Cannabis withdrawal

Essential (Required) Features:

• The presence of a clinically significant cluster of symptoms, behaviours, and/or physiological features that occurs upon cessation or reduction in the use of cannabis in individuals who have developed dependence on cannabis or have used cannabis for a prolonged period or in large amounts. Note: Cannabis Withdrawal can occur when medicinal cannabinoids that contain δ-9- tetrahydrocannabinol (THC) or cannabinol—for example those used as antispasmodics, anxiolytics, or analgesics—have been used in therapeutic doses. There does not appear to be a clinically significant withdrawal syndrome associated with cannabidiol (CBD).
• Presenting features of Cannabis Withdrawal may include irritability, anger or aggressive behaviour, shakiness, insomnia, restlessness, anxiety, depressed or dysphoric mood, decreased appetite and weight loss, headache, sweating or chills, abdominal cramps and muscle aches.
• The occurrence, severity and duration of Cannabis Withdrawal vary according to the type and potency of the cannabis preparation, as well as the amount, frequency and duration of use before cessation or reduction of use.
• The symptoms are not better accounted for by another medical condition or another mental disorder.

Additional Clinical Features:

• Onset of Cannabis Withdrawal typically occurs at some point between 12 hours and 3 days after cessation or reduction of use. Symptom severity typically peaks at 4 to 7 days and may last for 1 to 3 weeks after cessation of use. However, Cannabis Withdrawal may also be briefer, in some cases lasting only a few days.
• Characteristic features of Cannabis Withdrawal are opposite to the acute pharmacological effects of cannabis.
• When Cannabis Withdrawal occurs in the context of a co-occurring mental disorder, the features of the other disorder (e.g., fluctuation of mood) may be exacerbated.
• Cannabis Withdrawal symptoms become more severe with repeated episodes of withdrawal (termed ‘kindling’), with aging, or in the presence of comorbid medical conditions.

Boundary with Normality (Threshold):

• Cannabis Withdrawal should only be diagnosed when symptoms are consistent with those recognized as occurring upon cessation or reduction in use of cannabis. Recent cessation or reduction of use and the presence of various non-specific transient symptoms is not sufficient to make the diagnosis of Cannabis Withdrawal.
• Withdrawal symptoms should be differentiated from the transient physiological aftereffects of intoxication (‘hangover effect’).
• Some individuals who have previously had Cannabis Dependence may experience symptoms similar to those of Cannabis Withdrawal months after the last use of the substance, particularly when the individual encounters stimuli (e.g., drug paraphernalia) and contexts (e.g., location where use was frequent) previously associated with past cannabis use. These symptoms are more transient than those observed during Cannabis Withdrawal and occur exclusively when in contact with associated stimuli and contexts. A diagnosis of Cannabis Withdrawal should not be assigned under these circumstances.

Course Features:

• Cannabis Withdrawal is time-limited. Factors that influence the features and time course of Cannabis Withdrawal include: (1) the severity of Cannabis Dependence, if present, (2) the dose, frequency of use, and duration of cannabis use prior to cessation or reduction of that use, (3) the half-life and duration of action of cannabis, and (4) the presence of comorbid medical conditions (e.g., metabolic disturbances).

Culture-Related Features:

• Symptoms of withdrawal depend largely on the psychotropic characteristics of cannabis. However, specific cultures may emphasize certain symptoms of withdrawal over others, making it more difficult to conduct a differential diagnosis. In addition, vernacular terms for withdrawal vary greatly.

Boundaries with Other Disorders and Conditions (Differential Diagnosis):

• Boundary with Cannabis Dependence: Many individuals with Cannabis Dependence develop Cannabis Withdrawal upon cessation or reduction in the amount of the substance. In such cases, both Cannabis Dependence and Cannabis Withdrawal should be diagnosed. However, Cannabis Withdrawal can be diagnosed in the absence of a diagnosis of Cannabis Dependence, for example in response to cessation of medicinal cannabinoids containing δ-9- tetrahydrocannabinol (THC) or cannabinol that have been used in therapeutic doses, when the other Essential Features of Substance Dependence are not present.
• Boundary with Cannabis Intoxication: The onset of Cannabis Intoxication occurs immediately or shortly after the consumption of cannabis. In contrast, Cannabis Withdrawal occurs upon cessation or reduction in the amount of cannabis in the context of Cannabis Dependence or when cannabis has been taken for a prolonged period or in large amounts. For cannabis, the intoxication and withdrawal syndromes are typically distinct.
• Boundary with other Cannabis-Induced Mental Disorders: Mental or behavioural symptoms that arise during Cannabis Withdrawal should only be used as a basis for diagnosing a Cannabis-Induced Mental Disorder if the intensity or duration of the symptoms is substantially in excess of those that are characteristic of the Cannabis Withdrawal and the symptoms are sufficiently severe to warrant specific clinical attention. In such cases, if the withdrawal syndrome is ongoing, diagnoses of both Cannabis Withdrawal and a Cannabis-Induced Mental Disorder may be assigned.
• Boundary with other mental disorders: Various symptoms associated with Cannabis Withdrawal overlap with those that are characteristic of other mental disorders (e.g., depressive and anxiety symptoms). Symptoms of Cannabis Withdrawal occur in specific temporal relationship to the cessation of use of cannabis and diminish with the passage of time. Evidence supporting a mental disorder diagnosis would include the symptoms preceding the onset of cannabis use, the symptoms persisting for a substantial period of time after cessation of cannabis or withdrawal (e.g., 1 month or more, depending on the substance), or other evidence of a pre-existing mental disorder (e.g., a history of prior episodes not associated with cannabis use).
• Boundary with other medical conditions: It may be difficult to distinguish between various symptoms associated with Cannabis Withdrawal (e.g., shakiness, insomnia, decreased appetite and weight loss, headache, sweating or chills, abdominal cramps, muscle aches) and those that are characteristic of other medical conditions. Symptoms of Cannabis Withdrawal occur in specific temporal relationship to the cessation of use of cannabis and diminish with the passage of time.