There is disagreement over whether or not there is such a thing as a cannabis withdrawal syndrome, but it’s definitely real, and with increased availability of legal marijuana and other products, even those who use it medicinally need to be aware of the symptoms, and what to do … Medical cannabis and recreational marijuana users may not realize the headaches, dizziness, anxiety and other symptoms they feel between hits are signs of withdrawal. In healthy volunteers, no evidence of withdrawal syndrome was found with abrupt discontinuation of short-term treatment with CBD.
If cannabis becomes a problem: How to manage withdrawal
Proponents of cannabis generally dismiss the idea that there is a cannabis withdrawal syndrome. One routinely hears statements such as, “I smoked weed every day for 30 years and then just walked away from it without any problems. It’s not addictive.” Some cannabis researchers, on the other hand, describe serious withdrawal symptoms that can include aggression, anger, irritability, anxiety, insomnia, anorexia, depression, restlessness, headaches, vomiting, and abdominal pain. Given this long list of withdrawal symptoms, it’s a wonder that anyone tries to reduce or stop using cannabis. Why is there such a disconnect between researchers’ findings and the lived reality of cannabis users?
New research highlights the problems of withdrawal, but provides an incomplete picture
A recent meta-analysis published in JAMA cites the overall prevalence of cannabis withdrawal syndrome as 47% among “individuals with regular or dependent use of cannabinoids.” The authors of the study raise the alarm that “many professionals and members of the general public may not be aware of cannabis withdrawal, potentially leading to confusion about the benefits of cannabis to treat or self-medicate symptoms of anxiety or depressive disorders.” In other words, many patients using medical cannabis to “treat” their symptoms are merely caught up in a cycle of self-treating their cannabis withdrawal. Is it possible that almost half of cannabis consumers are actually experiencing a severe cannabis withdrawal syndrome — to the point that it is successfully masquerading as medicinal use of marijuana — and they don’t know it?
Unfortunately, the study in JAMA doesn’t seem particularly generalizable to actual cannabis users. This study is a meta-analysis: a study which includes many studies that are deemed similar enough to lump together, in order to increase the numerical power of the study and, ideally, the strength of the conclusions. The authors included studies that go all the way back to the mid-1990s — a time when cannabis was illegal in the US, different in potency, and when there was no choice or control over strains or cannabinoid compositions, as there is now. One of the studies in the meta-analysis included “cannabis-dependent inpatients” in a German psychiatric hospital in which 118 patients were being detoxified from cannabis. Another was from 1998 and is titled, “Patterns and correlates of cannabis dependence among long-term users in an Australian rural area.” It is not a great leap to surmise that Australians in the countryside smoking whatever marijuana was available to them illegally in 1998, or patients in a psychiatric hospital, might be substantively different from current American cannabis users.
Medical cannabis use is different from recreational use
Moreover, the JAMA study doesn’t distinguish between medical and recreational cannabis, which are actually quite different in their physiological and cognitive effects, as Harvard researcher Dr. Staci Gruber’s work tells us. Medical cannabis patients, under the guidance of a medical cannabis specialist, are buying legal, regulated cannabis from a licensed dispensary; it might be lower in THC (the psychoactive component that gives you the high) and higher in CBD (a nonintoxicating, more medicinal component), and the cannabis they end up using often results in them ingesting a lower dose of THC.
Cannabis withdrawal symptoms are real
All of this is not to say that there is no such thing as a cannabis withdrawal syndrome. It isn’t life-threatening or medically dangerous, but it certainly does exist. It makes absolute sense that there would be a withdrawal syndrome because, as is the case with many other medicines, if you use cannabis every day, the natural receptors by which cannabis works on the body “down-regulate,” or thin out, in response to chronic external stimulation. When the external chemical is withdrawn after prolonged use, the body is left in the lurch, and forced to rely on natural stores of these chemicals, but it takes time for the natural receptors to grow back to their baseline levels. In the meantime, the brain and the body are hungry for these chemicals, and the result is withdrawal symptoms.
