Wednesday, December 2, 2009
Marijuana Withdrawal: A Survey of Symptoms (Part 2)
By Dirk Hanson
[Originally published in The Praeger International Collection on Addictions. Ed. by Angela Browne-Miller. Westport, Connecticut: Praeger, 2009. Vol. 2 Ch. 7 pp.111-124.]
All of the following comments can be found at the Addiction Inbox post on Marijuana Withdrawal. The unnumbered messages on the Web site are dated, and appear in chronological order.
Cave. (2008, February 8):
“Well I just stopped smoking pot after 4 years of everyday use, 5 days ago. I am feeling the withdrawal symptoms ridiculously hard. No appetite, slight nausea, extreme insomnia.”
Anonymous. (2008, February 26):
“My boyfriend (of 6 years) has been a smoker for approximately 16 years. He has tried to give up a few times seriously before but has never quite gotten there yet. His behavior is almost unbearable when he does. It really takes a toll on our relationship. I never realized that it could be so bad and that his actions are so exaggerated by withdrawal.”
Anonymous. (2008, February 26):
“I’m a 30-year-old man and have been a heavy cannabis user (3 to 4 joints per day, every day) since I was 19. . . . I’ve been through intense anxiety, depression, restlessness, lack of appetite. I can’t sleep for more than a few hours at a time and when I do, I sweat buckets. I have a terrible appetite, I’m cold all the time, like I can’t regulate my temperature.”
Anonymous. (2008, February 27):
“I thought I was going crazy because all other sites told me that there were no withdrawal symptoms from pot, I can’t think or eat and when I do finally get something down my gullet I get the runs straight after. . . . I feel like I have been hit by a truck and it has only been a week since I gave up.”
Anonymous. (2008, March 1):
“I am 31 and a heavy smoker of 10 years. . . . What is really troubling me, however, is the excessive dreaming. . . . The dreams are vivid and strong, enough to wake me up sometimes.”
Anonymous. (2008, March 3):
“This idea of ‘intense dreaming’ is very real and for the first 5 or 6 days after quitting I experienced life-like dreams/nightmares (99% nightmares), which would wake me from my sleep. . . . This idea of breaking out in cold sweat is also very real and quite scary when [it] occurs as [it] got me worried there was something else wrong with me.”
Scott. (2008, March 3):
“I was blown away when I saw ‘excessive sweating’ as I have been experiencing that for a few days. . . . If I could cut back drastically, that would be the ideal situation. But I know from experience that I can’t just smoke pot ‘a little bit.’ If I’m going to reduce, it’s going to have to be all the way to zero.”
Anonymous. (2008, March 7):
“I’m on day seven of abstinence and boy, do I feel lousy. Night sweats, anxiety, extreme insomnia, and loads of irritability/anger problems. . . . It’s a bit like when you have a bad flu. You plain feel rotten. Anything stress-related is magnified ten-fold.”
Bob. (2008, March 7):
“I’m 38 years old and have been using weed now daily for almost 21 years. . . . I’ve been ‘clean’ now for 4 days and so far it has obviously been difficult, but already I’m showing signs of improvement, the first two days I had no sleep at all. . . . My withdrawal symptoms: Loss of appetite, sweating, irritability, sudden crying fits.”
Anonymous. (2008, March 8):
“I am a 25-year-old female and I have been smoking pot since I was 13. I have NEVER stopped even a day that I can remember. Not unless I couldn’t get it. I have recently started to realize that it is a drug addiction. I was always on the ‘it’s not addictive’ side. I get very anxious if I think I’m not going to have any. . . . It is out of my control I think, and now I’m starting to not feel high. I REALLY wanna stop, but am so scared of the symptoms. I think I need help.”
Anonymous. (2008, March 18):
“Having read all of these comments and questions I no longer feel so abnormal. I have been experiencing most of these symptoms including vivid dreaming. . . . I have been a smoker since I was 15, every day smoking about 2–3 joints.”
Anonymous. (2008, March 24):
“I am a 25-year-old female. I started smoking at 18. . . . I quit a few weeks ago. . . . I can’t focus on anything. I can’t make myself do anything. . . . I snap at everyone, including my boyfriend who has been complaining about my excessive sweating. I didn’t even think of the sweating as a symptom until I read the other posts here.”
