Cannabis Withdrawal Scale
Cannabis Withdrawal Scale
by Allan Barger, Research Analyst, PRI
Allsop, D. J., Norberg, M. M., Copeland, J., Fu, S., & Budney, A. J. (2011). The Cannabis Withdrawal Scale development: patterns and predictors of cannabis withdrawal and distress. Drug and Alcohol Dependence, 119 (1), 123-129.
Purpose
The Cannabis Withdrawal Scale (CWS) is an assessment tool used to quantify the presence and intensity of various withdrawal symptoms cannabis dependent clients may experience. Intensity is measured both in how often a symptom occurs in a group of users and by quantifying the level of distress or interference in life functions each symptom may create for a client. For example, cannabis withdrawal is associated with strange dreams or nightmares and with an inability to get to sleep. Strange dreams may be common in cannabis withdrawal, but not particularly distressful, while the inability to get to sleep may be personally distressing and interfere with job performance.
This study had two goals. The first was to test the reliability of the Cannabis Withdrawal Scale and the validity of its items. These tests provide evidence that the CWS is a coherent instrument that will reliably measure cannabis withdrawal and that its individual items are valid experiences of actual cannabis withdrawal while further assessing their intensity. The second goal was to see if the CWS items were predicted by levels of cannabis use and/or various psychosocial factors. Thus, the CWS was used to see if cannabis withdrawal symptoms were predicted by age, gender, level of drug use, or severity of cannabis dependence – a measure different from the intensity of drug withdrawal.
Authors’ Conclusions
“This study extended previous work on cannabis withdrawal by creating a Cannabis Withdrawal Scale (CWS) based on a validity analysis that considers item intensity and endorsement prevalence…. The CWS demonstrated good psychometric properties, with high internal consistency and test–retest reliability…. Scores on the SDS [Severity Dependence Scale] were a significant predictor of cannabis withdrawal intensity, but cannabis use, age and gender were not. Dependence diagnoses from the SCID [a structured clinical interview to determine DSM defined dependence] also did not predict withdrawal, possibly owing to very low variability in the current sample. Total CWS intensity scores remained elevated above baseline levels at the end of the 2 weeks of abstinence for high SDS participants…. Thus it would appear that cannabis users who score highly on the SDS may benefit from interventions with more of a withdrawal management related focus.” [For a list of which symptoms were found to be valid, see the Results section below.]
Implications for Prime For Life Instructors and Prime Solutions Counselors
It is still widely believed that marijuana does not cause either addiction or withdrawal. This is in contrast to a significant body of research clearly identifying common cannabis dependence symptoms in the general population of marijuana users1,2 and data on withdrawal in some marijuana users when they abstain.3,4,5 Moreover, for those who do experience withdrawal, it is distressing enough to cause a relapse into using to relieve the symptoms. We can speculate the erroneous beliefs persist because not all users experience significant withdrawal when they stop using marijuana, even some of those defined as dependent by the DSM. This is coupled with a mistaken belief that the absence of withdrawal means the absence of addiction. This may be further complicated by clients having an inaccurate mental image of withdrawal that resembles the intense physical discomfort that can be seen with alcohol or opiate withdrawal. They may then fail to recognize the milder (but still significant) symptoms of cannabis withdrawal, even as they experience it. Also, the lack of correlation between withdrawal symptoms and the amount of cannabis used suggests there are individual differences, possibly genetic, which may increase risk for some individuals to experience more withdrawal than others. This is also consistent with relationships between levels of use and withdrawal symptoms in other substances such as heroin.6,7 Nevertheless, the DSM-5 has, for the first time, added a cannabis withdrawal syndrome in its diagnostic criteria for cannabis dependence because it is now clinically defined in research.
This article provides additional support for Prime For Life Instructors to understand the addictive nature of marijuana and helping group members to recognize that risk. It can also help groups to understand that marijuana use can lead to a significant withdrawal in some—but not all—who develop a dependence on it. While the Red Phase notes loss of control as the hallmark of addiction, withdrawal can also happen and, when it does, it may complicate or even sabotage efforts to abstain. Instructors can increase credibility by noting withdrawal does not happen to everyone and further observe that, for those who do have the experience, it can be distressing enough to contribute to relapse. These findings also support what PRI has often noted; that both Orange and Red Phase participants could meet DSM criteria for dependence which is a different, broader paradigm than the traditional view of addiction. Moreover, since withdrawal symptoms were predicted by scores on the Severity of Dependence Scale but not the number of DSM criteria, the DSM symptoms criteria may measure some things unrelated to physiological dependence and withdrawal. One can have DSM-IV dependence without withdrawal.
This article also identifies a reliable and valid assessment scale Prime Solutions counselors and other practitioners can use to determine the presence and severity of cannabis withdrawal. It provides a means to describe withdrawal symptoms and to caution clients that they may experience one or more of these symptoms. Counselors and clients can then discuss how individuals can manage, should symptoms occur. The study authors further suggest those who have significant withdrawal may benefit from treatment time focused on managing withdrawal symptoms until they subside. Not all of the symptoms had returned to baseline at the end of the two-week study period. Moreover, while these data showed an overall trend for symptoms to subside in strength and frequency over time, that change was not completely linear. There were days when symptoms reoccurred with greater intensity despite being further in time from the last day of use. While these occurrences may be distressing, they should be viewed as normal and not a reason for undue concern or a sign of failure on the part of the client.
Further details of how the study was conducted, its findings, including a list of which symptoms were found valid, and the study limitations are included below.
