DrugFacts 2010 Repost: Comparing Cannabis and Nicotine Withdrawal

Nov 08 2010 Published by under Cannabis, Drug Abuse Science, Nicotine

This is Drug Facts Week, an effort of NIDA to promote understanding of the effects of recreational drugs. I have a little bit of interest in such things. Unfortunately, I've been a bit busy and will continue to be so this week. So I thought I would get at least partially in the game with a series of re-posts. This post originally went up at Scienceblogs.com on April 29, 2008.


For some reason many people are in denial about cannabis dependence and wish to assert that there is no such thing, or if there is, it is somehow of lesser importance than is dependence on other substances of abuse. There are many ways to assess importance of course. What gets me going, however, are the assertions about cannabis abuse and dependence that are informed by anecdote and personal experience with a handful of users instead of an understanding of the available evidence.
To provide a little context for todays' post, I took MarkH of denialism blog to task for his expression of what I viewed as standard cannabis science denialism a fair while ago. In a comment following his post, MarkH specifically identified nicotine withdrawal as being worse than cannabis withdrawal. This is the perfect setup since there are two recent papers which set out explicitly to test this hypothesis. Let us see what they found, shall we?


First off, what does cannabis withdrawal look like? As I've mentioned before the Diagnostic and Statistical Manual of Mental Disorders (DSM; current major version DSM-IV) employs generic substance abuse and dependence criteria for cannabis dependence. One of the ways the DSM gets revised over time is that researchers provide data and studies in-between revisions to attempt to refine and clarify diagnoses. The individual I most associate with the effort to describe the nature of cannabis dependence, and specifically withdrawal, is Alan J. Budney. He has a 2006 review of his (and others') work in this area and anyone who wishes to grapple with the consistency of findings and the subtleties of the subject samples under investigation should track back through the reviewed articles. For today, the important issue is that Budney proposes that a symptom list for cannabis withdrawal should be included in the next revision of the DSM as follows (from Table 1):
Common symptoms

  • Anger or aggression
  • Decreased appetite or weight loss
  • Irritability
  • Nervousness/anxiety
  • Restlessness
  • Sleep difficulties including strange dreaming

Less common symptoms/equivocal

  • Chills
  • Depressed mood
  • Stomach pain
  • Shakiness
  • Sweating

Hmm. Very broadly consistent with symptoms established for other drugs of abuse, including nicotine. This brings us to the two papers comparing nicotine and cannabis withdrawal which have recently appeared; perhaps unsurprisingly, Budney is an author on each of these.

Vandrey RG, Budney AJ, Hughes JR, Liguori A. A within-subject comparison of withdrawal symptoms during abstinence from cannabis, tobacco, and both substances.
Drug Alcohol Depend. 2008 Jan 1;92(1-3):48-54. Epub 2007 Jul 23.
Budney AJ, Vandrey RG, Hughes JR, Thostenson JD, Bursac Z. Comparison of cannabis and tobacco withdrawal: Severity and contribution to relapse. J Subst Abuse Treat. 2008 Mar 12; [Epub ahead of print]

The first study, Vandrey et al, 2008, includes a relatively small sample (N=12) of cannabis/tobacco users (>6mo of 25 days/mo cannabis smoking, 10 tobacco cigarettes or more per day; all the usual exclusions of other issues). Importantly these individuals were not seeking treatment for either tobacco or cannabis use. The design was a series of blocks of Smoking As Usual (SAU) and the abstaining from cigarettes, cannabis or both for a 5 day interval. SAU for 9 days was interleaved between any of the abstinence intervals. Okay, so what did they find?

Vandrey08-WithdrawalFigure.jpg

Fig. 2. Mean ratings for WSC items for which significant condition by day interactions were observed. Filled symbols indicate values significantly different from SAU. Subscripts designate differences by condition on a given study day (a = dual > cannabis and tobacco; b = dual and tobacco > cannabis; c = dual > cannabis;
d = dual > tobacco). Squares indicate abstinence from cannabis only, circles indicate abstinence from tobacco only, and triangles indicate abstinence from cannabis and tobacco.

