The terms “cannabis use disorder” and “cannabis withdrawal syndrome” are not without controversy.
Headlines containing either of these terms is enough to draw vitriolic comments from skeptics on social media.
Given decades of government-sponsored fearmongering and racially disproportionate detainment for possession of what many perceive to be a benign plant, a deeply held skepticism toward negative information about weed is understandable.
But having an open mind is a two-way street: A complete understanding of cannabis — like all potential medicines or recreational substances — is one that considers its potential benefits, as well as its potential harms.
A recent meta-analysis conducted by researchers at Queen’s University crunches the numbers from 47 studies to determine how many people suffer from cannabis withdrawal syndrome (CWS), as defined in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), and what population segments suffer more.
The results show that as much as 17 per cent of people in the overall population could qualify for cannabis withdrawal syndrome, and the number spikes to 47 per cent in people with “regular” or “dependent” use.
Though these averages aren’t to be understood without qualification. Prevalence estimates of withdrawal syndrome vary widely from study to study, affecting anywhere 11 to 94 of cannabis users, according to this study’s analysis.
Some experts also note that the negative outcomes associated with cannabis use are far less than those of other popular intoxicants. On the other hand, as an author of the current study notes, comparing diagnoses of mental health conditions to one another isn’t as sensible as it may seem.
“Substance use disorders are probably ‘apple and oranges’ in a way. Also, someone can meet criteria for several concurrent diagnoses,” said Anees Bahji, a psychiatrist in residence at Queen’s. “Because of these things, I don’t think, for example, that cannabis use disorder and alcohol use disorder are identical, but, that doesn’t mean that one is more or less important than another.”
As fear-mongering relies on exaggeration over evidence, dismissing the potential of cannabis to cause harm can diminish lived negative experiences and stigmatize people who could seek help.
‘Untreated withdrawal may be a driver for continued cannabis use’
One of the main drivers behind the CWS study is a lack of understanding of cannabis use conditions and related clinical approaches, compared to other substance use disorders.
“CWS is particularly interesting as we theorize that untreated withdrawal may be a driver for continued cannabis use. From the available literature, there are few effective pharmacologic treatments for people that have [cannabis use disorder (CUD)],” Bahji said.
Cannabis withdrawal syndrome was first recognized in the DSM-5, published in 2013, and requires at least three of the following symptoms developing within seven days of reduced cannabis use: (1) irritability, anger, or aggression; (2) nervousness or 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.
Of the 23,518 participants in the analysis, 16,839 were white (72 per cent) and 14,387 were men (69 per cent). The median age was 29.9 years.
The studies included a significant proportion people with medically significant needs, with 50 per cent of the sample groups defined as treatment-seeking individuals. Participants in the included sources were from primarily clinical samples, with 14 per cent of the groups from inpatient samples and 56 per cent from outpatient samples.
When divided on lines of study setting, withdrawal in population-based samples was 17 per cent, 54 per cent in outpatient samples and 87 per cent in inpatient samples. The finding that prevalence of CWS was substantially higher in clinical populations, the researchers said, is consistent with a two-way association between cannabis use and mental health disorders.
“CWS was more frequently encountered among patients with comorbid tobacco and drug use,” the study reads. “Although our study did not identify an association between psychiatric comorbidity or alcohol use and CWS prevalence, the prevalence of CUD comorbidity is known to be substantially higher among individuals with a primary anxiety, mood, eating or psychotic disorder, relative to the general population.”
Among the study’s strengths, its authors said this is the largest systematic review of cannabis withdrawal among people with cannabis use disorder, and the first meta-analysis.
Its biggest limitation is the wide range of tools used to define CUD and CWS, the authors said, which contributed to a high degree of statistical variance across studies. They also noted that the inclusion of only validated rating scales may have mitigated that variance.
According to Bahji, there are probably several barriers facing people experiencing CUD and CWS.
It’s often hard to recognize the impact a substance use disorder has on you, he says, especially for more subtle signs and symptoms.
“For something like withdrawal, there are often overlapping symptoms with other conditions, so it might be hard for someone to appreciate that their experience is consistent with withdrawal,” Bahji said.
He also notes that legalization has likely had a complex impact on barriers. While it improved access to products that have undergone rigorous screening for safety, it might also support perceptions that it’s healthy or harmless.
“We are also probably bombarded by information about cannabis. And for many of us, understanding what’s true and what’s misinformation is challenging,” Bahji said. “As a researcher, one of my goals is to help guide people — whether it’s other clinicians, patients, family members, policymakers, etc. — in helping to appraise the information that is out there.”
Through education, Bahji hopes people can become “cannabis-literate,” which he says could help people advocate for themselves when deciding what they want their relationship with weed to look like.
Top image: “Anxiety on the Brain” abstract photo of the 2015 Vancouver Celebration of Light fireworks. Photo by inabstract via Wikimedia Commons