Introduction

The term “withdrawal” is also known as detoxification, it is often applied to usage of drugs or alcohols, where you start to develop dependence on a certain product, this dependence can be physically or psychologically, and when there is a decrease in frequency or a sudden stop is put to the usage of this product, a withdrawal response is likely to occur due to the sudden decline in blood concentration of the substance, driving the motivation to take more.¹ It is both the result of drug addiction and a driver of its continuation, which can be dangerous if handled inappropriately, in some cases, lethal.

Symptoms of withdrawal can vary from drug to drug and from person to person, with differing severity. A classic example of a mild withdrawal response is caffeine headache, which many who favour a coffee in the morning to get going can relate to, whilst there are others that can be more life-threatening, for example, severe symptoms of alcohol withdrawal can include seizures and delirium tremens (DTs).² Statistically, about 33% of patients experiencing alcohol addiction required treatment in hospital intensive care units(ICUs), emergency departments(EDs), as well as critical care units(CCUs).³ This article is about dependence and withdrawal response resulting from the use of cannabis, which is also a drug for which withdrawal can be common. Cannabis is classified as schedule I drug by the FDA (Food and Drug Administration), which means it has a high potential of being abused, although there has been ongoing clinical investigations to explore its medical use, for example as a potential cancer treatment, it is still not officially approved for any medical purpose by the FDA.⁴ According to studies of a population over 23,000, 47% of people with regular cannabis use have experienced withdrawal effects.⁵

Cannabis withdrawal 

Cannabis is a plant of the Cannabaceae family with multiple biologically active compounds, with the 2 most potent compounds being δ9‐tetrahydrocannabinol (THC) (delta-9-tetrahydrocannabinol) and cannabinoid (CBD), In terms of addiction, THC is the one responsible for the psychoactive properties of cannabis by binding to cannabinoid receptors CB1 and CB2. It is typically smoked and inhaled, or orally ingestion, via tea, candies, or other edible means. This administration route tends to delay the peak blood concentration in comparison to inhalation. Regular or heavy use of cannabis can lead to the development of tolerance and dependence, which can cause problems when people attempt to quit. Cannabis withdrawal refers to symptoms following the reduction of cannabis product usage, in particular, δ9‐tetrahydrocannabinol (THC) containing products, which contain THC is the psychoactive ingredient in cannabis. On the other hand, cannabinoid (CBD), another major component of cannabis, has not been reported to have any withdrawal effects. In addition, synthetic cannabinoids, which are a heterogeneous group containing multiple synthetic compounds, making SCBs 2-100 times more potent than THC, are likely to develop tolerance faster than THC-containing products with potentially more severe withdrawal symptoms.⁶ The common symptoms for natural cannabis-based products reported include: anxiety, insomnia, decreased appetite, and other physical symptoms such as nausea, stomach ache, perspiration(sweating) and tremors. ⁷

Cannabis withdrawal timeline

The duration and severity of cannabis withdrawal response are related to the amount of cannabis consumed regularly before cessation occurs and vary between individuals. The symptoms typically start showing within 24-48 hours after cessation, and peak at approximately 2-6 days.

First 1-3 days: Adverse effects are observed, and gradually become stronger. Excessive sweating is common during this stage. Stomach pain is likely to occur, which may be accompanied by vomiting. This is when the urge to retake cannabis reaches climax, and relapse is most likely to occur at this stage.⁸

First week - 10 days: When withdrawal symptoms reach peak. During this stage, the physical symptoms will start to wear off, however, the psychological side effects can intensify for many people. As your body adjusts itself to function without cannabis, the development of fatigue and depression is not uncommon during this period.⁸ 

Over 10 days: Withdrawal symptoms start to disappear, and most people will be feeling stable and balanced again. In most cases, the withdrawal effects only last for 3 weeks, and the drug will be excreted by your body completely by 30 days. It is notable that psychological effects are likely to last longer than physical symptoms, which can persist for several weeks or months.⁸ 

Comparing cannabis withdrawal to other substances

Despite the fact that long-term usage of cannabis can have negative effects on lungs, respiratory functions and brain development, and cessation after regular consumption can lead to painful withdrawal effects, cannabis withdrawal is still reported to be less severe than most other addictive substances.