Discontinuation of both substances seemed to cause the greatest degree of withdrawal, particularly in terms of anger, irritability and aggression on day 2. Cannabis discontinuation (alone) seemed to cause sleep disturbances for longer than did nicotine discontinuation (alone). Perhaps most strikingly, the discontinuation of cannabis (alone) or nicotine (alone) seemed to produce approximately equivalently severe withdrawal symptoms as rated by these dual-users.
The next study, Budney et al, 2008, included a larger samples of individuals who had recently attempted to quit tobacco (N= 54) or cannabis (N= 67). This was a retrospective method (unlike the above prospective method) to survey symptoms experienced during the subjects' prior attempts to quit substance use. Nevertheless the outcome was strikingly similar.

Budney08-SymptomSeverity.jpg

Fig. 1. Group mean severity scores for the WDS (refer to Y-axis scale on left side of figure) and individual symptoms on the Withdrawal Symptom Checklist
(refer to Y-axis scale on right side of figure). Asterisk indicates a significant difference between groups after controlling for age, gender, race, and Global Symptom Index score from the Brief Symptom Inventory in the linear regression models.

With the exception of appetite, craving and sweating symptoms, the severity of withdrawal symptoms was approximately equivalent across substances. This study also included the frequency of symptoms, i.e., the proportion of the sample which experienced each symptom.

Budney08-SymptomFreq.jpg

Fig. 2. Percentage of participants from each group that reported each withdrawal symptom, i.e., scoring greater or equal to 1 on the 0-3 point Withdrawal
Checklist Scale. Asterisk indicates significant differences between groups on chi square analysis (p b .05).

As with symptom severity, the frequencies were similar. Except that cannabis withdrawal resulted in more individuals with irritability and decreased appetite while nicotine discontinuation resulted in more individuals with increased appetite and craving.
In total, these studies paint a picture in which the discontinuation of nicotine and cannabis produce withdrawal symptoms of relatively similar severity and in similar proportion.

13 responses so far

  • Isabel says:

    You should have reposted the comments.

  • Dunc says:

    I'm sure a similar thread will doubtless bloom here in short order...

  • Tom says:

    That's some interesting data. I wonder if the strain of marijuana (specifically, THC to CBD ratio) has a significant effect on the severity of withdrawal symptoms? Tobacco was far, far more difficult for me to to quit than cannabis. Even as a heavy user of cannabis, the worst withdrawal symptoms I had after quitting were increased reading of fiction and more vivid dreams.

  • drugmonkey says:

    Tom:

    Curran and Morgan and colleagues have a few papers now looking at the effects of strains of cannabis that differ in cannabidiol content. It is definitely intriguing.

    At present, however, there is a big old flaw in the design which is that we have no idea if selection of cannabidiol-heavy strains is random or highly correlated with the individual user.

    If a given user who has access to (cannabidiol-heavy strains are in the minority, from the available evidence) or prefers a given category of cannabis is consistent, not random, then our ability to conclude much about the role of cannabidiol is severely reduced.

    Do you have any views on the availability of cannabidiol-heavy strains, how you would detect those, whether they are being marketed as such, etc that you would care to share with us?

  • Isabel says:

    Interesting. The NIDA "shatter the myths" IQ test you link to above says that the most abused drug by teens is alcohol, the drug responsible for the most preventable birth defects and the most car accidents is alcohol, yet the accompanying "teen brochure" has four pages of 'information' about cannabis, and even three about marker sniffing, yet barely mentions alcohol.

    The biggest myth about 'drugs' is that alcohol is not a drug.

    To shatter another common myth: Testing positive for cannabis (after a car accident in quiz) does not mean the person was high at that time, so is a meaningless stat. There is no evidence anyway (after many studies) that cannabis use actually results in more accidents, as people tend to avoid driving or compensate by driving more slowly and carefully.

    There was nothing in either document about alcohol leading to addiction or violence. Nothing about date rape, or alcohol and sexual assault. Just a vague reference to drugs in general 'lowering inhibitions' and putting kids at risk for HIV.

