by Marina Goldman, MD (Guest Author)
Private Practice (General and Addiction Psychiatry), Jenkintown, PA, and
Clinical Associate, Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia PA
Why cannabis withdrawal is important
Cannabis-addicted patients consistently report that symptoms of anxiety and insomnia maintain their use of cannabis or trigger relapse, but they may not be aware that these represent cannabis withdrawal symptoms. It is important for clinicians to identify cannabis withdrawal so that it can be appropriately managed, but the diagnosis is easy to miss if we are not appropriately educated and aware about this.
Symptoms associated with cannabis withdrawal include both neurovegetative and psychological symptoms. Symptoms that may be present include:
- Loss of appetite that can result in transient weight loss.
- Trouble sleeping or sleep disrupted by strange dreams.
- Anxiety, irritability, and depressed mood represent the major psychological symptoms.
- Physical malaise may develop which can include abdominal discomfort, chills, and feeling shaky.
- Withdrawal symptoms usually begin with 24 to 48 hours of last marijuana use.
- Most symptoms resolve within 10 to 14 days.
- In some cases, anxiety and irritability can persist for up to a month or longer.
Amount of use and risk of withdrawal
The amount and frequency of cannabis used is the single best predictor of who develops withdrawal symptoms during attempted abstinence. The standard unit of measure of marijuana use is “one joint”. A joint contains about 0.5 to 1 gram of marijuana, and an ounce of marijuana contains about 28 grams (40 joints). Smoking one joint per occasion on two or fewer occasions per week is less likely to result in significant symptoms of withdrawal. Smoking two or more joints per occasion on three or more occasions per week is more likely to result in withdrawal with heavier amounts and higher frequency increasing the risk. A history of “chronic use”, defined as greater than two years of marijuana use, can also increase the risk of developing withdrawal symptoms.
The level of THC in marijuana can vary, depending on the strain, the growing process, the part of the plant that is used, and the way the plant is prepared for use. Indoor cultivation (“hydro” cannabis) produces higher potency. The flowering tops, or “buds” of the female cannabis plant have the highest concentrations of THC, followed by the leaves. Much lower THC levels are found in the stalks and seeds of the cannabis plant. The resin secreted from the plant can be dried to make “hash,” with THC concentrations ranging from 10% to 20%. The dried buds and leaves of the plant, commonly known as marijuana, can vary widely in potency from less than 1% to 20%.
As noted, it is important to identify cannabis withdrawal in order to not mistake it for something else. In cases of significant distress, cannabis withdrawal can be managed symptomatically. For example, mirtazapine can be helpful with supporting appetite and sleep in cases of acute marijuana withdrawal and can be started in anticipation of the marijuana quit attempt. Clinically, addiction specialists also use medications off-label such as gabapentin, clonidine, and n-acetylcysteine for acute symptoms, as well as SSRIs in cases of significant, prolonged anxiety. N-acetylcysteine was the only one of these treatments shown to be effective in a placebo-controlled trial.
Rajnish Mago, MD:
Cannabis withdrawal can only occur in persons with moderate or severe cannabis use disorder. If the cannabis use disorder is mild, it is not really possible that cannabis withdrawal is occurring.
Rajnish Mago, MD:
In ICD-10-CM, F12 is Cannabis-related disorders. The code to be used for cannabis withdrawal is F12.288.
Gray KM, Carpenter MJ, Baker NL, DeSantis SM, Kryway E, Hartwell KJ, McRae-Clark AL, Brady KT. A double-blind randomized controlled trial of N-acetylcysteine in cannabis-dependent adolescents. Am J Psychiatry. 2012 Aug;169(8):805-12. PubMed PMID: 22706327; PubMed Central PMCID: PMC3410961.
Copyright 2016, Rajnish Mago, MD. All rights reserved. May not be reproduced in any form without express written permission.
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