Anonymous. (2008, April 2):
“I just wanted to say I’m glad I found this site because as many people have noted the common wisdom is that there are few, if any, symptoms of withdrawal. . . . I’ve noticed the irritability and mood swings, which I expected, but didn’t make the connection between the vivid and frequent dreams and waking at night until I read all the other comments.”
Anonymous. (2008, April 8):
“I finally feel sane again after reading these postings. I am a 48-year-old male who has been smoking weed since 1975. Anywhere from 2–6 joints per day of good quality pot for the last four years. Decided to quit about a week ago and my life has been a living hell since. . . . Haven’t eaten a full meal in a week, very tired and depressed, stomach in knots.”
Anonymous. (2008, April 25):
“I quit weed 46 days ago. . . . pretty similar symptoms as everyone else and the most severe anxiety and depression I have ever known. . . . I can’t concentrate or focus, I can’t seem to forget about what has happened even though I want to, it feels as though my brain keeps reminding me about the ‘situation’ or some general anxious or negative thought just pops into my consciousness . . . like it’s never going to end, like my thoughts are caught in a vicious circle.”
Richard. (2008, May 3):
“It’s not suicidal ideation but it’s the feeling that life will just never ‘be right’. . . . when you suffer from symptoms that you’ve been told don’t exist, you are left looking for the wrong cause. So, if you’re told that marijuana withdrawal does not increase anxiety, anger, or ‘hopelessness,’ you want to look for a cause of those things. . . . I went through withdrawal periods where I was inappropriately angry at the wrong thing, thinking that specific PEOPLE were upsetting me when they were not.”
The U.S. government’s essentially unchanged opposition to marijuana research has meant that, until quite recently, precious few dollars were available for research. This official recalcitrance is one of the reasons for the belated recognition and characterization of marijuana’s distinct withdrawal syndrome. According to research undertaken as part of the Collaborative Study of the Genetics of Alcoholism, 16 percent of people with a lifetime history of regular marijuana use reported a history of cannabis withdrawal symptoms (Schuckit et al., 1999, p.41). In earlier research, Mason discovered that those seeking treatment for cannabis addiction tended to cluster in two age groups—college age and mid-50s (Somers, 2008).
Budney et al. (2004, p. 1973) write:
Regarding cross-study reliability, the most consistently reported symptoms are anxiety, decreased appetite/weight loss, irritability, restlessness, sleep problems, and strange dreams. These symptoms were associated with abstinence in at least 70% of the studies in which they were measured. Other clinically important symptoms such as anger/aggression, physical discomfort (usually stomach related), depressed mood, increased craving for marijuana, and increased sweating and shakiness occurred less consistently.
Today, scientists have a much better picture of the tasks performed by anandamide, the body’s own form of THC. Among the endogenous tasks performed by anandamide are pain control, memory blocking, appetite enhancement, the suckling reflex, lowering of blood pressure during shock, and the regulation of certain immune responses. This knowledge helps shed light on the wide range of THC withdrawal symptoms, particularly anxiety, chills, sweats, flu-like physical symptoms, and decreased appetite.
Furthermore, we can look to indications for which marijuana is already being prescribed—anxiety relief, appetite enhancement (compounds similar to anandamide have been discovered in dark chocolate), suppression of nausea, relief from the symptoms of glaucoma, and amelioration of certain kinds of pain—for more insight into the common hallmarks of cannabis withdrawal.
What treatment measures can help ameliorate marijuana withdrawal and craving in heavy users who wish to quit? The immediate threat to any decision in favor of abstinence is what might fairly be called the “hair of the dog” effect. Note the findings of a 2004 paper in Neuropsychopharmacology: “Oral THC administered during marijuana abstinence decreased ratings of ‘anxious,’ ‘miserable,’ ‘trouble sleeping,’ ‘chills,’ and marijuana craving, and reversed large decreases in food intake as compared to placebo, while producing no intoxication” (Haney et al., p. 158).
Moreover, “Overall withdrawal severity associated with cannabis alone and tobacco alone was of a similar magnitude. . . . cannabis withdrawal is clinically important and warrants detailed description in the DSM–V and ICD–11” (Vandrey, Budney, Hughes, & Liguori, 2008, p. 48). It is possible that many more people are trying—and failing—to quit marijuana than researchers have previously suspected. Daily use of marijuana may be driven in part by the desire to avoid or eliminate abstinence symptoms (Haney, Ward, Comer, Foltin, & Fischman, 1999, p. 395).
