Synthetic cannabinoid 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 synthetic cannabinoids in individuals who have developed dependence on synthetic cannabinoids or have used synthetic cannabinoids for a prolonged period or in large amounts. Note: Synthetic Cannabinoid 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.
• Presenting features of Synthetic Cannabinoid Withdrawal may include irritability, anger, aggression, shakiness, insomnia and disturbing dreams, restlessness, anxiety, depressed or dysphoric mood and appetite disturbance. In the early phase, Synthetic Cannabinoid Withdrawal may be accompanied by residual features of intoxication from the drug, such as paranoid ideation and auditory and visual hallucinations.
• The occurrence, severity and duration of Synthetic Cannabinoid Withdrawal vary according to the type and potency of the synthetic cannabinoid used, 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:

• Synthetic Cannabinoid Withdrawal typically lasts for 1 to 3 weeks after cessation of use.
• Characteristic features of Synthetic Cannabinoid Withdrawal are opposite to the acute pharmacological effects of synthetic cannabinoids.
• Synthetic Cannabinoid 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):

• Synthetic Cannabinoid Withdrawal should only be diagnosed when symptoms are consistent with those recognized as occurring upon cessation or reduction in use of synthetic cannabinoids. Recent cessation or reduction of use and the presence of various non-specific transient symptoms is not sufficient to make the diagnosis of Synthetic Cannabinoid Withdrawal.
• Withdrawal symptoms should be differentiated from the transient physiological aftereffects of intoxication (‘hangover effect’).
• Some individuals who have previously had Synthetic Cannabinoid Dependence may experience symptoms similar to those of Synthetic Cannabinoid 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 synthetic cannabinoid use. These symptoms are more transient than those observed during Synthetic Cannabinoid Withdrawal and occur exclusively when in contact with associated stimuli and contexts. A diagnosis of Synthetic Cannabinoid Withdrawal should not be assigned under these circumstances.

Course Features:

• Synthetic Cannabinoid Withdrawal is time-limited. Factors that influence the features and time course of Synthetic Cannabinoid Withdrawal include: (1) the severity of Synthetic Cannabinoid Dependence, if present, (2) the dose, frequency of use, and duration of synthetic cannabinoid use prior to cessation or reduction of that use, (3) the half-life and duration of action of synthetic cannabinoids, 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 synthetic cannabinoids. 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 Synthetic Cannabinoid Dependence: Many individuals with Synthetic Cannabinoid Dependence develop Synthetic Cannabinoid Withdrawal upon cessation or reduction in the amount of the substance. In such cases, both Synthetic Cannabinoid Dependence and Synthetic Cannabinoid Withdrawal should be diagnosed. However, Synthetic Cannabinoid Withdrawal can be diagnosed in the absence of a diagnosis of Synthetic Cannabinoid 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 Synthetic Cannabinoid Intoxication: The onset of Synthetic Cannabinoid Intoxication occurs immediately or shortly after the consumption of synthetic cannabinoids. In contrast, Synthetic Cannabinoid Withdrawal occurs upon cessation or reduction in the amount of synthetic cannabinoids in the context of Synthetic Cannabinoid Dependence or when synthetic cannabinoids have been taken for a prolonged period or in large amounts. For synthetic cannabinoids, the intoxication and withdrawal syndromes are typically distinct.
• Boundary with other Synthetic Cannabinoid-Induced Mental Disorders: Mental or behavioural symptoms that arise during Synthetic Cannabinoid Withdrawal should only be used as a basis for diagnosing a Synthetic Cannabinoid-Induced Mental Disorder if the intensity or duration of the symptoms is substantially in excess of those that are characteristic of the Synthetic Cannabinoid Withdrawal and the symptoms are sufficiently severe to warrant specific clinical attention. In such cases, if the withdrawal syndrome is ongoing, diagnoses of both Synthetic Cannabinoid Withdrawal and a Synthetic Cannabinoid-Induced Mental Disorder may be assigned.
• Boundary with other mental disorders: Various symptoms associated with Synthetic Cannabinoid Withdrawal overlap with those that are characteristic of other mental disorders (e.g., depressive and anxiety symptoms). Symptoms of Synthetic Cannabinoid Withdrawal occur in specific temporal relationship to the cessation of use of synthetic cannabinoids and diminish with the passage of time. Evidence supporting a mental disorder diagnosis would include the symptoms preceding the onset of synthetic cannabinoid use, the symptoms persisting for a substantial period of time after cessation of synthetic cannabinoids 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 synthetic cannabinoid use).
• Boundary with other medical conditions: It may be difficult to distinguish between various symptoms associated with Synthetic Cannabinoid Withdrawal (e.g., shakiness, insomnia, restlessness, decreased appetite and weight loss, headache, sweating or chills, abdominal cramps and muscle aches) and those that are characteristic of other medical conditions. Symptoms of Synthetic Cannabinoid Withdrawal occur in specific temporal relationship to the cessation of use of synthetic cannabinoids and diminish with the passage of time.