Methods
Participants: Forty-five study participants (30 male, 15 female) aged 18 to 57 provided data for this study. They had used cannabis on five or more days per week, met DSV-IV criteria for cannabis dependence, experienced at least one withdrawal symptom, and were willing to abstain from cannabis for two weeks. Of the 131 telephone interviews, 53 were excluded due to either failing to meet cannabis dependence criteria, having been in substance abuse treatment within the past 3 months, or being pregnant or planning to become pregnant during the study period. Of the remaining 78 possible participants, 21 failed to arrive for the study intake session and an additional eight were excluded due to dependence on another substance other than nicotine or caffeine. An additional seven people failed to remain abstinent during the abstinence phase of the study. Five chose to restart and completed the study. Two more participants showed increased drug urine levels during the mid-point of the abstinence period despite reporting no use and were excused from the study and their data was discarded. Of the 45 completing the study, the median age was 30.4 years and they averaged 2.7 years of higher education. Weekly cannabis use ranged from 5 to 12 times per week with an average of 8.2 occasions of use. Participants had initiated regular use of marijuana at an average of 19.6 years of age, although the range was from ages 14 to 40. The number of years using marijuana ranged from 2 to 35 with an average use of 14.2 years.
Procedures: Participants were paid for their participation with increasing levels of reimbursement as they finished defined stages of the three week study. After screening and giving verbal and written consent, participants were given a Severity of Dependence Scale (SDS) survey by telephone and the AUDIT to control for alcohol use disorders. Those selected came to a laboratory where they were given a urinalysis, a research version of the DSM structured clinical interview for dependence (SCID-RV), a timeline follow back investigation (TLFB) of their cannabis use, and the Marlow-Crown Social Desirability Scale test which measures social bias, allowing researchers to assess if a participant is likely to give accurate answers versus what they suppose the researcher wants to hear. They were also given the Cannabis Withdrawal Scale (CWS) which asks if the participant has experienced a particular symptom and, if so, to rate the intensity of that symptom on a 10-point scale ranging from mild to severe. They were also given a urinalysis to verify the presence of cannabinoids in their system resulting from recent use.
Participants then entered the baseline phase where they continued their marijuana use as normal for one week but were assessed with the CWS for withdrawal symptoms each day. Participants were allowed to select the time of day they completed the CWS, but it was done at the same time each day. They received a daily automated text message reminding them to complete the survey. On study day 8, participants returned to the laboratory where they were again given a urinalysis for marijuana use, a TLFB of their use during the previous week, and the CWS. They attended a 60 minute “quit session” where they were given information on halting their marijuana use and given strategies for managing abstinence. Participants then entered a two week abstinence phase of the study where automated reminders continued to prompt them to fill out the CWS daily. Midway through the two week abstinence period (study day 15), individuals returned to the laboratory for another urinalysis and TLFB of any marijuana use. Data from any participant with an increase in urine cannabis levels above baseline was removed from the data set. The study concluded on day 21 with further assessments of cannabis use via TLFB and urinalysis when participants were given their final payment.
Data Analysis: All of the data were analyzed using SPSS version 18. The main set of reliability and validity analyses focused on the normalized symptom intensity data. Cronbach’s alpha assessed the internal reliability of the CWS intensity data at the time of peak withdrawal which was day 5 of the abstinence phase. The MCSD was used to check participant responses to each item of the CWS for social bias. Each item was also checked for acquiescence bias where participants merely endorse every item regardless of content. Items were considered valid if more than 20% of participants had a 5 point increase in intensity of the symptom. A separate analysis was then done to test the relationship between the intensity of the symptom and the amount of distress or impairment it created in daily functioning.
Results
None of the items were found to be subject to social bias. Six items were removed due to acquiescence bias leaving a total of 26 symptoms in the Cannabis Withdrawal Scale. The internal reliability scores were high (Cronbach’s alpha = 0.91 on day 5 of abstinence) supporting the CWS is a reliable measure of cannabis withdrawal.
Of the 26 candidate symptoms, 19 were found to have validity. Those with significant intensity were nightmares or strange dreams, trouble getting to sleep, woke up sweating at night, woke up early, angry outbursts, feeling irritated, physical tension, nausea, restlessness, nervousness, cravings for cannabis (imagining being stoned and/or thinking about smoking), depression, “life felt like an uphill struggle,” loss of appetite, headaches, hot flashes, mood swings, and stomach ache. The sleep related items were the most common, but participants reported trouble getting to sleep, angry outbursts, and imaging being stoned as the most distressing symptoms.
Participants who scored higher on the Severity of Dependence Scale at the beginning of the study were more likely to experience withdrawal symptoms. However, neither age, gender, the number of DSM-IV dependence criteria, the amount of cannabis consumed, nor the SCID-RV severity score, predicted withdrawal. The finding that the amount of cannabis consumed was not related to withdrawal symptoms is consistent with findings on use and withdrawal of other substances.6 For example, one study of heroin users found only a weak link between the quantity of heroin individuals used and the presence of withdrawal symptoms.7
Limitations as Noted by the Authors
“Whilst all participants met criteria for cannabis dependence, with an average of 5.6 dependence criteria being endorsed, the majority of the sample was not seeking treatment for cannabis use problems. Overall the sample size is small and greater numbers and multiple samples are required to enable factor analytical approaches to test the factor structure of the CWS. Sample size restrictions also mean that the scoring frame for the CWS still needs more robust development. Participants were allowed to choose their own time of day for filling out the CWS (so long as it was the same time each day), which could feasibly influence the experience or recollection of withdrawal symptoms between people.”
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