**3. Cannabis withdrawal syndrome**

While it is popularly reported that there are no withdrawal effects from cannabis, there is evidence for withdrawal symptoms in CUD that are comparable to nicotine withdrawal in magnitude and consequences [10, 11]. The DSM-5 now includes a Cannabis Withdrawal Syndrome [7] which consists mostly of emotional and behavioral symptoms including anxiety, irritability, restlessness, depression, anger, as well as sleep, weight and appetite disturbances [12]. Less common physical symptoms include stomach pain, shakiness and sweating [12]. The clinical significance of the withdrawal syndrome was originally questioned; however, those symptoms are linked with increased functional impairment in normal daily activities [13]. The delayed onset of the withdrawal syndrome may explain why it is often overlooked: symptoms peak 2–3 days after cessation of heavy cannabis use and can last 2–3 weeks [12, 14]. Given the daily use of many individuals with CUD, they may not notice the symptoms. Withdrawal symptoms are nevertheless closely linked to relapse: most abstinent individuals experiencing withdrawal symptoms will take the drug to alleviate symptoms, thereby perpetuating cannabis use [15, 16]. The withdrawal syndrome is also important in medicinal cannabis use. Notably, cannabis withdrawal symptoms overlap with mood and anxiety disorder symptoms [7]—the very symptoms that some cannabinoid products are posited to treat. Many individuals cite mood modification as a motivation for cannabis use and are unaware that their short term use for symptomatic relief may result in a long-term withdrawal syndrome [17]. More

generally, medicinal cannabis can be thought of as no different than other medications for which the pharmacology results in physiological dependence including a withdrawal syndrome (e.g., benzodiazepines and opioids), requiring clinical consideration and management.

**Table 1.** Diagnostic criteria for cannabis use disorder in the Diagnostic and Statistical Manual of the American Psychiatric

Cannabis Use Disorder

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http://dx.doi.org/10.5772/intechopen.80344

Cannabis remains the most commonly used illicit\* (\*state/country-dependent) psychoactive drug. Large epidemiological studies show that ~43% of individuals in the US and Canada report having tried cannabis, with ~35% having tried it more than once [18–20]. Cannabis use

Indeed, the same is true for its abuse liability in the context of CUD.

Association (5th edition).

**4. Prevalence of cannabis use and cannabis use disorder (CUD)**


substantial need for an evidence-based understanding of the risks associated with cannabinoids. Of particular concern is a potential rise in the development of cannabis use disorder (CUD), the psychiatric diagnosis of addiction to cannabis, and it is still unclear how legalization of the drug relates to the prevalence and severity of CUD [6]. Here we review the definition of CUD, its prevalence and associated conditions, and the contemporary understanding of its causes to inform policy, prevention efforts and treatment of CUD in a dynamic and

The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) [7] defines CUD as any 2 of 11 diagnostic criteria (**Table 1**), which include hazardous use of the drug (e.g. driving while under the influence), taking the drug in larger/longer amounts than intended, preoccupation with cannabis, unsuccessful efforts to cut down, drug tolerance, neglecting major roles to use, and social/interpersonal problems related to use. While the DSM-IV included two categories, including both abuse (putatively lower severity) and dependence (putatively higher severity), research supports a dimensional one-factor model, indicating that CUD can best be described as a unidimensional construct [8]. The number of endorsed criteria serves as a disorder severity marker: mild (2–3 criteria), moderate (4–5 criteria) and severe (6+ criteria) CUD [7]. Criteria for craving as well as withdrawal were added in the DSM-5, with 60% endorsement of craving and over 30% reporting withdrawal symptoms

While it is popularly reported that there are no withdrawal effects from cannabis, there is evidence for withdrawal symptoms in CUD that are comparable to nicotine withdrawal in magnitude and consequences [10, 11]. The DSM-5 now includes a Cannabis Withdrawal Syndrome [7] which consists mostly of emotional and behavioral symptoms including anxiety, irritability, restlessness, depression, anger, as well as sleep, weight and appetite disturbances [12]. Less common physical symptoms include stomach pain, shakiness and sweating [12]. The clinical significance of the withdrawal syndrome was originally questioned; however, those symptoms are linked with increased functional impairment in normal daily activities [13]. The delayed onset of the withdrawal syndrome may explain why it is often overlooked: symptoms peak 2–3 days after cessation of heavy cannabis use and can last 2–3 weeks [12, 14]. Given the daily use of many individuals with CUD, they may not notice the symptoms. Withdrawal symptoms are nevertheless closely linked to relapse: most abstinent individuals experiencing withdrawal symptoms will take the drug to alleviate symptoms, thereby perpetuating cannabis use [15, 16]. The withdrawal syndrome is also important in medicinal cannabis use. Notably, cannabis withdrawal symptoms overlap with mood and anxiety disorder symptoms [7]—the very symptoms that some cannabinoid products are posited to treat. Many individuals cite mood modification as a motivation for cannabis use and are unaware that their short term use for symptomatic relief may result in a long-term withdrawal syndrome [17]. More

evolving legislative landscape.

138 Recent Advances in Cannabinoid Research

in past-year individuals with CUD [9].

**3. Cannabis withdrawal syndrome**

**2. Definition of CUD**

**Table 1.** Diagnostic criteria for cannabis use disorder in the Diagnostic and Statistical Manual of the American Psychiatric Association (5th edition).

generally, medicinal cannabis can be thought of as no different than other medications for which the pharmacology results in physiological dependence including a withdrawal syndrome (e.g., benzodiazepines and opioids), requiring clinical consideration and management. Indeed, the same is true for its abuse liability in the context of CUD.
