February 11, 2022 — At the center of emerging science on the unintended consequences of long-term daily use of marijuana lies a paradox.
During years, medical marijuana has been used to alleviate nausea cancer chemotherapy and gastrointestinal conditions. Now, with increased legalization comes increased awareness that the chronic use of marijuana, also known as cannabis, can trigger a condition where, ironically, a person has difficult-to-control vomiting and nausea.
Some people with the disorder, known as “cannabinoid hyperemesis syndrome,” also report a crippling stomach pain.
Linda can relate. The 33-year-old Oregonian, who asked to remain anonymous to protect her privacy, refers to a medieval spiked metal ball on a chain when she describes the pain.
“Imagine a mace inside your stomach, pushing up inside your chest, and at the same time exploding,” she says.
To seek relief, he kneels, assumes a child’s yoga pose and runs hot water in the bathroom for hours on end, a trick that many with the disorder say has provided relief. She also goes out from time to time and tries to walk.
“I was just walking around my neighborhood, often at 4 or 5 in the morning,” he says.
“Fresh air helps a bit. I keep walking down the street, take about 10 steps, stop, throw up, walk some more, stop, throw up.”
His first experience with the disorder began in the middle of a night in 2017 while attending a conference in Las Vegas.
“We went out to eat the night before and I woke up around 4 in the morning with the most intense pain I’ve ever had,” he says.
“I found myself in a very hot shower between vomiting everything and trying to tell her to drink some water,” she says. “I was sharing an Airbnb with my colleagues, so it wasn’t ideal.”
Many people with cannabinoid hyperemesis syndrome find relief with hot baths or showers. Researchers believe that hot water helps because temperature sensors in the skin send signals to the brain that can help relieve symptoms, at least for a while.
The problem is that people with this syndrome “can’t live in water,” says emergency room physician and medical cannabis expert Leigh Vinocur, MD.
Fast forward 6 months to another event in Boulder, CO. Once again, Linda woke up and couldn’t stop throwing up.
“I didn’t feel any better. Showering didn’t help. I ended up in the hospital,” he says.
She received opioids for her pain. But neither she nor the emergency room staff were quite sure what was going on. Her discharge paperwork said “cannabis allergy.”
Cannabinoid hyperemesis syndrome “shatters the image that cannabis is only a good thing. It’s a bold statement, but, you know, once you start thinking about it, it’s like too much of anything is not a good thing,” Linda says.
Experts suggest that greater awareness is needed to identify this syndrome earlier, both by cannabinoid users and clinicians. Vomiting episodes, in particular, can become so severe that people can end up hospitalized with dehydration, electrolyte disturbances, and weight loss.
Serious electrolyte imbalances “can really be life-threatening,” says David Johnson, MD, professor of medicine and chief of gastroenterology at Eastern Virginia School of Medicine in Norfolk.
“By the time they get to the emergency room, they are in bad shape,” agrees Vinocur. “Many try to ignore it, but they keep throwing up.”
Genetic risk factors?
One mystery is why some regular marijuana users develop this syndrome while others do not.
“I can tell you that not everyone understands this, thank goodness,” says Ethan Russo, MD. “But there has to be a reason why certain people are susceptible and others are not.”
Interestingly, a new study by Russo and colleagues suggests that genes play a role. They identified five genetic changes that could make a chronic marijuana user more likely to have cannabinoid hyperemesis syndrome in a study published in July 2021 in the magazine Research on cannabis and cannabinoids.
They compared 28 people with the disorder to 12 other high-frequency marijuana users without these symptoms.
The results aren’t definitive, but they could help guide future research, Russo says.
“What we discovered, and it was much more than we expected, is that there is much more to this than hypersensitivity to cannabis,” says Russo, a neurologist and founder/CEO of CReDO Science, a firm that promotes cannabis research and develops products. commercial.
In addition, he says, those affected by cannabinoid hyperemesis syndrome could be at increased risk of other conditions, such as addiction to alcohol or other substances, dementiadiabetes and heart disease.
“Most people with CHS are going to be younger,” he says. “What we have shown is that there is a risk of more serious problems in the coming decades. So someone who has these symptoms really deserves a genetic screen.”
Returning to the paradox, many users do not believe that marijuana can cause severe nausea and vomiting due to its reputation for doing the opposite.
