What is the treatment for cannabis withdrawal?

Treatment for Cannabis Withdrawal

Start with short-duration psychosocial support (5-30 minutes) incorporating motivational principles, individualized feedback, and advice on reducing or stopping cannabis use, with follow-up monitoring—this is the first-line treatment for cannabis withdrawal in non-specialized settings. 1, 2

Recognition and Clinical Features

Cannabis withdrawal occurs in approximately 50-95% of heavy users and up to one-third of regular users, making it a common clinical entity that requires recognition. 1

Symptom Timeline:

• Onset occurs 24-72 hours after cessation 3, 1, 4
• Symptoms peak during days 2-6 4
• Duration is typically 1-2 weeks, though may persist up to 3 weeks in heavy users 1, 4

Core Symptoms to Assess:

• Irritability, anxiety, and anger 3, 1, 4
• Sleep disturbances and altered dreaming 1, 4
• Appetite changes and abdominal pain 3, 1
• Restlessness and depressed mood 1, 4
• Physical symptoms: chills, headaches, sweating, physical tension 4

Diagnosis requires three or more symptoms after cessation of prolonged cannabis use. 1

First-Line Management Algorithm

Step 1: Psychosocial Support (All Patients)

Initiate brief interventions that include: 1, 2

• Individualized feedback on cannabis consumption patterns 2
• Specific advice on reducing or stopping use 1, 2
• Supportive counseling 1
• Follow-up monitoring arrangements 1, 2

Conduct withdrawal in a supportive environment with regular monitoring using the Cannabis Withdrawal Scale to assess symptom severity. 1

Step 2: Symptomatic Medication (As Needed)

Use targeted medications for specific symptoms: 1, 2

• Anxiolytics for agitation 1
• Sleep aids for insomnia 2, 5
• Anti-emetics for nausea 4

No specific medication is routinely recommended for uncomplicated cannabis withdrawal—symptomatic relief is the approach. 2, 6, 4

Cannabinoid Agonist Replacement Therapy (High-Dose Users Only)

Consider nabilone or nabiximols substitution ONLY for patients meeting these specific thresholds: 1

• Consumed more than 1.5 g/day of high-THC smoked cannabis, OR 1
• Consumed more than 20 mg/day of THC-dominant cannabis oil 1

Do NOT use cannabinoid agonist replacement for: 1

• Patients consuming below these thresholds 1
• Cannabis products with unknown CBD/THC content used less than 2-3 times per day 1

Referral Criteria to Specialist Services

Refer immediately to psychiatry or addiction medicine when: 1, 2

• Patient fails to respond to short-duration psychological support 1, 2
• Significant comorbid mental health disorders are present (anxiety, depression, psychosis) 2, 6
• Polysubstance use complicates the clinical picture 2, 6
• Severe withdrawal symptoms develop requiring close monitoring 2, 6
• Depression or psychosis emerges during withdrawal 2, 6

Inpatient admission for medically assisted withdrawal is indicated for patients with significant comorbid mental health disorders, polysubstance use, or risk of severe complications. 1, 4

Pharmacological Considerations from Research

While not first-line, some medications show promise in controlled settings: 4, 5

• Gabapentin has promising results for cannabis withdrawal syndrome 5
• Mirtazapine can be beneficial specifically for insomnia 5
• THC analogs show promise but require specialist guidance 4, 5

Venlafaxine can worsen cannabis withdrawal syndrome and should be avoided. 5

Critical Pitfalls to Avoid

NEVER use dexamphetamine for treatment of cannabis withdrawal or cannabis use disorders—this is explicitly contraindicated. 1, 2, 6

Do not taper or cease cannabis within 24 hours of surgery due to increased risk of withdrawal syndrome. 6

Avoid weaning CBD while maintaining THC consumption, as adverse effects of THC may be exacerbated. 6

Do not use cannabinoid agonist replacement in low-dose users below the specified thresholds. 1, 6

Gender Considerations

Women report stronger withdrawal symptoms than men, including more prominent physical symptoms such as nausea and stomach pain—adjust monitoring and symptomatic treatment accordingly. 5

Combining Approaches for Optimal Outcomes

Pharmacological approaches must be combined with psychosocial support for optimal outcomes—medication alone is insufficient. 1

The clinical significance of cannabis withdrawal is that symptoms may precipitate relapse to cannabis use, making supportive management during the withdrawal period critical for long-term abstinence. 4