Getting support for withdrawal symptoms
Uncomfortable withdrawal symptoms can prevent people who are dependent on or addicted to cannabis from remaining abstinent. The commonly used treatments for cannabis withdrawal are either cognitive behavioral therapy or medication therapy, neither of which has been shown to be particularly effective. Common medications that have been used are dronabinol (which is synthetic THC); nabiximols (which is cannabis in a mucosal spray, so you aren’t actually treating the withdrawal); gabapentin for anxiety (which has a host of side effects); and zolpidem for the sleep disturbance (which also has a list of side effects). Some researchers are looking at CBD, the nonintoxicating component of cannabis, as a treatment for cannabis withdrawal.
Some people get into serious trouble with cannabis, and use it addictively to avoid reality. Others depend on it to an unhealthy degree. Again, the number of people who become addicted or dependent is somewhere between the 0% that cannabis advocates believe and the 100% that cannabis opponents cite. We don’t know the actual number, because the definitions and studies have been plagued with a lack of real-world relevance that many studies about cannabis suffer from, and because the nature of both cannabis use and cannabis itself have been changing rapidly.
How do you know if your cannabis use is a problem?
The standard definition of cannabis use disorder is based on having at least two of 11 criteria, such as: taking more than was intended, spending a lot of time using it, craving it, having problems because of it, using it in high-risk situations, getting into trouble because of it, and having tolerance or withdrawal from discontinuation. As cannabis becomes legalized and more widely accepted, and as we understand that you can be tolerant and have physical or psychological withdrawal from many medicines without necessarily being addicted to them (such as opiates, benzodiazepines, and some antidepressants), I think this definition seems obsolete and overly inclusive.
For example, if one substituted “coffee” for “cannabis,” many of the 160 million Americans who guzzle coffee on a daily basis would have “caffeine use disorder,” as evidenced by the heartburn and insomnia that I see every day as a primary care doctor. Many of the patients that psychiatrists label as having cannabis use disorder believe that they are fruitfully using cannabis to treat their medical conditions — without problems — and recoil at being labeled as having a disorder in the first place. This is perhaps a good indication that the definition doesn’t fit the disease.
Perhaps a simpler, more colloquial definition of cannabis addiction would be more helpful in assessing your use of cannabis: persistent use despite negative consequences. If your cannabis use is harming your health, disrupting your relationships, or interfering with your job performance, it is likely time to quit or cut down drastically, and consult your doctor. As part of this process, you may need to get support or treatment if you experience uncomfortable withdrawal symptoms, which may make it significantly harder to stop using.
More Than Half of People Using Cannabis for Pain Experience Multiple Withdrawal Symptoms
Minority experience worsening of symptoms over time, especially younger people.
More than half of people who use medical marijuana products to ease pain also experience clusters of multiple withdrawal symptoms when they’re between uses, a new study finds.
And about 10% of the patients taking part in the study experienced worsening changes to their sleep, mood, mental state, energy and appetite over the next two years as they continued to use cannabis.
Many of them may not recognize that these symptoms come not from their underlying condition, but from their brain and body’s reaction to the absence of substances in the cannabis products they’re smoking, vaping, eating or applying to their skin, says the University of Michigan Addiction Center psychologist who led the study.
When someone experiences more than a few such symptoms, it’s called cannabis withdrawal syndrome – and it can mean a higher risk of developing even more serious issues such as a cannabis use disorder.
In the new research published in the journal Addiction, a team from the University of Michigan Medical School and the VA Ann Arbor Healthcare System reports findings from detailed surveys across two years of 527 Michigan residents. All were participating in the state’s system to certify people with certain conditions for use of medical cannabis, and had non-cancer-related pain.
“Some people report experiencing significant benefits from medical cannabis, but our findings suggest a real need to increase awareness about the signs of withdrawal symptoms developing to decrease the potential downsides of cannabis use, especially among those who experience severe or worsening symptoms over time,” says Lara Coughlin, Ph.D., the addiction psychologist who led the analysis.