To date, there is no effective anticraving medication approved for use against marijuana withdrawal syndrome. More than a decade ago, Ingrid Wickelgren wrote in Science: “For instance, chemicals that block the effects of CRF or even relaxation exercises might ameliorate the miserable moods experienced by people in THC withdrawal. In addition, opiate antagonists like naloxone may, by dampening dopamine release, block the reinforcing properties of marijuana in people” (1997, p. 1967). Since stimulation of THC receptors has homologous effects on the endogenous opioid system, various investigators have speculated that naltrexone, the drug used as an adjunct of heroin withdrawal therapy, may find use against symptoms of marijuana withdrawal in people prone to marijuana dependence (Tanda et al., 1997, p. 2049). Further research is needed on the reciprocal relationship between THC and opioid receptor systems.
Serzone (nefazodone), an antidepressant, has been used to decrease some symptoms of marijuana withdrawal in human subjects who regularly smoked six joints per day (Haney et al., 2003, p. 157). Anxiety and muscular discomfort were reduced, but Serzone had no effect on other symptoms, such as irritability and sleep problems.
Preliminary studies have found that lithium, used to treat bipolar disorder, curbed marijuana withdrawal symptoms in an animal study (Cui, Gu, Hannesson, Yu, & Zhang, 2001, p. 9867). Another drug for mania and epilepsy—Depakote—did not aid significantly in marijuana withdrawal (Haney et al., 2004, p.158).
Since difficulty sleeping is one common symptom of withdrawal, common prescription medications might be indicated for short-term use in the case of severe marijuana withdrawal. Some researchers have reported that even brief interventions, in the form of support group sessions, can be useful for dependent pot smokers (Copeland, Swift, & Rees, 2001, p. 45).
It is also plausible to suggest that the use of marijuana by abstinent substance abusers may heighten the risk of relapse. In a study of 250 patients at a psychiatric/substance abuse hospital in New York, “Postdischarge cannabis use substantially and significantly increased the hazard of first use of any substance and strongly reduced the likelihood of stable remission from use of any substance” (Aharonovich et al., 2005, p. 1507). However, the researchers found that cannabis posed a greater risk to cocaine and alcohol abusers. For heroin, “cannabis use after inpatient treatment did not significantly affect remission and relapse.”
It is surprising to note the relative paucity of previous clinical data the researchers had to work with in the case of alcohol and marijuana. “The gap in the literature concerning the relationship of cannabis use to the outcome of alcohol dependence was surprising,” according to Aharonovich and colleagues. “We were unable to find a single study that examined the effects of cannabis use on post-treatment outcome for alcohol dependence, despite the fact that the majority of patients now in treatment for alcoholism dependence also abuse other drugs. Clearly additional studies of this issue are warranted” (2005, p. 1512).
Addiction researcher Barbara Mason of the Scripps Research Institute of La Jolla, California, is overseeing a four-year study of the neurobiology of marijuana dependence under a grant from NIDA. The comprehensive project will involve both animal and human research, and will make use of state-of-the-art functional brain imaging. The federal grant will also be used as seed money for the new Translational Center on the Clinical Neurobiology of Cannabis Addiction at the Scripps Institute (“Scripps Given,” 2008).
Above all, it is time to move beyond the common mistake of assuming that if marijuana causes withdrawal in some people, then it must cause withdrawal in everybody. And if it doesn’t, it cannot be very addictive. This thinking has been overtaken by the growing understanding that a minority of people suffer a chemical propensity for marijuana addiction that puts them at high risk, compared to casual, recreational drug users. The fact that most people do not become addicted to pot and do not suffer from withdrawal is no more revealing than the fact that a majority of drinkers do not become alcoholics.
The idea of marijuana addiction and withdrawal remains controversial in both private and professional circles. For an unlucky few, a well-identified set of symptoms characterizes abstinence from heavy, daily use of pot. In this, marijuana addiction and withdrawal does not differ greatly from alcoholism—the vast majority of recreational users and drinkers will never experience it.
For those that do, however, the withdrawal symptoms of marijuana abstinence can severely impact their quality of life.
Note: Sources and references can be found at the end of Part 1 below.