What medications are helpful for managing side effects from cannabis (marijuana) cessation?

Medications for Cannabis Withdrawal Symptoms

For patients experiencing cannabis withdrawal syndrome, nabilone or nabiximols should be considered ONLY if they were heavy users (>1.5 g/day of high-THC cannabis or >20 mg/day THC oil) and are actively experiencing withdrawal symptoms; otherwise, supportive care with symptomatic medications is the appropriate approach. 1, 2

Understanding Cannabis Withdrawal Syndrome

Cannabis withdrawal occurs in 50-95% of heavy users and up to one-third of regular users, with symptoms beginning 24-72 hours after cessation, peaking in the first week, and typically lasting 1-2 weeks (occasionally up to 3 weeks in heavy users). 1, 3, 2

Key withdrawal symptoms include: 1

• Irritability or anger
• Anxiety and restlessness
• Insomnia
• Decreased appetite
• Altered mood
• Physical symptoms: abdominal pain, tremors, sweating, fever, chills, headache

First-Line Management: Psychosocial Support

The cornerstone of treatment is short-duration psychosocial support (5-30 minutes) incorporating motivational principles, individualized feedback on consumption patterns, and advice on reducing or stopping use, with follow-up monitoring. 3 This should be conducted in a supportive environment with regular monitoring using tools like the Cannabis Withdrawal Scale. 3, 2

Pharmacological Management

Cannabinoid Agonist Replacement Therapy

Nabilone or nabiximols are appropriate ONLY for patients meeting ALL of the following criteria: 1, 2

Who qualifies:

• Patients with active withdrawal symptoms AND
• Prior consumption of >1.5 g/day of high-THC (>20%) smoked cannabis, OR
• Prior consumption of >20 mg/day THC-dominant oil

Who does NOT qualify (do NOT use nabilone/nabiximols): 1

• Patients consuming <1.5 g/day smoked cannabis
• Patients consuming <300 mg/day CBD-dominant oil
• Patients consuming <20 mg/day THC-dominant oil
• Patients using cannabis products with unknown CBD/THC content less than 2-3 times per day
• Patients without active withdrawal symptoms

Critical implementation details: 1, 4

• Nabilone and nabiximols reduce withdrawal symptoms and cannabis craving similar to nicotine replacement in tobacco smokers
• Optimal dosages are not established; do not exceed standard approved dosages
• Abrupt discontinuation should be avoided; tapering is recommended
• Monitor closely for side effects: drowsiness, dizziness, vertigo, postural hypotension, dry mouth
• Older adults are particularly vulnerable to dizziness and falls

Symptomatic Medications

For specific withdrawal symptoms, consider: 3, 2

• Anxiety/agitation: Benzodiazepines (short-term use only, typically diazepam for single doses or very short courses of 1-7 days) 5
• Insomnia: Benzodiazepines with medium duration of action (temazepam, loprazolam, lormetazepam) for transient use, ideally limited to a few days or courses not exceeding 2 weeks 5
• Nausea (if present): Supportive care; avoid opioids

Important caveat: Benzodiazepines should be used cautiously and for the shortest duration possible due to risks of tolerance, dependence, and withdrawal effects with prolonged use. 5

Special Consideration: Cannabinoid Hyperemesis Syndrome

If the patient presents with chronic nausea and vomiting (typically after 6.6 years of cannabis use), suspect cannabinoid hyperemesis syndrome rather than simple withdrawal. 3

Acute management of CHS: 3

• Topical capsaicin (0.1%)
• Benzodiazepines, haloperidol, promethazine, olanzapine, or ondansetron
• Avoid opioids (worsen nausea and high addiction risk)

Long-term CHS management: 3

• Cannabis cessation counseling
• Tricyclic antidepressants (amitriptyline 75-100 mg at bedtime, starting at 25 mg with weekly titration)

When to Refer to Psychiatry/Addiction Medicine

Immediate referral is indicated for: 3, 2

• Patients who fail to respond to short-duration psychological support
• Significant comorbid mental health disorders (anxiety, depression, psychosis)
• Polysubstance use
• Severe withdrawal symptoms requiring close monitoring
• Depression or psychosis emerging during withdrawal
• Need for guidance on nabilone/nabiximols initiation and dosing

Critical Pitfalls to Avoid

NEVER use dexamphetamine for cannabis withdrawal or cannabis use disorders—this is explicitly contraindicated. 3, 2

Other important warnings: 3

• Do not taper or cease cannabis within 24 hours of surgery (increased withdrawal risk)
• Avoid weaning CBD while maintaining THC consumption (may exacerbate THC adverse effects)
• Do not use cannabinoid agonist replacement in low-dose users below specified thresholds

Emerging Evidence

Preliminary evidence suggests fatty acid amide hydrolase inhibitors and CBD may reduce cannabis use, but larger validation studies are needed before clinical recommendation. 1, 3 Additionally, naltrexone has been observed to reduce cannabis self-administration in active users, though this requires further study. 1