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Cannabis Withdrawal Syndrome (CWS)

‘Cannabis withdrawal syndrome’ (CWS) is the proper medical term used to describe marijuana withdrawal. Before the 1990s, many doubted that cessation of marijuana could lead to similar symptoms of withdrawal seen with other drugs. However, as marijuana use began to rise over the next two decades, more patients began to seek treatment for marijuana-related disorders, including cognitive deficits, psychosis, and dependence.

As time went on, scientists and doctors observed that discontinuation of regular marijuana use was frequently associated with behavioral, emotional, and physical symptoms that, in some people, disrupted daily living, and were associated with relapse. Based on support from neurobiological, clinical, and epidemiological studies, cannabis withdrawal syndrome was added to the Diagnostic and Statistical Manual of Mental disorders (DSM-5) in 2013.

Diagnostic Criteria for Cannabis Withdrawal Syndrome

DSM-5, 2013

Three or more of the following signs and symptoms which develop within approximately one week of cessation of heavy, prolonged cannabis use (daily or almost daily use over a period of at least a few months):

  • Irritability; anger or aggression
  • Nervousness or anxiety
  • Sleep difficulty
  • Decreased appetite or weight loss
  • Restlessness
  • Depressed mood
  • Physical symptoms causing significant discomfort (at least one)
    • Headaches
    • Night Sweats
    • Abdominal Pain
    • Tremors
    • Dizziness
    • Fatigue
  • Symptoms cause significant distress or impairment in social, occupational, or other important areas of functioning.
  • Symptoms cannot be due to another medical disorder like major depression or inflammatory bowel disease. Similarly, detoxifying from another substance, like alcohol, prevents you from having this diagnosis.

If this sounds like something you’ve experienced, or something you’re going through right now, don’t panic. Population studies are pointing to marijuana withdrawal as being more common than previously thought, and huge progress has been made from just a few decades ago, when people didn’t even think marijuana could cause withdrawal.

How Commons is Cannabis Withdrawal Syndrome?

The exact prevalence of cannabis withdrawal syndrome still remains poorly defined. Even so, existing epidemiologic studies, including national and community based surveys, suggest that the prevalence of cannabis users meeting criteria for CWS ranges anywhere from 12.1% to 47% (Nocon, J Psychiatr Res, 2006; Livne, Drug Alcohol Depend, 2019; Bahji, JAMA Netw Open, 2020).

Lower rates are mostly representative of people who use marijuana more than three times a week or less, or who did not seek treatment for their symptoms. In contrast, treatment-seeking users have a much higher prevalence of withdrawal, as is expected from greater intensity of marijuana use causing more withdrawal severity. Rates of CWS in people who are daily or near daily users, and who are enrolled in outpatient or inpatient treatment, can approach 77.6-95.5% (Stephens, Addiction, 2002; Copeland, J Subst Abuse Treat, 2001).

The takeaway from all of this is simply to say that CWS is common, and the vast majority of people who have withdrawal will recover without the need for formal medical treatment. Remember, knowledge is power, and the ability to put a diagnosis to what you may be experiencing, or have experienced in the past, can be validation in and of itself.

Risk Factors

There is no guaranteed method for predicting who will have cannabis withdrawal syndrome after quitting marijuana, just as there is no way to predict how long it will last. There are, however, some predisposing factors, which may place you at risk for CWS.

Frequency of Use

By far, the dominant risk factor for CWS is how much and when you last smoked. In short, you are at higher risk for marijuana withdrawal if you are a heavy marijuana user. This means being a daily smoker, or if you have used more than 3 times a week for a year or more. As we previously illustrated, multiple studies have demonstrated a positive association between intensity of cannabis use and rates of withdrawal (Stephens, Addiction, 2002; Copeland, J Subst Abuse Treat, 2001). If you are a heavy user, use other substances like alcohol, tobacco, or cocaine, or have a co-morbid psychiatric diagnosis, you may consider consulting with your doctor or other healthcare provider so that you can be monitored for symptoms of severe withdrawal.

Genetic Factors, Race, and Gender

In some individuals, inherited susceptibility may play a huge part in how likely they are to have marijuana withdrawal. Studies of twins with cannabis use disorder have shown that, when it comes to withdrawal, at least half of the variability between individuals can be attributed to genes (Verweig, Psychol Med, 2013). Other studies have found that African Americans and Asian/Pacific Islanders may be at elevated risk of CWS.

Gender may also be a significant factor in risk of CWS and women may experience more severe symptoms of marijuana withdrawal. In a 2015 study, women reported higher withdrawal discomfort than men for symptoms including irritability, restlessness, increased anger, violent outbursts, as well as for gastrointestinal symptoms including nausea and stomach pain (Hermann, Exp Clin Psychopharmacol, 2015).

Comorbid Psychiatric Illness

If you have a personal or family history of psychiatric illness, including anxiety, depression, or other substance use, you are likely at an increased risk for CWS. National surveys have found that people who have had a history of a mood or anxiety disorder within the past year are nearly two times as likely to have CWS compared to healthy counterparts (Livne, Drug Alcohol Depend, 2019). If you are suffering from a psychiatric disorder, it may be best to consult your healthcare provider if you plan to curtail your marijuana habit.

Treatment Options

Most people with cannabis withdrawal syndrome do not need any formal medical treatment. Physical exercise, mindfulness techniques (like meditation, yoga, or prayer), and other lifestyle modifications can reduce the burden of mild withdrawal symptoms.

In some people, however, withdrawal symptoms might be bothersome enough that they require medical help to help them stay abstinent. Examples include falling asleep during the day because you aren’t getting any sleep at night, severe anxiety, or bad GI upset. In these situations, people are often tempted to resume using marijuana in order to make the withdrawal symptoms go away.

If you are worried that this may happen to you, just know that there are pharmacologic strategies which may help reduce withdrawal symptoms, including medications for sleep and cravings. Some of these drugs, like dronabinol or nabiximol, are similar to THC, the active ingredient in marijuana—if you choose to take these medications, you will still test positive for cannabinoids in drug tests. Importantly, there are no medications that are FDA-approved for treatment of marijuana withdrawal. If you require medication for severe withdrawal, make sure to consult with your doctor to determine which drug, if any, is best suited for you.

Reduces Withdrawal Intensity
Levin, Drug Alcohol Depend, 2011
Reduces Withdrawal Intensity
Allsop, JAMA Psychiatry, 2014
Reduces Withdrawal Intensity
Mason, Neuropsychopharmacology, 2012
Improves Sleep Duration / Sleep Quality
Vandrey, Drug Alcohol Depend, 2011
Improves Sleep Duration / Sleep Quality
Allsop, J Clin Sleep Med, 2015

Marijuana Withdrawal Symptoms

The symptoms of marijuana withdrawal can vary significantly from person to person, and are influenced by how much you use, how often you use, and a host of other personal factors. Even so, knowing what to anticipate may help further reduce any added stress that may accompany the dread of withdrawal. Importantly, it should also raise alarm bells if some symptoms lasting longer than expected, or if they are not showing signs of improvement.