What are the symptoms and management options for chronic daily marijuana use?

Symptoms of Chronic Daily Marijuana Use

Chronic daily marijuana use can lead to significant physical and psychological symptoms including cannabis use disorder, cannabis withdrawal syndrome, cannabinoid hyperemesis syndrome, psychiatric effects, cognitive impairment, and increased risk of motor vehicle accidents. 1, 2

Physical Symptoms

Gastrointestinal Effects

• Cannabinoid Hyperemesis Syndrome (CHS):
  • Occurs after long-standing cannabis use (>4 times per week for over a year)
  • Characterized by cyclical episodes of severe vomiting
  • Relief with hot showers/baths
  • Treatment requires complete cannabis cessation 1, 2

Cardiovascular Effects

• Arrhythmias
• Orthostatic hypotension
• Tachycardia
• Note: No clear evidence that lifetime use increases cardiovascular disease incidence or mortality 1

Respiratory Effects

• Data is conflicting and often confounded by concomitant nicotine use
• Unclear association with impaired lung function, asthma, COPD, and pneumonia 1

Other Physical Symptoms

• Dry mouth
• Conjunctival injection (red eyes)
• Impaired coordination and performance 3

Psychological and Cognitive Symptoms

Psychiatric Effects

• Increased risk for developing depressive disorders
• Exacerbation of existing psychiatric disorders in vulnerable individuals
• Anxiety and panic attacks
• Psychotic symptoms (particularly with high-THC products)
• Suicidal ideation/tendencies 1, 3

Cognitive Effects

• Impaired memory, attention, and complex cognitive processes
• Neurocognitive impairments with prolonged use 3, 4

Cannabis Use Disorder (CUD)

• Develops in approximately 10% of adults with chronic cannabis use
• Characterized by:
  • Using more cannabis than expected
  • Difficulty cutting back on use
  • Clinically significant impairment or distress
• Early onset of cannabis use (especially weekly/daily) strongly predicts future dependence 1

Cannabis Withdrawal Syndrome (CWS)

• Occurs within 3 days after cessation
• May last up to 14 days
• Symptoms include:
  • Irritability or anger
  • Anxiety
  • Sleep disturbances
  • Decreased appetite
  • Restlessness
  • Altered mood
  • Physical symptoms (abdominal pain, tremors, sweating, fever, chills, headache) 1

Safety Concerns

Driving Safety

• Cannabis users have twice the risk of motor vehicle crashes
• Fatal motor vehicle accidents involving cannabis alone increased from 9.0% (2000) to 21.5% (2018)
• Fatal accidents involving cannabis with alcohol increased from 4.8% (2000) to 10.3% (2018)
• Higher blood levels of cannabis associated with increased risk of fatal motor vehicle accidents co-involving alcohol 1

Special Populations

• Pregnancy: Convincing evidence of harmful effects including small for gestational age (1.61 times risk) and low birth weight (1.43 times risk) 4
• Mental health: Convincing evidence of increased risk of psychosis (1.71 times risk) 4
• Adolescents and young adults: Higher risk of adverse neurodevelopmental effects 1

Management Approaches

Cannabis Cessation

• Complete cessation is the definitive management approach for cannabis-related disorders, especially CHS 2

Treating Cannabis Withdrawal Syndrome

• For patients with significant daily intake (>1.5g/day of smoked cannabis or >20mg/day THC oil):
  • Consider nabilone or nabiximols substitution for withdrawal symptoms
  • Refer to psychiatry or addiction medicine specialists 1

Managing Cannabinoid Hyperemesis Syndrome

• First-line interventions:
  • IV fluid rehydration
  • Dopamine receptor antagonists (haloperidol 0.5-2mg IV/PO every 4-6 hours)
  • Hot showers/baths
  • Topical capsaicin cream 2
• Second-line options:
  • Serotonin receptor antagonists
  • Benzodiazepines (lorazepam 0.5-2mg PO/SL/IV every 6 hours)
  • Olanzapine (5-10mg PO daily)
  • Corticosteroids 2

Patient Education

• Open, non-judgmental conversations about risks and benefits
• Education about cannabis withdrawal syndrome
• Caution about driving (avoid driving within at least 6 hours of cannabis use)
• Information about potential drug interactions 1, 2

Common Pitfalls in Management

• Failure to recognize CHS: Often misdiagnosed as cyclic vomiting syndrome
• Overlooking withdrawal symptoms: Can be mistaken for other conditions
• Stigmatizing approach: May prevent patients from disclosing cannabis use
• Ignoring drug interactions: Cannabis can interact with medications metabolized by cytochrome P450 enzymes
• Not addressing driving risks: Patients should be explicitly warned about impaired driving ability 1, 2