Cannabis Withdrawal Syndrome: How to Ease the Symptoms By: Bruce Barcott

When Pittsburgh Steelers wide receiver Martavis Bryant stopped his regular cannabis consumption in order to pass the NFL’s drug test, he encountered an unexpected challenge. Insomnia kept him up at night. “I would get frustrated,” Bryant told Sports Illustrated. “I’d yell, ‘Why can’t I sleep!?’”

Symptoms typically start within the first two days of cessation, and stop within four weeks of abstinence.

The answer may have been cannabis withdrawal syndrome, or CWS.

For regular, long-term cannabis consumers who want to take a tolerance break or need to abstain completely, cannabis withdrawal syndrome can be a mild but very real challenge. It’s nowhere near the severity of withdrawal induced by tobacco, alcohol, or other drugs, but it may be irritating and mildly discomforting for a few days. In fact, it may most resemble the withdrawal a daily coffee drinker might feel upon going cold turkey.marijuana-withdrawal

“For many people who smoke marijuana, withdrawal is a non-issue,” says Roger Roffman, a University of Washington researcher who studied cannabis use for more than 25 years. People who consume cannabis occasionally, or use a higher amount for a short period of time, generally don’t experience any withdrawal symptoms. “But the person who smokes a lot of dope for quite a long period of time is likely to have an experience of withdrawal,” Roffman says.

Insomnia is often an indicator of CWS, but symptoms aren’t limited to sleeplessness.

According to German researchers who recently published an overview of the current CWS knowledge in Substance Abuse Rehabilitation, discontinuation of regular consumption can lead to one or a number of these symptoms:

  • Sleeping problems
  • Anxiety
  • Weakness
  • Sweating
  • Restlessness
  • Dysphoria, a feeling of general unease or dissatisfaction
  • Craving for resumed cannabis use
  • Nausea
  • Stomach pain

Any combination of those symptoms occur in 35% to 75% of patients who quit cannabis after longtime regular use. (It’s a wide percentage range because different percentages were found in several separate studies.)

How Severe?

guy on couchSymptoms of cannabis withdrawal “are much less severe than those associated with withdrawal from chronic opioid or depressant use,” researchers with the National Institute on Drug Abuse (NIDA) wrote in a 2015 study, “but aversive enough to encourage continued cannabis use and interfere with cessation attempts in some individuals.”

In that NIDA study, scientists noted that the effects induced by simply discontinuing exposure “are not severe and can be hard to detect, probably due to the slow elimination of lipophilic compounds like THC from the brain.”

The symptoms and mild severity of CWS resemble the experience of patients going through caffeine withdrawal.

Because the federal government—specifically, agencies like NIDA itself—has made it so difficult to conduct cannabis research, the NIDA scientists used studies of non-human animals to describe the typical symptoms. So we know what CWS in rats looks like: “symptoms include scratching, face rubbing, licking, wet-dog shakes, arched back and ptosis.” Ptosis is the medical term for droopy eyelids.

If you’re stopping cannabis use after regular intake, face licking and wet-dog shakes are not likely to figure among the symptoms you will experience. The severity of CWS among humans “is dependent on the amount of cannabis used pre-cessation, gender, and heritable and several environmental factors,” the German researchers noted. Women, they wrote, tended to report stronger symptoms of CWS, and their experience included more physical discomfort, nausea, and stomach pain.

These mood and behavioral symptoms are usually “of light to moderate intensity,” the researchers wrote.

Symptoms typically start within the first two days of cessation, and stop within four weeks of abstinence.

The symptoms and mild severity of CWS resemble the experience of patients going through caffeine withdrawal, a condition described in the DSM-5 as including headache, fatigue, drowsiness, dysphoric mood, irritability, depression, nausea, muscle aches and impairment of cognitive or behavioral performance.

What Causes CWS?

Prolonged exposure to cannabinoids causes complex adaptations in the brain’s neuronal circuits and their components. Some researchers believe that regular cannabis intake can desensitize and downregulate human brain cannabinoid (CB1) receptors.

It’s a physiological process. The brain is adapting to the absence of cannabinoids.

“If you administer a lot of THC, and you do it at a heavy rate over a pretty intense period of time, you’re going to change the functioning of the brain,” says Roffman. The German study published in Substance Abuse Rehabilitation, Roffman said, confirms what a number of previous researchers have found. “After a couple days of cessation, cannabis withdrawal syndrome starts. It will likely be largely over within two weeks to a month.”

The time span and severity of symptoms will differ from person to person, Roffman adds.

“Ultimately, it’s not a psychological process,” he says. “It’s a physiological change in the brain as the body becomes adapted to marijuana no longer being there.”

What Works? What Doesn’t?depression meds

Certain antidepressants may be given to lessen the symptoms of CWS. Mirtazapine (an antidepressant also known as Remeron) can be prescribed to counteract the insomnia that’s sometimes associated with CWS. But other antidepressants, including Venlafaxine (the antidepressant known as Effexor) were found to worsen the CWS, the researchers wrote.

One thing that might work: an alternate form of cannabinoids. In a study published last year in the journal Drug and Alcohol Dependency, Canadian researchers tested the use of Sativex, GW Pharma’s 1:1 THC:CBD pharmaceutical, on patients experiencing symptoms of CWS.

Not surprisingly, “high fixed doses of Sativex were well tolerated and significantly reduced cannabis withdrawal during abstinence,” the researchers found.

Sativex is, after all, composed of the same cannabinoids the patient has ceased to ingest. So is it really withdrawal, or a continuation of the same psychotropic substance in a different form?

Here’s where it gets interesting. In theory, longtime regular cannabis consumers who wish to cease consumption could lessen their CWS symptoms by substituting Sativex for cannabis—and then gradually tapering their daily dosage of Sativex over the course of two to four weeks.

It’s the Form, Not the Function

Of course, the same sort of tapering could be done with the cannabis itself. But there are also psychological factors at play. It may be easier to taper off when the cannabinoid delivery vehicle (Sativex is usually taken as an oral spray) differs from the cannabis routine to which a patient has grown accustomed. Just as it’s easier to quit tobacco by using a transdermal patch, rather than tapering off cigarettes, it may be easier to ease out of a cannabis routine by using a different form of intake.

‘The research evidence supports the idea that most people are able to stop on their own.’

Roger Roffman, University of Washington

By altering the form of cannabinoid intake, “you’re changing the routine of the individual,” says Roffman. “If the person smokes a lot, now you’re giving them something [like Sativex] orally.” Sativex is designed to have fewer psychoactive properties, so the patient may experience it as a gradual step-down from regular cannabis consumption.

Most people, though, probably don’t need the aid of Sativex. “The research evidence supports the idea that most people are able to stop on their own,” says Roffman. “Clearly, there’s some part of the population for whom withdrawal is unpleasant.” He recommends working with a physician who can help the patient through the process, which could include a short-term prescription for a sleeping aid or mood stabilizer.

Going into the adjustment period with a game plan can also be a big help, Roffman says. “We worked with a number of behavioral approaches” in his research, including anticipating difficulties with mood and sleeping, and planning activities—everything from exercise to a warm glass of milk—that can alleviate the difficulties.

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