cannabis and use tobacco (independently or mixing), the evidence indicates that there are better outcomes associated with quitting both tobacco and cannabis simultaneously. However, inability or client preference to continue tobacco use should not be a barrier to accessing or continuing cannabis treatment.