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Is your patient in marijuana withdrawal? The approach to irritability or anxiety depends on whether your patient is a light, moderate, or heavy cannabis user.

Marijuana-dependent patients often report that withdrawal symptoms hinder their attempts to quit and trigger relapse. Up to 95% of marijuana users report withdrawal symptoms during abstinence, and you can gauge a patient's withdrawal risk by knowing how much cannabis he or she has used. (1)

Light to heavy use

Using greater amounts of marijuana, meeting criteria for abuse or dependence, and a history of chronic use (>10 years) increase the risk of developing clinically significant withdrawal symptoms. (1,2)

* Light use -- smoking [less than or equal to]2 joints/day on fewer than 4 days a week -- is associated with low withdrawal risk. (1)

* Moderate use -- 2 to 3 joints almost daily -- results in significant withdrawal symptoms in 50% to 60% of marijuana users, with the higher rate associated with chronic use. (1,2)

* Heavy use -- [greater than or equal to]4 joints daily or almost daily -- usually results in significant withdrawal symptoms. (1)

Symptoms

Marijuana withdrawal is associated with neurovegetative symptoms, such as loss of appetite that can result in transient weight loss; trouble sleeping or sleep disrupted by strange dreams; and physical malaise, such as abdominal discomfort, chills, and feeling "shaky." (1) Patients may also report psychiatric symptoms such as anxiety, irritability, or depressed mood. (2)

Most studies show irritability, appetite changes, sleep disruption, and anxiety occur more frequently than craving, abdominal discomfort, and increased sex drive during marijuana abstinence. (1) One preliminary study found that women were more likely to describe abdominal discomfort and men were more likely to report marijuana craving and increased sex drive during withdrawal. (3)

Withdrawal symptoms usually begin 24 to 48 hours after patients' last marijuana use, and most resolve within 2 to 4 weeks. In some cases, anxiety and irritability can persist >4 weeks.

Recommendations

Determine if your patient's marijuana use is light, moderate, or heavy by asking about lifetime and current use. Based on these answers, the risk of withdrawal is <50% or >50%.

If irritability is prominent in a light user, consider causes other than withdrawal. In a patient with chronic anxiety symptoms and light marijuana use, consider starting medication for the anxiety. Provide psychoeducation and supportive therapy to help a patient with heavy marijuana use and acute anxiety get through the withdrawal period.

References

1. Budney AJ, Hughes JR, Moore BA, Vandrey R. Review of the validity and significance of cannabis withdrawal syndrome. Am J Psychiatry 2004;161(11):1967-77.

2. Kouri EM, Pope HG, Jr. Abstinence symptoms during withdrawal from chronic marijuana use. Exp Clin Psychopharmacol 2000;8(4):483-92.

3. Copersino ML, Boyd SJ, Tashkin DP, et al. Gender differences in the experience of spontaneous cannabis quitting. Presented at: Annual Meeting of the College on Problems of Drug Dependence; June 17-22, 2006; Scottsdale, AZ.

Dr. Goldman is an addiction fellow at the University of Pennsylvania. Dr. Markov is assistant professor of psychiatry and Dr. Kunkel is professor of psychiatry at Thomas Jefferson University. Dr. Ehrman is associate clinical professor of psychology, University of Pennsylvania.

Marina Goldman, MD, Dimitri Markov, MD, Elisabeth J.S. Kunkel, MD, and Ron Ehrman, PhD
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Title Annotation:Pearls
Author:Goldman, Marina; Markov, Dimitri; Kunkel, Elisabeth J.S.; Ehrman, Ron
Publication:Current Psychiatry
Geographic Code:1USA
Date:Jan 1, 2008
Words:513
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