Conference Coverage

Cannabis withdrawal syndrome real but underrecognized



– Marijuana withdrawal syndrome is real, and physicians and patients should recognize the phenomenon and take it seriously as legalization rolls out across the United States, an investigation from Columbia University in New York suggests,

Ofir Livne, MD, until recently a research fellow at Columbia, but now with Tel-Aviv University, in Israel M. Alexander Otto/MDedge News

Dr. Ofir Livne

“Most clinicians don’t really believe there is a withdrawal syndrome, but there definitely is. The prevalence we found was 12% among frequent cannabis users,” meaning three or more times a week, said psychiatrist and lead investigator Ofir Livne, MD, who until recently was a research fellow at Columbia but now is affiliated with Tel Aviv University in Israel (Drug Alcohol Depend. 2019 Feb 1;195:170-7).

“Usually what happens is a cannabis user will feel a bit agitated, and they’ll take another joint without even realizing they are just perpetuating the addiction.”

Dr. Livne said the syndrome is seen with other substances but is underrecognized with cannabis. “The word needs to get out more,” he said at the annual meeting of the American Psychiatric Association.

Withdrawal symptoms usually start within 48 hours but are experienced sooner with particularly heavy users. The symptoms can last for several days – or longer.

To get an idea of the extent of the problem, he and his team analyzed data from the National Epidemiologic Survey on Alcohol and Related Conditions-III. The survey collected data on more than 36,000 adults about drug use, associated effects, and other issues in 2012-13.

The investigators focused on the 1,527 people who reported frequent use in the preceding 12 months, and looked to see whether the symptoms they reported when they stopped or cut back would qualify them for cannabis withdrawal syndrome (CWS) in the DSM-5, the first edition of the manual to include the diagnosis.

Overall, 12.1% made the cut. The most common symptoms were nervousness/anxiety (76%), irritability (72%), sleep difficulty (68%), and depressed mood (59%). CWS patients also had lower health-related quality of life scores than peers without CWS.

Physical symptoms associated with CWS included headache, tremors, and sweating, among others. Overall, 70% of people reported some sort of physical discomfort associated with withdrawal.

“We also saw that frequent cannabis users who experience withdrawal are a lot more prone to other psychiatric disorders,” Dr. Livne said, including mood disorders (adjusted odds ratio, 1.9-2.6), anxiety disorders (aOR, 2.4-2.5), and personality disorders (aOR, 1.7-2.2). They more often had a family history of depression (aOR, 2.5).

“This study provides the first nationally representative large-scale report on the DSM-5 cannabis withdrawal syndrome. ... Its shared symptoms with depressive and anxiety disorders call for clinician awareness of CWS and the factors associated with it,” Dr. Livne and his colleagues concluded.

The work was adjusted for social demographics and other confounders, including tobacco withdrawal, which has overlapping symptoms.

It’s possible that in some cases, the survey simply caught a return of the anxiety and other issues that caused people to use in the first place, instead of true withdrawal, but Dr. Livne didn’t think so. “Some of them might have been prone to anxiety, but we controlled for that as much as we could,” he said.

The work was funded by the National Institute on Drug Abuse. Dr. Livne had no disclosures.

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