Treatment for Cannabis Withdrawal
Cannabis withdrawal should be managed primarily with supportive care and psychosocial interventions, with cannabinoid agonist replacement therapy (nabilone or nabiximols) reserved for patients with moderate-to-severe withdrawal symptoms, particularly those consuming >1.5 g/day of smoked cannabis or >20 mg/day of THC oil. 1
Recognition and Diagnosis
Cannabis withdrawal syndrome occurs in approximately 50-95% of heavy users and up to one-third of regular users in the general population. 1 The diagnosis requires three or more of the following symptoms after cessation of prolonged or heavy cannabis use: 1
- Irritability or anger
- Anxiety
- Insomnia
- Decreased appetite
- Restlessness
- Altered mood
- Physical symptoms (abdominal pain, tremors, sweating, fever, chills, headache)
Symptom onset occurs 24-72 hours after cessation, peaks in the first week, and typically lasts 1-2 weeks, though some symptoms may persist up to 3 weeks in heavy users. 1, 2
First-Line Treatment Approach
Psychosocial Support
Short-duration psychosocial support modeled on motivational principles should be offered as initial treatment in non-specialized settings. 3, 4 This includes: 3, 4
- Brief interventions (5-30 minutes) incorporating individualized feedback
- Advice on reducing or stopping cannabis consumption
- Supportive counseling and psychoeducation
- Follow-up monitoring to assess progress
Patients who do not respond to short-duration psychological support should be referred for specialized treatment. 3, 4
Supportive Environment
Withdrawal should be conducted in a supportive environment with regular monitoring. 3, 4 The Cannabis Withdrawal Scale can be used to assess symptom severity. 1
Pharmacological Management
Cannabinoid Agonist Replacement Therapy
No medication is currently FDA-approved specifically for cannabis withdrawal, but cannabinoid agonists (nabilone, nabiximols, dronabinol) show the most promise for reducing withdrawal symptoms. 3, 4, 5
Consider nabilone or nabiximols substitution for patients with cannabis withdrawal symptoms if they were consuming: 1
- More than 1.5 g/day of high-THC (>20%) smoked cannabis
- More than 20 mg/day of THC-dominant cannabis oil
- More than 300 mg/day of CBD-dominant oil
Do NOT use nabilone or nabiximols for patients consuming less than these thresholds or using cannabis products with unknown CBD/THC content less than 2-3 times per day. 1
The evidence suggests these medications reduce withdrawal symptoms and cannabis craving with a dose-dependent effect, demonstrating good tolerability and few adverse effects. 5 However, optimal dosing remains unclear. 1
Symptomatic Medications
Symptomatic medications may be used for relief of specific withdrawal symptoms: 3, 4
- Sleep disturbance: Mirtazapine shows benefit for cannabis withdrawal insomnia 6
- Agitation: Symptomatic relief with appropriate anxiolytics 3, 4
- Other physical symptoms: Gabapentin shows promising results 6
Avoid venlafaxine, as it may worsen cannabis withdrawal symptoms. 6 Other antidepressants, atomoxetine, lithium, buspirone, and divalproex have shown no relevant effect. 6
Referral Criteria
Patients with suspected cannabis withdrawal syndrome should be referred to psychiatry or addiction medicine providers for: 1
- Initiation or guidance of treatment with nabilone or nabiximols
- Exploration of other treatment options
- Management of complicated withdrawal
Inpatient admission for medically assisted withdrawal is indicated for patients with: 2
- Significant comorbid mental health disorders
- Polysubstance use
- Risk of severe complications
Monitor closely for less common but serious complications including depression or psychosis; these require specialist consultation. 3, 4
Critical Pitfalls to Avoid
Do not use dexamphetamine for treatment of cannabis use disorders or withdrawal. 3, 7 This is explicitly contraindicated by addiction medicine guidelines. 3
Do not rely solely on pharmacological approaches without providing psychosocial support. 4 The combination is essential for optimal outcomes. 4
Do not overlook the need for close monitoring in patients with comorbid mental health conditions. 4 Cannabis withdrawal can precipitate relapse and worsen underlying psychiatric disorders. 2
Women may experience more severe withdrawal symptoms including physical symptoms like nausea and stomach pain, requiring closer monitoring. 6