What are the treatment options for cannabis withdrawal?

Management of Cannabis Withdrawal

For cannabis withdrawal, no specific medication is recommended as first-line treatment; instead, symptom management with supportive care in a supportive environment is the recommended approach, with symptomatic medications used as needed for specific symptoms like agitation and sleep disturbance. 1, 2

Clinical Presentation of Cannabis Withdrawal

Cannabis withdrawal syndrome typically:

• Begins 24-72 hours after cessation of regular use
• Peaks within the first week
• Can last 1-2 weeks (longer in heavy users) 2, 3

Common symptoms include:

• Anxiety, irritability, anger or aggression
• Disturbed sleep/vivid dreaming
• Depressed mood
• Loss of appetite
• Less common: chills, headaches, physical tension, sweating, stomach pain 3

Risk factors for more severe withdrawal:

• Heavy cannabis use (>1.5 g/day of inhaled cannabis or >20 mg/day of THC oil)
• Higher pre-cessation frequency of use
• Female gender (women report stronger physical symptoms) 2, 4

Treatment Approach

Non-Pharmacological Interventions (First-Line)

1. Supportive environment 1

   • Quiet setting with minimal stimulation
   • Ensure adequate hydration
   • Regular reassurance and monitoring

2. Psychosocial support 1, 2

   • Brief interventions (5-30 minutes) incorporating individualized feedback
   • Short-duration psychosocial support using motivational principles
   • Cognitive behavioral therapy and motivational enhancement therapy

Symptomatic Medication Management

For specific symptoms, the following may be used:

• Sleep disturbance: Low-dose sedating medications (consider mirtazapine) 4
• Headaches/pain: Acetaminophen or NSAIDs 2
• Anxiety/agitation: Short-term benzodiazepines (use with caution) 2, 4
• Nausea: Antiemetics as needed

Pharmacological Options for Moderate-to-Severe Withdrawal

While no medications are specifically approved for cannabis withdrawal, evidence suggests:

1. Synthetic cannabinoids may be considered for heavy users with moderate-to-severe withdrawal:

   • Dronabinol: Start at lowest available dose and titrate based on symptoms 2, 5
   • Treatment duration typically 1-2 weeks during acute withdrawal phase 2

2. Other medications with limited evidence:

   • Cannabidiol (CBD): May help without psychoactive effects, though more research needed 2
   • N-acetylcysteine: Shows some promise but evidence is limited 6
   • Gabapentin: Limited evidence but may warrant further investigation 6

Special Considerations

When to Consider Inpatient Treatment

• Patients with significant comorbid mental health disorders
• Polysubstance use
• Risk of severe withdrawal complications
• Inadequate social support 3, 4

Monitoring for Complications

• Depression or psychosis can occur during withdrawal and require close monitoring
• Seek specialist advice if these complications develop 1
• Monitor for cannabinoid hyperemesis syndrome in chronic users 2

Follow-up Care

• Offer follow-up appointments to assess progress
• For ongoing cannabis use problems not responding to brief interventions, refer for specialist assessment 1
• Consider mutual help groups where available

Common Pitfalls to Avoid

1. Underestimating withdrawal severity: Cannabis withdrawal is clinically significant and can lead to relapse if not properly addressed 2, 7

2. Overlooking gender differences: Women may experience more severe physical symptoms 4

3. Missing comorbid conditions: Withdrawal may exacerbate underlying psychiatric conditions 2

4. Using certain medications: Venlafaxine may worsen cannabis withdrawal symptoms 4

5. Inadequate duration of treatment: Symptoms can persist for several weeks in heavy users 3