  • drugmonkey says:

    Testing positive for cannabis (after a car accident in quiz) does not mean the person was high at that time, so is a meaningless stat.

    this doesn't make it "meaningless". just because you blow a 0.08BAC doesn't mean you were impaired at driving either.

    There is no evidence anyway (after many studies) that cannabis use actually results in more accidents, as people tend to avoid driving or compensate by driving more slowly and carefully.

    You repeatedly make this assertion. Yet I can't recall you citing any studies...can you help us out on this one?

    The biggest myth about ‘drugs’ is that alcohol is not a drug.

    You certainly won't find this idea being promulgated around these parts, nor by NIDA. You do realize, though, that since there is a whole National Institute of Health devoted to alcoholism (that would be NIAAA) that perhaps there is a reason why it is not NIDA's main focus? (and before you start frothing, search the blog for my opinion on the proposed NIAAA/NIDA merger...)

  • drugmonkey says:

    a quick scan on pub med shows that while it is true that people slow down to try to compensate for cannabis related driving impairment, there are still deficits in ability to respond to changing conditions, deficits in automaticity of certain driving processes and an inability to adapt / learn in the context of experience to the same degree that the unimpaired adapt.

    so it is pretty clear that despite some attempt to compensate deficits remain. these results are in controlled studies so it is unclear how to predict the real world outcome. if you have an effect that changes driving capability only under some circumstances but not others you may throw a lot of variability into the mix.

    Perhaps this is one of the reasons why the epidemiological studies are mixed.

    It seems to me that it would be of interest to try to categorize accidents between situations where expected value of a crash is vanishingly low (open road, little traffic) versus where it is higher (congested, distracting conditions inside and outside of car, etc).

  • Isabel says:

    You are being disingenuous once again. There is no overall increase in accidents. There are many recent major reviews that discuss these studies. Again, texting, being tired, on legal prescription drugs, having kids in the car etc. are probably as big or bigger concerns.

    As far as your earlier comment about other agencies covering alcohol, the teenagers do not know this when they are reading a 'drug facts' pamphlet so it is irrelevant. The message they are getting from that pamphlet is that cannabis and marker sniffing are major concerns, but alcohol is not. Are you seriously defending that message?

    For a regular user the effects are different, which I have never seen addressed in a study. Some tasks are done more efficiently, because of increased focus, etc.

  • Paul says:

    Just like the poster Tom, my own personal experience with cannabis withdrawal contradicts this study. I was a daily user for over a year, but quit without any withdrawal symptoms.I was not, however, a heavy daily user--I was a very light daily user. And I think a distinction in research needs to be made.

    Let's run some hypothetical test cases:

    The average cannabis smoker does not actually test their pot for THC levels (the percentage of THC varies A LOT) and users have a tough time quantifying the amount they smoke because each joint/bowl/blunt has a different amount of herb in it. Cigarettes, on the other hand, are fairly standardized for nicotine levels and weight because they are a regulated product. And cigarettes are easy to count.

    Essentially, when a smoker says "I smoke 15 cigarettes of Brand X/day" it's much easier to gauge his intake. When a cannabis smoker says, "I smoke every day" they could be smoking one 0.4 gram bowl containing 5% THC, which would be a maximum of 20mg/day.

    A heavy daily cannabis smoker could be smoking larger amounts of cannabis (0.8 gram blunts) with THC levels of, say, 12%, 3-4 times a day. This would total up to a maximum of 380 mg/day. The method of smoking will also cause varying levels of THC intake.

    So in these two hypothetical cases, we have two 'daily' users. The heavier user is taking in 19 times as much THC in one day! That's the difference between smoking one cigarette a day and a pack. And I can verify that one cigarette a day is not the portrait of addiction, and neither is a single glass of wine with dinner.

  • Isabel says:

    http://networkedblogs.com/bebEw

    If you scroll about halfway down there are a number of links to *real actual studies* regarding cannabis and driving.

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