What are the ICD-11 (International Classification of Diseases, 11th revision) criteria for diagnosing cannabis withdrawal in a patient with a history of heavy and prolonged cannabis use?

ICD-11 Criteria for Cannabis Withdrawal

While the evidence provided does not contain the specific ICD-11 diagnostic criteria, the ICD-10 and DSM-5 criteria are well-established and clinically equivalent: cannabis withdrawal requires abrupt cessation of prolonged or heavy cannabis use accompanied by three or more characteristic symptoms occurring within 24-72 hours of cessation. 1, 2

Core Diagnostic Requirements

The diagnosis of cannabis withdrawal syndrome requires all of the following components:

• Abrupt cessation or significant reduction of prolonged or heavy cannabis use 1, 3
• Three or more symptoms from the characteristic symptom list 1, 2
• Symptoms cause clinically significant distress or functional impairment 4

Characteristic Withdrawal Symptoms

Primary Psychological Symptoms

• Irritability or anger 1, 2, 5
• Anxiety 1, 2, 5
• Restlessness 1, 2, 5
• Depressed or altered mood 1, 2, 3
• Sleep disturbances or insomnia 1, 2, 3

Physical Symptoms

• Decreased appetite or weight loss 1, 2, 5
• Abdominal pain or stomach discomfort 1, 2, 5
• Tremors or shakiness 1, 2, 5
• Sweating 1, 2
• Fever or chills 1, 2
• Headaches 1, 2, 3

Temporal Pattern and Course

Symptom onset typically occurs within 24-48 hours of cessation, peaks between days 2-6, and the acute withdrawal phase generally lasts 1-2 weeks, though some symptoms may persist for up to 3 weeks or more in heavy users. 1, 3, 5

• Onset: 24-72 hours post-cessation 1, 6, 3
• Peak intensity: Days 2-6 6, 3, 5
• Duration of acute phase: 1-2 weeks 1, 6
• Extended symptoms possible: Up to 3 weeks or longer in heavy users 3, 5
• Cannabis craving may persist for months or years 6

Risk Factors and Severity Predictors

Withdrawal is more likely to occur in patients consuming more than 1.5 g/day of inhaled cannabis, more than 20 mg/day of THC-dominant cannabis oil, or more than 300 mg/day of CBD-dominant oil. 1, 2, 6

Additional risk factors include:

• Patients using cannabis products with unknown THC/CBD content more than 2-3 times daily 1, 2, 6
• Female gender (women report stronger withdrawal including more physical symptoms like nausea and stomach pain) 4
• Severity correlates with amount of cannabis used pre-cessation 2
• Heritable and environmental factors influence severity 4

Clinical Significance

Cannabis withdrawal occurs in approximately 47-50% of regular cannabis users after cessation of heavy and prolonged use, and its primary clinical importance lies in precipitating relapse to cannabis use. 6, 3, 4

• Withdrawal symptoms are a significant contributor to relapse and difficulty maintaining abstinence 2
• May contribute to increased distress and decreased pain tolerance in perioperative settings 1, 2
• Complicated withdrawal may occur in patients with concurrent mental health disorders and polysubstance use 3

Important Clinical Distinctions

Cannabis withdrawal syndrome must be differentiated from cannabinoid hyperemesis syndrome (CHS), as they present oppositely: CWS causes vomiting after stopping cannabis use, while CHS causes vomiting during active chronic use. 6

• CHS requires cannabis use >1 year with frequency >4 times per week and resolution only with 6+ months of abstinence 6
• CHS is characterized by pathognomonic hot water bathing behavior in 44-71% of cases 6

Neurobiological Basis

Regular cannabis intake causes desensitization and downregulation of cortical and subcortical CB1 receptors, which begins to reverse within 48 hours of abstinence and returns to normal functioning within approximately 4 weeks. 1, 4