Alcohol

Like cannabis, alcohol also possesses addictive properties; the more you drink, the more likely you will be affected by withdrawal effects. Alcohol is a CNS (central nervous system) depressant that can lead to a range of manifestations including sedation, euphoria and disinhibition in acute intoxication.⁹ Alcohol withdrawal symptoms can be included in a medical condition called Alcohol Withdrawal Syndrome. Although cannabis withdrawal can bring a sense of dysphoria as well as other physical symptoms, and some of the symptoms overlap with alcohol withdrawal effects, in general, it is considered less severe than alcohol withdrawal; some would even recommend substituting cannabis for alcohol to reduce drinking among alcohol dependent populations.¹⁰ Alcohol withdrawal symptoms can range from mild to severe and may progress quickly and result in fatality; for example, seizures and psychosis can be triggered in extreme cases. 

Alcohol withdrawal symptoms can be physical or psychological:

• Perspiration
• Rapid pulse rate
• Nausea
• Vomiting
• Insomnia
• Depression

Severe symptoms can additionally include: hallucinations, seizures or delirium tremens (DTs).¹¹

Tobacco & nicotine

Nicotine is a stimulant found in both tobacco products and many vaping products, like cannabis and alcohol. It is the reason why people get addicted to cigarettes, as nicotine can be absorbed quickly into the blood and delivered to the brain, “hijacking” the brain’s reward circuit by increasing the dopamine level. The immediate effects of nicotine remain short, which draws smokers to continue taking tobacco products, thus forming a cycle. Similar to cannabis, nicotine can damage brain development, making it dangerous to adolescents.¹² In terms of withdrawal symptoms, a study was done by Budney et al. to compare withdrawal severity between 67 daily cannabis users and 54 daily tobacco smokers, the outcome was measured by the Withdrawal Discomfort Score (WDS), where the scores of 9 items that are reported as the common symptoms of withdrawal for both cannabis and tobacco are summed:

• Aggression
• Anger
• Appetite change (increase for tobacco; decrease for cannabis)
• Depression
• Irritability
• Anxiety
• Restlessness
• Insomnia
• Strange dreams

Their regression analysis revealed that, other than the expected increased appetite for tobacco and decreased appetite for cannabis, none of the other common symptoms showed any significant difference. In addition, scores for sweating and craving during the quit attempt were also measured, which both occurred to be significantly lower in the cannabis group; whereas their supplementary prevalence analysis of each individual symptom reported by each group shows the only significant differences to be a greater prevalence of irritability in the cannabis group (96% VS 81%) and a greater prevalence of craving in tobacco group (85% VS 96%). In general, these findings suggest similar severity profiles of cannabis and tobacco during the cessation period in a real-world setting.¹³

Managing and treating withdrawal

Uncomfortable withdrawal symptoms can be great obstacles to people who have developed dependence and tolerance attempting to quit drugs, therefore, withdrawal symptoms can be important. For alcohol, there is a range of withdrawal management, including medications and non-medical supports, as well as home-based management for mild symptoms. One example of a commonly used medication is Benzodiazepine, a first-line treatment for the prevention of several alcohol withdrawal responses, such as seizures and Delirium Tremens (DTs). This should only be prescribed if the CIWA (Clinical Institute Withdrawal Assessment) score of the patient is above 10.¹⁴

There are fewer choices of withdrawal management for cannabis-based products; the commonly used treatments are either cognitive behavioural therapy or medications, however, the quality of evidence demonstrating their efficacy remains low.¹⁵ One example of medications is dantrolene,  a synthetic THC (delta-9-tetrahydrocannabinol) showing reduction in cannabis withdrawal symptoms in laboratories, but the utilisation remains undetermined, should it be used similarly to nicotine gum, in a temporary manner, or as a maintenance agent to prevent relapse?¹⁶ There are also medications targeting specific conditions, such as gabapentin for anxiety and zolpidem for sleep disturbance, for which both are accompanied by a list of side effects. Due to the limited choices of evidence-based approaches, supportive counselling and psychoeducation are considered the first-line treatments; currently, no medications have been approved for cannabis withdrawal.⁶ 

Conclusion

In general, cannabis withdrawal symptoms tend to be less severe among those addicted to substances such as alcohol, opioids or benzodiazepines, with less need for withdrawal management. Unlike the harder drugs, risk of death associated cannabis is almost negligible, but this does not suggest it is a harmless substance and the withdrawal symptoms when you try to quit on it can still have a great impact on life quality as severity varies between people and is dependent on various factors including duration of usage, quantity of drugs, administration route, tolerance of individuals to cannabis and vice versa, thus do not hesitate to go to healthcare provider if you consider there is a need for supervision to have a safe withdrawal, especially if you show signs of severe symptoms or have any coexisting mental health conditions.