Tuesday, February 05, 2008

Marijuana withdrawal

Using marijuana (way, way back when and never,ever inhaling!) made me as fumble-mouthed as an evening news anchor and rather forgetful, so I gave it up before college. I've been surprised to learn, however, in my role as privileged exam room confidante that quite a few people continue to smoke up daily. Before they even go to work! Very few express any desire to quit, and no wonder considering new evidence from Johns Hopkins University researchers.

In a small series, the Baltimore psychiatrists found that subjects withdrawing from regular marijuana use suffered from withdrawal symptoms equivalent to those which occur on giving up cigarettes. The symptoms included irritability, anxiety, difficulty in focusing, and insomnia.

The problem I've come up against in helping those few who'd like to walk away from the marijuana habit is a lack of available medical adjuncts to shore up their will power. We have alternative nicotine delivery systems such as patches, lozenges*, and gum for those giving up cigarettes. A newish drug called Chantix* acts as a weak nicotine analogue in the brain, working on nicotine receptors to release a little bit of the feel-good neurotransmitter called dopamine but not so very much as to perpetuate the addiction. Naltrexone helps alcoholics give up drinking, as, theoretically, does Campral although efficacy data on the latter is not so very convincing.

But, alas, there are no legal marijuana analogues on the market FDA-approved for withdrawal purposes. Marinol (generic ronabinol) is a synthetic version of the active compound in marijuana called delta-9-tetrahydrocannabinol or THC. It is indicated for suppression of nausea associated with cancer chemotherapy or as an appetite stimulant for persons with AIDS. Its use could perhaps supply THC to marijuana addicts in much the same way that Nicoderm provides nicotine to withdrawing cigarette smokers.

Acomplia*** or rimonabant is an endocannabinoid receptor blocker which was developed to help persons with a prediabetic condition called the metabolic syndrome get a grip on their elevated blood fat levels and weight. It would probably take the fun out of smoking marijuana as the THC could not meet up with its receptors if Acomplia was already sitting in place, but it is not available in the US.

The bottom line is that quitting addictions is a lot of unpleasant work. I quit smoking 30 years ago this month, and I'd never care to have to motor my way through another withdrawal experience.
*A patient recently told me about a nicotine lozenge called Ariva. Sold behind the Walgreen's cigarette counter, 20 lozenges for about the same price as a pack of cigarettes, Ariva was very helpful in her quest to quit. I gave a pack to a near and dear one who wished to cut back on his habit, and the product set off powerful and painful gagging. Great, gagging or smoking, which would you pick?

**A pesky little post-release problem with Chantix has the FDA re-examining safety data. Apparently partially blocking nicotine receptors sets off suicidal depressions in some people.

***Acomplia is also linked with suicidal depression. Apparently, you can't block the body's feel good receptors without making some people feel bad.


Eric, AKA The Pragmatic Caregiver said...

The key to Ariva, as with Nicorette, is proper positioning of the lozenge or gum wad; it has to be in a place with moderate salivation, or you get the hiccups and gagging. Ariva, not having the gum base matrix of the Nicorette, is much more sensitive to dissolution rates.

One thing to consider; Ariva is made of compressed powdered tobacco (cured with a special process that drastically reduces the harmful Tobacco-Specific Nitrosamines, aka TSNAs, which are associated with cancer). It has a different release profile than the nicotine lozenges, so it's worth trying one if the other fails. I happen to like Ariva, and I've never been a smoker, but I can see how if someone parked it wrong, they'd be miserable.


Femail doc said...

Very interesting, Eric. So where do you 'park it?'

Ruth said...

Nabilone is used occasionally on the pain unit where I work for treating neuropathic pain. One 40ish woman who has a form of MD is being treated with it now, and is allowed to smoke marijuana as well until her dosage is optimized. The part time security officers had quite a confrontation with her last weekend! I haven't heard of withdrawal issues though. Interesting.

rlbates said...

Interesting post. No suggestions to help you. It was the gagging on a "stolen" tobacco cigarette (one of my mom's) when I was young that kept me from EVER smoking!

Mauigirl said...

Very interesting thoughts - it hadn't occurred to me that there are no helpful drugs or aids to help people quit smoking pot. Most of the people I know who used to smoke pot(including me, "back in the day") never had a problem stopping; we kind of just outgrew the desire to feel like that. But I did know some hard-core potheads who probably smoke to this day and would have a lot of trouble quitting.

Eric, AKA The Pragmatic Caregiver said...

Personally, I'm partial to the buccal space between 21 and 22 or 25/26. I don't tend to slobber so much there, so the pellet lasts longer. Other people might be more comfortable with a 5/6 or 10/11. The key is to keep it between the cheek and gum a la oral tobacco, not to suck on them like Tic-Tacs.


dorsey said...

does this mean I could park an Ariva and get some nicotine without having to smoke? Or is this just another form of chew and I lose my lip? There must be some way to get the benefits of nicotine without the messy parts. (is there such a thing as mild addiction? Or is that like being slightly pregnant?)

Eric, AKA The Pragmatic Caregiver said...


The nasty part of oral tobacco seems to be the tobacco-specific nitrosamines (TSNAs) created during the curing process (partially as a result of the use of high-nitrogen fertilizers in tobacco cultivation).

Sweden has the highest rate of oral tobacco use in the industrialized world. It also has the lowest rate of oral cancers. The fact that Sweden restricts TSNAs very severely may not be entirely coincidental.

When it comes right down to it, the safest use of nicotine is probably "none". The various pharmaceutical products are probably the next lowest risk (and some research seems to indicate that nicotine users have less Parkinson's and lower rates of lower GI trouble, probably due to nicotine's effect on cholinergic pathways - and it's a pleasant sensation for many people, and quite frankly, there's some value to that, so there could be a health benefit to nicotine, as much as that horrifies the anti-nicotine sorts - the jury is out).

Anyway. . . Ariva is probably higher-risk than pharmaceutical nicotine preparations, but is clearly safer than other delivery systems. You don't get the combustion products, the TSNAs or the added flavoring agents like smoking materials. You do get a couple mg of nicotine in a pleasantly minty pellet with nothing to spit or dig out at the end.


Femail doc said...

Thanks Eric, you are pragmatic indeed! My son's brain works way better with respect to focus post-nicotine fix. Maybe if he doesn't work an Ariva over like a Tic-Tac, these lozenges could be the perfect adjunct to his studies balancing the dangers of the delivery system with the benefits of the nicotine.

I appreciate your chiming in with the information!

Eric, AKA The Pragmatic Caregiver said...

The thanks are due to you; a harm reduction approach to nicotine use is probably the best bet, but it gets drowned out in the anti-smoking rhetoric. I have lots of friends and a few loved ones who were either duped by cigarette companies, compelled by peer pressure or just love the buzz, and I'd like to see them happy and non-dead.

Just for the record, again, I'm not a smoker, I've never been a smoker, I'm an asthmatic who avoids airborne irritants in general.

There are other tobacco-based products made with TSNA-reduced tobacco. Ariva is but one, marketed to be as palatable as possible, both from a flavor perspective and a societal one. Personally, I favor the various oral tobacco products of Swedish Match, but I'm both Scandinavian and a bit contrarian. ;0)


dorsey said...

eric, thanks for all the info. (and judy for having the site). I stopped smoking 17 years ago this month, for a time before that I used nicorette gum, had terrible mouth sores from it. I've wondered about using a patch, whether it would cause skin irritation. (and whether my doctor would prescribe it). If I remember Ariva when I'm at the store, I'll try it, see if I notice nicotine benefits.

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