“People who have this are exceptionally resistant to the concept that cannabis is actually the problem and not the solution,” says Russo.
“It’s a bit counterintuitive because people think, ‘Oh, cannabis helps with nausea,’ so they use more,” says Vinocur, who is also a spokesperson for the American College of Emergency Physicians and runs a medical cannabis practice.
Most types of marijuana work this way: they do opposite things at different doses. Once a certain threshold is passed, people with cannabinoid hyperemesis syndrome are “uniquely susceptible and can’t really tolerate any significant amount of THC,” says Russo, referring to tetrahydrocannabinol, the substance that gets marijuana users high. .
Once diagnosed, quitting smoking is the most effective strategy. But it can be hard to persuade someone to stop using marijuana.
“You have to try to convince them … to try abstinence and watch and see what happens,” says Vinocur.
People should “realize that the root cause of this is cannabinoid ingestion, and treatment is really best aimed at outright avoidance,” says Johnson.
Unfortunately, the evidence also shows that once a person stops using marijuana and gets relief, going back to marijuana or other forms of cannabinoids can cause the syndrome to start all over again.
“We’ve had people who quit smoking for a month, a year, 2 years and when they resume, they almost invariably go back to hyperemesis along with everyone else. [symptoms]says Russian.
Marijuana and cannabinoids can cause digestive problems, says Johnson, which can cause more problems.
What Recent Research Reveals
Cannabinoid hyperemesis syndrome is a relatively young disorder, first described in 2004, and early reports and case studies are now giving way to studies looking at possible treatments.
So far, the strongest evidence suggests that an over-the-counter cream called capsaicin has a role in helping control symptoms, but more study is needed.
Similar to hot showers, this chili ingredient Peppers it can heat the skin and activate temperature-sensitive skin sensors to lessen symptoms, says Johnson.
A October 2021 Study in Spain analyzed 54 visits to the emergency department among 29 people with cannabinoid hyperemesis syndrome. For the 75% treated with capsaicinvomiting ceased after an average of 18 minutes.
Lead author Guillermo Burillo-Putze, MD, PhD, says he is very surprised by the growing number of new cases of the disorder.
“This should be a cause for concern given the increase in cannabis use due to its legalization and permissiveness,” says Burillo-Putze, an emergency physician at Hospital Universitario de Canarias in Spain.
Cannabinoid hyperemesis syndrome does not appear to discriminate between racial and ethnic groups. Although most studies to date include white participants, one July 2021 Study of 29 people, 90% of whom were black, found that repeat emergency room visits were common.
The study found that 16 people returned to the emergency room 42 times and accounted for 10 hospital admissions, for example.
Cannabis conspiracy theories
“Unfortunately, this condition has become the subject of much speculation that hinges on conspiracy theories as its true cause,” Russo notes in a September 2021 letter to the editor in TheAmerican journal of emergency medicine.
A little “myth busting” is in order, he says.
For example, cannabinoid hyperemesis syndrome does not occur due to exposure to products from a tree called neem or pesticides applied to marijuana plants during cultivation, Russo says. It can also happen with high doses of synthetic cannabinoids, she says.
The State of Medical and Recreational Marijuana
Recreational marijuana is legal in 18 states, Washington, DC and Guam as of January 2022, according to a report in US News. More states allow medical marijuana usage: 37 total, plus Washington, DC, according to Britannica ProCon.
One of the states where only medicinal use is legal is Maryland, which is where Vinocur is practiced.
“We’re seeing an increasing number of cases” of cannabinoid hyperemesis syndrome, she says.
In addition to chronic or higher dose use, the higher potency levels of THC in the legal marijuana industry are also likely to trigger the syndrome in some people.
Linda estimates that she ended up in emergency rooms at least half a dozen times in the last 5 years. In April 2021, she had a “pretty serious event”. She blames traveling a lot for work, not eating right, and not getting enough sleep. She broke her 2-year abstinence from alcohol.
“I basically didn’t listen to my body and I paid a pretty high price for it,” he says.
Linda didn’t stop completely, but says she “dramatically changed the types and form of cannabis I was using.”
“I can officially tell you that I would be 100 percent dead without this plant,” she says.
“The prospect of living without it was more damaging to me than all those things I just described to you, because addiction runs in the family and I myself had problems with opiates that I overcame with cannabis.”