Management of Cannabis Withdrawal
Cannabis withdrawal should be managed primarily with psychosocial support and symptomatic treatment, with cannabinoid agonist replacement therapy (nabilone or nabiximols) reserved for heavy users experiencing moderate-to-severe withdrawal symptoms. 1
Recognition and Assessment
Cannabis withdrawal syndrome occurs in 50-95% of heavy users and up to one-third of regular users after cessation. 1 Symptoms begin 24-72 hours after stopping cannabis, peak during the first week, and typically resolve within 1-2 weeks, though some symptoms may persist up to 3 weeks in heavy users. 1, 2
Key diagnostic criteria require three or more of the following symptoms: 1
- Irritability or anger
- Anxiety
- Insomnia or disturbed sleep/dreaming
- Decreased appetite
- Restlessness
- Altered mood
- Physical symptoms (abdominal pain, tremors, sweating, fever, chills, headache)
Use the Cannabis Withdrawal Scale for standardized assessment and monitoring. 3, 1 This validated tool has excellent psychometric properties (Cronbach's alpha=0.91) and should be employed for regular symptom tracking. 4
First-Line Treatment: Psychosocial Approach
Begin with short-duration psychosocial support modeled on motivational principles. 1 This includes:
- Brief interventions focused on reducing or stopping cannabis use
- Supportive counseling in a non-judgmental environment
- Psychoeducation about withdrawal symptoms and timeline
- Regular follow-up monitoring 1
Engage patients in open, non-stigmatizing conversations using their preferred terminology rather than pejorative terms like "addict" or "user." 3 This approach is critical as patients may be reluctant to discuss cannabis use due to fear of censure. 3
Pharmacological Management
Cannabinoid Agonist Replacement Therapy
Consider nabilone or nabiximols ONLY for patients meeting these thresholds who are experiencing active withdrawal symptoms: 3, 1
- Consuming >1.5 g/day of inhaled cannabis (particularly high-THC >20%)
- Consuming >20 mg/day of THC-dominant cannabis oil
- Consuming >300 mg/day of CBD-dominant oil
- Using cannabis products with unknown CBD/THC content >2-3 times daily
Do NOT use nabilone or nabiximols for patients below these consumption thresholds. 3, 1 Withdrawal symptoms are unlikely in patients consuming ≤300 mg/day of smoked CBD-dominant cannabis (approximately one cigarette). 3
Symptomatic Medications
Target specific withdrawal symptoms with appropriate medications: 1
- Sleep disturbances: Mirtazapine has shown benefit for cannabis withdrawal-related insomnia 5
- Anxiety/agitation: Short-term anxiolytics may be used, though benzodiazepines carry addiction risk 1, 6
- Nausea: Antiemetics as needed 3
Avoid these medications: 1
- Dexamphetamine is explicitly contraindicated for cannabis withdrawal
- Venlafaxine may worsen withdrawal symptoms 5
Medications with limited evidence (no clear benefit): 5
- Other antidepressants (except mirtazapine)
- Atomoxetine
- Lithium
- Buspirone
- Divalproex
Referral Criteria
Refer to psychiatry or addiction medicine services when: 3, 1
- Patients fail to respond to initial psychosocial support
- Suspected cannabis withdrawal syndrome requires cannabinoid agonist therapy
- Complicated withdrawal occurs
Inpatient admission for medically assisted withdrawal is indicated for: 1, 2
- Significant comorbid mental health disorders
- Polysubstance use
- Risk of severe complications
- Need for intensive monitoring
Clinical Pitfalls and Considerations
Withdrawal severity correlates with pre-cessation cannabis consumption. 7, 5 Women typically report more severe withdrawal symptoms, including physical symptoms like nausea and stomach pain. 5
Cannabis users with concurrent opioid dependence are less likely to experience withdrawal. 3, 7 Naltrexone administration has been observed to reduce cannabis self-administration. 3
Withdrawal symptoms may increase postoperative pain perception by removing cannabis as an external coping mechanism. 3 Consider this when managing surgical patients who are regular cannabis users.
The neurobiological basis involves CB1 receptor downregulation that begins reversing within 48 hours of abstinence and normalizes within 4 weeks. 5 This provides a biological framework for the withdrawal timeline.
Combine pharmacological approaches with psychosocial support for optimal outcomes. 1 Medication alone without supportive counseling is insufficient for managing cannabis withdrawal effectively.