Long-term study in medical cannabis use
The researchers asked the patients whether they had experienced any of 15 different symptoms – ranging from trouble sleeping and nausea to irritability and aggression – when they had gone a significant time without using cannabis.
The researchers used an analytic method to empirically group the patients into those who had no symptoms or mild symptoms at the start of the study, those who had moderate symptoms (meaning they experienced multiple withdrawal symptoms) and those who had severe withdrawal issues that included most or all of the symptoms.
They then looked at how things changed over time, surveying the patients one year and two years after their first survey.
At baseline, 41% of the study participants fell into the mild symptoms group, 34% were in the moderate group and 25% were classed as severe.
Misconceptions about medical cannabis
Many people who turn to medical cannabis for pain do so because other pain relievers haven’t worked, says Coughlin, an Assistant Professor in the Department of Psychiatry who sees patients as part of U-M Addiction Treatment Services . They may also want to avoid long-term use of opioid pain medications because they pose a risk of misuse and other adverse health consequences.
She notes that people who experience issues related to their cannabis use for pain should talk with their health care providers about receiving other pain treatments including psychosocial treatments such as cognitive behavioral therapy.
The perception of cannabis as “harmless” is not correct, she says. It contains substances called cannabinoids that act on the brain – and that over time can lead the brain to react when those substances are absent.
In addition to a general craving to use cannabis, withdrawal symptoms can include anxiety, sleep difficulties, decreased appetite, restlessness, depressed mood, aggression, irritability, nausea, sweating, headache, stomach pain, strange dreams, increased anger and shakiness.
Previous research has shown that the more symptoms and greater severity of symptoms a person has, the less likely they are to be able to reduce their use of cannabis, quit using it or stay away from it once they quit.
They may mistakenly think that the symptoms happen because of their underlying medical conditions, and may even increase the amount or frequency of their cannabis use to try to counteract the effect – leading to a cycle of increasing use and increasing withdrawal.
“Our findings suggest a real need to increase awareness about the signs of withdrawal symptoms developing to decrease the potential downsides of cannabis use, especially among those who experience severe or worsening symptoms over time.”
Coughlin says people who decide to use a cannabis product for a medical purpose should discuss the amount, route of administration, frequency and type of cannabis product with their regular health provider. They should also familiarize themselves with the symptoms of cannabis withdrawal and tell their provider if they’re experiencing them.
Feeling the urge to use cannabis after a period without use, such as soon after waking up, can be a sign of a withdrawal syndrome, she notes. So can the inability to cut back on use without experiencing craving or other symptoms of withdrawal.
Because there is no medically accepted standard for medical cannabis dosing for different conditions, patients are often faced with a wide array of cannabis products that vary in strength and route of administration. Some products could pose more risk for development of withdrawal symptoms than others, Coughlin says. For example, people who smoked cannabis tended to have more severe withdrawal symptoms than others, while people who vaped cannabis reported symptoms that tended to stay the same or get worse, but generally did not improve, over time.
As more states legalize cannabis for medical or general use, including several states that will legalize its use based on the results of last November’s election, use is expected to grow.
More about the study
The researchers asked the patients about how they used cannabis products, how often, and how long they’d been using them, as well as about their mental and physical health, their education and employment status.
Over time, those who had started off in the mild withdrawal symptom group were likely to stay there, but some did progress to moderate withdrawal symptoms.
People in the moderate withdrawal group were more likely to go down in symptoms than up, and by the end of the study the number of the people in the severe category had dropped to 17%. In all, 13% of the patients had gone up to the next level of symptoms by the end of the first year, and 8% had transitioned upward by the end of two years.
Sleep problems were the most common symptom across all three groups, and many in the mild group also reported cravings for cannabis. In the moderate group, the most common withdrawal symptoms were sleep problems, depressed mood, decreased appetite, craving, restlessness, anxiety and irritability.
The severe withdrawal symptom group was much more likely to report all the symptoms except sweatiness. Nearly all the participants in this group reported irritability, anxiety, and sleep problems. They were also more likely to be longtime and frequent users of cannabis.
