What is the evidence‑based treatment plan for an adolescent/young adult with cannabis use disorder presenting with irritability, insomnia, decreased appetite, and anxiety?

Evidence-Based Treatment for Adolescent/Young Adult Cannabis Use Disorder

The cornerstone of treatment is brief psychosocial intervention (5-30 minutes) incorporating motivational interviewing principles, individualized feedback on consumption patterns, and specific advice on reducing or stopping cannabis use, combined with symptomatic management of withdrawal and close monitoring for psychiatric complications. 1, 2

Initial Assessment and Safety Planning

Conduct immediate screening for suicidal ideation and psychotic features, as high-dose THC exposure can precipitate psychosis in vulnerable individuals, and depression/anxiety are very common comorbid conditions. 3, 1 The patient's irritability, insomnia, decreased appetite, and anxiety are consistent with cannabis withdrawal syndrome, which occurs in 42-47% of regular users attempting cessation. 2

Cannabis Withdrawal Timeline and Expectations

• Withdrawal symptoms begin 24-72 hours after cessation, peak during the first week, and persist for 1-2 weeks (up to 3 weeks in heavy users). 3, 2
• Common symptoms include irritability, restlessness, anxiety, sleep disturbances, decreased appetite, and abdominal pain—all matching this patient's presentation. 2, 4
• Educate the patient that withdrawal symptoms are time-limited and that using cannabis to relieve them perpetuates the cycle. 2

First-Line Psychosocial Intervention

Deliver a structured brief intervention (5-30 minutes) that includes: 1, 2, 4

• Individualized feedback on the patient's specific cannabis consumption patterns
• Personalized advice on reduction/cessation strategies
• Motivational interviewing techniques to enhance readiness for change
• Offer of follow-up monitoring at 2-3 weeks and 12 weeks 2

For adolescents and young adults with ongoing problems who do not respond to brief interventions, refer for specialist assessment incorporating cognitive-behavioral therapy (CBT) combined with motivational enhancement therapy. 1, 5 This combination has demonstrated moderate to large effect sizes (Cohen's d = 0.53-0.9) on cannabis consumption and psychosocial functioning. 6

Symptomatic Pharmacotherapy for Withdrawal

No specific medication is routinely recommended for uncomplicated cannabis withdrawal, but symptomatic relief is appropriate: 1, 2, 4

• For insomnia: Short-acting benzodiazepines (lorazepam, temazepam) or non-benzodiazepine hypnotics (zolpidem) 2
• For anxiety/agitation: Low-dose anxiolytics as needed 1, 2
• For depression: Consider starting an SSRI (sertraline, citalopram, or fluoxetine) if depressive symptoms are prominent and functionally impairing 3, 2

Monitor closely during the first 2-4 weeks for worsening anxiety, agitation, or emergent suicidality when initiating antidepressants. 3

Critical Contraindications

NEVER prescribe dexamphetamine for cannabis use disorder—this is explicitly contraindicated. 2, 4 Avoid opioids due to worsening nausea and high addiction risk. 1, 2

Mandatory Referral Criteria

Refer immediately for specialist psychiatric assessment if: 2, 4

• Patient fails to respond to brief psychosocial support
• Depression or psychosis emerges during withdrawal 1, 2
• Significant psychiatric comorbidity is present (severe anxiety, major depression)
• Polysubstance use complicates the clinical picture
• Severe withdrawal symptoms develop requiring close monitoring

Co-management with a psychologist or psychiatrist is particularly helpful for patients with extensive psychiatric comorbidity or lack of response to standard therapies. 1

Monitoring and Follow-Up Schedule

• Schedule visits at 2-3 weeks and 12 weeks after initiating therapy 2
• Use validated tools like the Cannabis Withdrawal Scale to track symptoms 2
• Monitor specifically for worsening depression or emergence of psychosis, which requires immediate specialist referral 2
• Ensure continuous access to relapse-prevention resources, as withdrawal symptoms are a major driver of relapse 3

Cognitive Recovery Expectations

• Partial improvement in attentiveness and routine functioning may be observed between 1-6 months of abstinence 3
• A minimum of six months of continuous abstinence is required to reliably assess resolution of cannabis-related neurological effects 3
• Full cognitive recovery assessment should wait until at least six months 3

Common Pitfalls to Avoid

• Do not underestimate the severity of cannabis withdrawal—patients may experience marked distress that jeopardizes treatment adherence 3
• Do not delay addressing comorbid psychiatric symptoms—anxiety and depression are very common associated conditions requiring concurrent treatment 1
• Avoid switching to "lower THC/higher CBD formulations" or edible forms as harm reduction strategies—these lack scientific validation and prioritize complete cessation over harm reduction 1, 3
• Do not use serotonergic antidepressants without close monitoring, as there is some evidence they can worsen withdrawal manifestations in certain contexts 6

Expected Outcomes and Recidivism

With integrated psychosocial and symptomatic pharmacologic treatment, withdrawal symptoms typically resolve within 1-2 weeks, but recidivism rates remain high. 1, 3 Sustained support and monitoring are essential to maintain abstinence and prevent relapse. 3 Approximately 40% of patients can eventually stop all treatments for cannabis use disorder over time, but ongoing support is critical. 1