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The Science, The Solution, The Decision

When Pittsburgh Steelers wide receiver Martavis Bryant stopped his regular cannabis consumption in order to pass the NFL’s drug test, he encountered an unexpected challenge. Insomnia kept him up at night. “I would get frustrated,” Bryant told Sports Illustrated. “I’d yell, ‘Why can’t I sleep!?’” The answer may have been Cannabis Withdrawal Syndrome, or CWS.

For regular, long-term cannabis consumers who want to take a tolerance break or need to abstain completely, cannabis withdrawal syndrome can be a mild but very real challenge. It’s nowhere near the severity of withdrawal induced by tobacco, alcohol, or other drugs, but it may be irritating and mildly discomforting for a few days. Symptoms typically start within the first two days of cessation, and stop within four weeks of abstinence.

The Science

Cannabis withdrawal syndrome (CWS) is a criterion of cannabis use disorder. Cannabis use disorder (CUD), also known as cannabis addiction or marijuana addiction, is defined in the fifth revision of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) and ICD-10 published by World Health Organization as the continued use of cannabis despite clinically significant impairment, ranging from mild to severe.

Cannabis is a psychotropic substance with widespread recreational use worldwide, surpassed only by nicotine and alcohol. The cannabis withdrawal syndrome is part of a cannabis use disorder and dependence-syndrome being characterized by frequent, heavy, or prolonged cannabis use. Frequent cannabis users had reported that withdrawal symptoms negatively influence their desire and ability to quit.

Abstaining from cannabis was reported to be followed by an increase of alcohol and tobacco use, which decreased again after continuation of cannabis use. Mood and behavioral symptoms, namely, insomnia, dysphoria, and anxiety, are the key symptoms of the cannabis withdrawal syndrome. Regular alcohol drinking might influence the clinical expression of the cannabis withdrawal syndrome, and this is not through the overlapping alcohol withdrawal symptoms. Alcoholic drinks were reported to be co-used by 33%–46% of regular cannabis users. The rates of co-use for cocaine, stimulants, and hallucinogens were 37%–43%, 30%–52%, and 36%–42%, respectively all putatively being able to influence the course and intensity of the CWS.

Approximately 90% of cannabis users are also tobacco smokers, possibly reflecting the common route of administration, and even synergistic and compensatory actions of cannabis and tobacco as well as genetic and epigenetic factors assumed to mediate addiction vulnerability. More specifically, smoking tobacco use was shown to increase the number of cannabis dependence symptoms and precipitated cannabis relapse. Vice versa, cannabis use decreased the likelihood of abstaining from tobacco. There is a preliminary evidence that simultaneous tobacco and cannabis abstinence predicts better psychosocial treatment outcomes. There is still a paucity of clinical studies on this important subject, although alcohol, tobacco, and cannabis were consistently identified to be the substances with earliest onset of use, the highest prevalence of lifetime use, and the highest prevalence of lifetime disorder.

In addition to an increasing awareness of the existence of the CWS, its increasing emergence in the last 20 years might result from the increasing psychotropic potency of the used marijuana originating from the breeding of strains with high THC (10%–18.5%) and low cannabidiol concentrations (<0.15%) being found especially in high-income countries.

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It is known that the chemical composition of the resin itself varies with cannabidiol activities between 0% and 50% depending on the provenance of the drug. Whether the users of more potent cannabis strains adjust their intake according to the potency is still unclear. However, there is first evidence that the occurrence of first-episode psychosis as well as the intensity of the CUD increased alongside the use of high potency cannabis preparations. This throws an extremely critical light on emerging modern cannabis ingestion methods (“dabbing” or “cannavaping” of cannabis concentrates with 20%–80% THC) used by individuals seeking a more rapid and even bigger than being possible with smoking flowers that THC contents are usually in the range of 2% and 6%. Marijuana users who had turned to “dabbing” reported higher tolerance and withdrawal experiences.

In 2018, the 11th revision of the ICD-11/International Classification of Diseases is planned to be published. The so-called Beta-Draft of the chapter about “Mental and Behavioral Disorders” is already available online (accessed November 25, 2016). The current version of this ICD-11 Beta Draft lists the usual mood and behavioral CWS symptoms according to DSM-5 but does not consider physical CWS symptoms. We recommend to include at least “nausea” and “stomach pain” into the final version because these symptoms were recently found to be more prominent in the female CWS, and yet, it seems likely that the increasing use of high potency cannabis preparations are associated with more physical CWS symptoms. It is also recommended to include a note on the high intra- and interpersonal variability of the CWS intensity and the observation that – if a CWS occurs – it is extra distressing between the first and the third week after quitting a frequent, heavy, or prolonged cannabis use. Heavy users were shown to experience a CWS whose average severity is comparable to the burden of a moderate depression or moderate alcohol withdrawal syndrome. In outpatient settings, the average discomfort of CWS was similar to that of tobacco withdrawal.

Certainly, it awaits future study whether the inhalation of very potent cannabis concentrates is indeed associated with a further decrease of psychosocial functioning, higher comorbidity, and a stronger CUD and CWS – eventually with more physical features (eg, hyperalgesia, nausea, sweating, tremor, flu-like symptoms) than occurring after the cessation of a heavy or prolonged use of traditional non-concentrated cannabis preparations.

Characteristics of Cannabis Withdrawal Syndrome [CWS]

Considering the cannabis research of the last 20 years,there was no doubt that cessation of heavy or prolonged cannabis use is most likely followed by typical symptoms, such as

  1.  Irritability 
  2.  Nervousness/anxiety
  3.  Sleep difficulty
  4.  Decreased appetite or weight loss
  5.  Depressed mood
  6.  One of the following physical symptoms such as abdominal pain, shakiness/tremors, sweating, fever, chills, or headache.

According to DSM-CWS is diagnosed if three or more of these symptoms (1–6) develop within ~1 week after quitting cannabis use abruptly. Withdrawal severity and duration can vary widely between individuals and fluctuate depending on the amount of prior cannabis use, context of cessation (eg, outpatient vs inpatient, voluntary vs involuntary), personality traits, psychiatric and somatic comorbidity, current life stressors, previous experiences, expectations, support, and severity of dependence.Women seeking treatment for CUD were shown to generate more frequent and more severe withdrawal symptoms than men after quitting their frequent cannabis use. 

National Institutes of Health, NIH
U.S. National Library of Medicine
The Cannabis Withdrawal Syndrome: Current Insights
Udo Bonnet, Ulrich W Preuss
Subst Abuse Rehabil. 2017; 8: 9–37. Published online 2017 Apr 27. doi: 10.2147/SAR.S109576

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5414724/ https://en.wikipedia.org/wiki/Cannabis_use_disorder https://www.leafly.com/news/health/cannabis-withdrawal-syndrome-ease-symptoms

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