Those in the severe group were more likely to be younger and to have worse mental health. Older adults were less likely to go up in withdrawal symptom severity, while those who vaped cannabis were less likely to transition to a lower withdrawal-severity group.
The study didn’t assess nicotine use, or try to distinguish between symptoms that could also be related to breakthrough pain or diagnosed/undiagnosed mental health conditions during abstinence.
Coughlin and her colleagues hope future research can explore cannabis withdrawal symptoms among medical cannabis patients further, including the impact of different attempts to abstain, different types of use and administration routes, and interaction with other physical and mental health factors. Most research on cannabis withdrawal has been in recreational users, or “snapshot” looks at medical cannabis patients at a single point in time.
Further research could help identify those most at risk of developing problems, and reduce the risk of progression to cannabis use disorder, which is when someone uses cannabis repeatedly despite major impacts on their lives and ability to function.
The study was funded by the National Institute on Drug Abuse (DA033397). The original study from which the data came was led by Mark Ilgen, Ph.D., the Director of the U-M Addiction Treatment Services and a co-author of the new paper. The new study’s senior author is Kipling Bohnert, Ph.D., formerly of U-M and now at Michigan State University.
Paper cited: “Progression of cannabis withdrawal symptoms in people using medical cannabis for chronic pain,” Addiction. DOI: 10.1111/add.15370
Abrupt withdrawal of cannabidiol (CBD): A randomized trial
Rationale: The rationale of this study was to assess occurrence of withdrawal symptoms induced by abrupt cessation of cannabidiol (CBD) after prolonged administration in healthy volunteers.
Methods: Thirty volunteers were randomized to receive 750 mg of a plant-derived pharmaceutical formulation of highly purified CBD in oral solution (100 mg/mL; Epidiolex® in the United States and Epidyolex® in Europe) twice daily (b.i.d.) for 4 weeks (Part 1) followed by 2 weeks of 750 mg b.i.d. CBD (Part 2, Arm 1) or matched placebo (Part 2, Arm 2). All volunteers completed the Cannabis Withdrawal Scale (CWS) and the 20-item Penn Physician Withdrawal Checklist (PWC-20) on days -1, 21, 28, 31, 35, 42, and at follow-up.
Results: Median CWS and PWC-20 scores slightly decreased from Part 1 to Part 2. Median CWS scores ranged from 0.0 to 4.0 (out of a possible 190) in Arm 1 and 0.0 to 0.5 in Arm 2. Median PWC-20 scores were 0.0 (out of a possible 60) in both arms. Twenty-nine (97%) volunteers in Part 1 reported all-causality treatment-emergent adverse events (AEs); the most commonly reported was diarrhea (63%). In Part 2, Arm 1, 6 (67%) volunteers reported all-causality AEs; the most commonly reported was diarrhea (44%). In Part 2, Arm 2, 9 (75%) volunteers reported all-causality AEs; the most commonly reported was headache (58%). Nine volunteers withdrew because of AEs in Part 1; 1 withdrew in Part 2, Arm 2, because of an AE that began in Part 1. Four severe AEs were reported in Part 1; the remainder were mild or moderate. No serious AEs were reported.
Conclusion: In healthy volunteers, no evidence of withdrawal syndrome was found with abrupt discontinuation of short-term treatment with CBD.
Keywords: Cannabidiol; Cannabinoid; Drug withdrawal; Epilepsy; Seizure.
Copyright © 2020 Elsevier Inc. All rights reserved.
Conflict of interest statement
Declaration of competing interest All authors met the International Committee of Medical Journal Editors authorship criteria. Neither honoraria nor payments were made for authorship. Lesley Taylor was an employee of GW Research Ltd. at the time the work was completed. Julie Crockett is an employee of GW Research Ltd. and has share options in the company. Bola Tayo is an employee of GW Research Ltd. and owns shares in the company. Daniel Checketts is an employee of GW Research Ltd. Kenneth Sommerville was an employee of Greenwich Biosciences, Inc. at the time the work was completed.
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