Validity of Three Operational Definitions of Cannabis Withdrawal in a Sample of Treated Adolescents

Controversy over the inclusion of cannabis withdrawal in DSM and ICD

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Controversy exists regarding the inclusion of cannabis withdrawal as an indicator of dependence in the next revision of the Diagnostic and Statistical Manual of Mental Disorders (DSM) and International Classification of Diseases (ICD). This study contrasted the concurrent and predictive validity of three operational definitions of cannabis withdrawal in a sample of treated adolescents. Design Prospective study of treated adolescents with 1-year follow-up. Setting and participants Adolescents (n = 214) were recruited from intensive out-patient treatment programs for substance abuse, and followed at 1 year (92% retention). Youth who were included in the analyses reported regular cannabis use. Measurements.

The number of DSM-IV cannabis abuse and dependence symptoms at baseline and 1-year follow-up, past year frequency of cannabis use at baseline and follow-up, and periods of abstinence at 1-year follow-up. Cannabis withdrawal was defined based on

(i) the presence of two or more cannabis withdrawal symptoms;

(ii) a definition proposed by Budney and colleagues (2006) that requires four or more withdrawal symptoms (foursymptom definition); and

(iii) the use of latent class analysis to identify subgroups with similar cannabis withdrawal symptom profiles.

Findings and conclusions All three definitions of cannabis withdrawal demonstrated some concurrent validity. Only the four-symptom and latent class-derived definitions of withdrawal predicted severity of cannabis-related problems at 1-year follow-up. No cannabis withdrawal definition predicted frequency of use at followup. Further research is needed to determine the clinical utility and validity of the four-symptom definition, as well as alternative definitions of cannabis withdrawal, to inform revisions leading to DSM-V and ICD-11.

Controversy exists regarding whether a cannabis withdrawal syndrome should be included in the next revision of the Diagnostic and Statistical Manual of Mental Disorders (DSM) [1]. If included in DSM-V, an operational definition of a cannabis withdrawal syndrome would facilitate recognition of an acute syndrome that warrants treatment (similar to criteria used to identify withdrawal syndromes for substances such as alcohol and cocaine), and would also provide a means of determining the presence of the ‘withdrawal’ criterion when evaluating an individual for a diagnosis of cannabis dependence.

In contrast to DSM-IV, the International Classification of Diseases (ICD) recognizes a cannabis withdrawal syndrome, but states that its diagnostic criteria remain to be determined [2]. Critics who oppose including cannabis withdrawal in DSM and ICD have cited the need for a clear operational definition of the syndrome with regard to time–course, symptom profile and clinical significance [3]. Proponents of including cannabis withdrawal emphasize research on its neurobiological basis [4], delineation of the typical time–course and symptoms of a cannabis abstinence syndrome [5–7] and reports of functional impairment due to cannabis withdrawal [8,9].

Optimal identification of cannabis withdrawal symptoms

Questions remain as to the type and number of symptoms that optimally identify cannabis withdrawal, and the extent to which withdrawal plays a role in maintaining the compulsive pattern of drug use that is the hallmark of dependence. Among adult heavy cannabis users, abstinence from cannabis typically precipitates withdrawal symptoms that emerge within 24–48 hours of abstinence [10]. The symptoms usually peak within a week, and last roughly 1–2 weeks [6,11]. Re-administration of cannabis relieves the symptoms associated with abstinence from the drug [6,12,13], and provides another way (i.e. withdrawal relief) in which cannabis withdrawal as a possible dependence criterion may manifest. Cannabis withdrawal symptoms generally represent physical and psychological dimensions based on results of principal components analysis [7].

Affective and behavioral, rather than physical (e.g. tremor, sweating) cannabis withdrawal symptoms are reported most often, and include irritability, decreased appetite, restlessness and sleep problems [7,10]. Among adults seeking treatment for cannabis use, 85% reported four or more cannabis withdrawal symptoms of at least mild severity during the most recent episode of abstinence [6]. Cannabis withdrawal is associated with greater severity of cannabis involvement both cross-sectionally and prospectively in adults [14]. Cannabis withdrawal also appears to play a role in maintaining dependence (e.g. use to relieve withdrawal) and impacting negatively attempts to quit or cut down on use [7,15], although the number and type of symptoms to use in defining a cannabis withdrawal syndrome, which would also function as a criterion used to diagnose cannabis dependence, remain to be specified in DSM and ICD. Less is known about the prevalence and symptom profile of cannabis withdrawal among adolescents, although cannabis is the illicit substance most commonly used by youth [16].

In a community sample, among adolescents with a cannabis use disorder 15% endorsed cannabis withdrawal (the operational definition used to identify withdrawal was not specified); withdrawal was the least prevalent dependence symptom [17]. Higher rates of cannabis withdrawal, ranging from 40 to 67%, have been reported among adolescents in addictions treatment ([18,19]; these studies also did not specify the operational definition of withdrawal used). In a sample of treated youth, 15% reported use to relieve withdrawal [19]. The most commonly reported cannabis withdrawal symptoms among adolescents include craving, depression, irritability, difficulty sleeping, restlessness and decreased appetite [18–21].

Among treated adolescents, one-third reported four or more withdrawal symptoms of at least moderate severity [20]. As an indication of the clinical significance of cannabis withdrawal, withdrawal symptoms in a sample of out-patient adolescents were found to interfere with completion of school work and the ability to maintain abstinence from cannabis [21]. Importantly, commonly reported cannabis withdrawal symptoms were similar for adults and adolescents, although withdrawal prevalence and severity were typically lower in youth [10]. In a comprehensive literature review, Budney and colleagues [10,22] proposed criteria for a cannabis withdrawal syndrome to be considered for inclusion in the next revision of the DSM. The proposed criteria include the following six symptoms: anger or aggression, irritability, decreased appetite, nervousness/anxiety, restlessness and insomnia (including strange dreams) [10,22].

Because most treated adult cannabis users generally reported four or more of these six commonly reported symptoms occurring with substantial severity, and because a four-symptom threshold has been used to define withdrawal syndromes for other substances in DSM-IV, report of four or more of the six more commonly reported symptoms, in combination with impairment in functioning or subjective distress, was proposed as an operational definition of a cannabis withdrawal syndrome [22,23]. Details on the method of selecting the six symptoms and the four-symptom threshold, however, were not provided. Research is needed to determine systematically the type and number of symptoms that defines optimally a cannabis withdrawal criterion, and the extent to which withdrawal predicts a relatively chronic course.