Cannabis Withdrawal Syndrome in Individuals With Chronic or Dependent Use of Cannabinoids: A Case Report

Case Report: Cannabinoids are the most commonly used group of illicit drugs. Cannabis use and dependence is estimated to have increased over the past 20 years. Despite common perceptions, there is a substantial amount of evidence to support the association between cannabis use and several medical, neurocognitive, functional and psychosocial conditions. Some of the short term risks of using cannabinoids include impaired short term memory, decreased motor coordination, altered judgment, paranoia and psychosis. Equally important, some of the long term effects include addiction, altered brain development, poor educational outcomes, cognitive impairment, diminished quality of life, increased risk of chronic respiratory and psychotic disorders, injuries, motor vehicle collisions and suicide. Cannabis withdrawal syndrome symptoms occur typically following a specific time course with cessation of cannabis use, are transient, and could be ameliorated by readministration of cannabis. This syndrome requires the presence of at least 3 of the following symptoms developing within 7 days of reduced cannabis use: (1) irritability, anger or aggression; (2) nervousness of anxiety; (3) sleep disturbance; (4) appetite or weight disturbance; (5) restlessness; (6) depressed mood; and (7) somatic symptoms, such as headaches, sweating, nausea, vomiting, or abdominal pain. Cannabis withdrawal syndrome appears to be very common in individuals that have a regular or dependent use of cannabinoids. The prevalence of cannabis use disorder is substantially higher in individuals who have mental health disorders. Roughly, 47% of individuals that fit within this category will experience cannabis withdrawal syndrome during the cessation of cannabis/cannabinoids. This condition is very prevalent yet underrecognized and underdiagnosed. Considering that almost half of the individuals that regularly and/or dependently use cannabis will experience cannabis withdrawal syndrome, it is vital that clinicians are appropriately screening and counseling patients on this matter. During a medication management appointment with myself and a clinical pharmacist, a patient presented with a past medical history of anxiety and depression. She had an exacerbated episode of depression and was seen inpatient. While inpatient, the patient was started on Duloxetine. She stated that the first few days that the Duloxetine was working for her. However, the side effects of the medication progressively got worse during the latter half of the first week upon discharge. She described her symptoms as excruciating abdominal pain, increased irritability and aggression and severe headaches. She stated that these symptoms were unbearable and stopped the Duloxetine. Upon asking routine appointment questions, we discovered that she was a regular and chronic user of cannabis. She stated that she had recently stopped using upon her inpatient visit because she wanted to know if the Duloxetine was working for her. Upon research, it was concluded that the patient was experiencing cannabis use withdrawal syndrome and that her medication was not ineffective or causing these side effects. To add to this, the patient reported that she started to smoke cannabis again and her symptoms began to subside. The purpose of discussing this case is to illustrate the commonality of cannabis withdrawal syndrome in individuals with regular or dependent use of cannabinoids. This case serves to educate clinicians on the identification, presentation, prevalence and clinical manifestations of cannabis withdrawal syndrome. As stated before, about half of the individuals that are regular or dependent users of cannabis will experience this syndrome upon cannabis cessation. Due to this, clinicians should be aware of its prevalence and should consider screening in those individuals that are at great risk, in order to counsel patients and support individuals who are reducing their use of cannabis.