Search Results for "hyperemesis"

Dec 31 2016

Cannabis hyperemesis syndrome rates increase with marijuana legalization

Published by under Cannabis,Public Health

A report by CBS News reports on a 2015 paper:

Howard S. Kim, MD, John D. Anderson, MD, Omeed Saghafi, MD, Kennon J. Heard, MD, PhD, and Andrew A. Monte, MD Cyclic Vomiting Presentations Following Marijuana Liberalization in Colorado. Acad Emerg Med. 2015 Jun; 22(6): 694–699.
Published online 2015 Apr 22.

From the Abstract:

The authors reviewed 2,574 visits and identified 36 patients diagnosed with cyclic vomiting over 128 visits. The prevalence of cyclic vomiting visits increased from 41 per 113,262 ED visits to 87 per 125,095 ED visits after marijuana liberalization, corresponding to a prevalence ratio of 1.92 (95% confidence interval [CI] = 1.33 to 2.79). Patients with cyclic vomiting in the postliberalization period were more likely to have marijuana use documented than patients in the preliberalization period (odds ratio = 3.59, 95% CI = 1.44 to 9.00).

For background on the slow, Case Report driven appreciation that a chronic cyclical vomiting syndrome can be caused by cannabis use, see blog posts here, here, here.

The major takeaway message is that when physicians or patients are simply aware that there is this syndrome, diagnosis can be more rapid and a lot less expensive. Patients can, if they are able to stop smoking pot, find relief more quickly.

As far as the present report showing increasing rates in CO, well, this is interesting. Consistent with a specific causal relationship of cannabis use to this hyperemesis syndrome. But hard to disentangle growing awareness of the syndrome from growing incidence of it. We'll just have to follow these relationships as more states legalize medical and recreational marijuana.

Additional coverage from Dirk Hansen.

No responses yet

Mar 07 2014

Hyperemesis associated with synthetic cannabinoid products

As you know, Dear Reader, a cyclical vomiting syndrome is often associated with chronic cannabis smoking. I've written about it a few more times (here, here, here) and you can check out additional posts at Addiction Inbox (here, here). I urge you to read through the comments posted under all of these blog entries. The numbers definitely rival the published Case Reports in number of affected individuals. Clearly there continues to be many folks suffering who go initially undiagnosed.

A Reader sent me a link to a medical diagnosis challenge published in the Well section of the New York Times recently which returned my interest to the topic. Mostly due to the following comment in the solution column:

Sure enough, there it was – two recent case reports describing several regular synthetic marijuana users who developed a syndrome that was indistinguishable from cannabinoid hyperemesis caused by the real stuff.

I had not seen any such reports so I went looking and found one of them on PubMed.

Hopkins CY, Gilchrist BL. A case of cannabinoid hyperemesis syndrome caused by synthetic cannabinoids. J Emerg Med. 2013 Oct;45(4):544-6. doi: 10.1016/j.jemermed.2012.11.034. Epub 2013 Jul 26.

By now, the diagnosis sounds very familiar. A 30 year old man presented at the ED with nausea and vomiting. He reported a prior history of such episodes, including gastro-enterology workups, scans, endoscopies, etc. Nothing that would explain his symptoms was ever found. The patient had found that hot showers relieved his pain and took several showers per day.

Naturally the patient had started using cannabis at the age of 13 and had been smoking several times per day for years.

Up until this point, everything is very familiar.

This particular individual had been cannabis free for 6 months due to legal surveillance under parole. After cleverly determining with over-the-counter tests that synthetic marijuana products (brand names of K2 and Spice were popular early in the cycle and have come to be familiar as semi-generic terms) didn't trigger cannabinoid positives:

...he quickly resumed his daily smoking habits and in the month before presentation was often smoking synthetic marijuana hourly, including waking up several times at night to get high.

The patient claimed that in the 2 months prior to presentation he'd been using "Scooby Snacks (sic)*" brand exclusively and provided some to the research team. This is cool because the team identified the cannabinoids in the product. It contained several, "JWH-018, JWH-073, JWH-122, AM-
2201, and AM-694" and they also found the patient's urine to be positive for JWH-018, JWH-073 and AM-2201.

As a bit of a sidebar, I really don't know why particular combinations are included in various synthetic cannabis products. It is unclear if it is accident of supply, illicit manufacturers who just throw stuff together at random, the end of the batches or something more intentional. There is an interesting paper from the Fantegrossi group (Brents et al, 2013) that suggests the possibility of synergistic effects.

Returning to the case report, on three month followup it was found the patient manged to remain abstinent and reported remission of his symptoms after the first 2 weeks.

Okay, so typical story for cannabinoid hyperemesis syndrome and in this case the patient had been exposed to multiple cannabinoid full agonists instead of delta-9-tetrahydrocannabinol prior to current episode. Of course his history suggests strongly that it was cannabis smoking that created his liability for the episodes in the first place.

One take-away message over the past several years is that we've rapidly gone from a point where nobody knows cannabis can cause a vomiting syndrome to some reasonable awareness. This is fantastic. The greater awareness, the greater the chances of rapid and accurate diagnosis. If you read the case reports you will see extensive and expensive gastrointestinal testing and diagnostic work in the history of many individual patients. Realization on the part of the patients that they should mention their cannabis smoking helps. Realization on the part of medical staff that they should ask about cannabis helps.

Knowledge can be a powerful bit of assistance for health care.

*more likely Scooby Snax?

One response so far

Oct 28 2013

More cannabis hyperemesis Cases

There was a twitt from Dirk Hansen today

which pointed to Chen and McCarron in Current Psychiatry. This paper seems to be a set of diagnostic and therapy recommendations and contains an example Case Report.

This triggered a bunch of the usual incredulity, in this case from @drogoteca.

those two are but the tip of this person's denialist iceberg on cannabis hyperemesis. He or she is quite convinced that this cannot be a real outcome of chronic pot smoking.

It can and is.

For background, I've discussed the evidence for a cyclical vomiting syndrome associated with cannabis use here, here and here. Also see Dirk's post.

For grins I thought I'd see if there were any new Case reports and found several I had not seen before.

Hickey and colleagues (2013) report a Case of Cannabis Hyperemesis Syndrome that was treated with haloperidol:

A 34-year-old man well known to our ED arrived with epigastric pain, nausea, and vomiting for 4 days. He had been unable to tolerate anything orally but reported temporary relief only with long hot showers. He came to the ED that night to be admitted because he knew his symptoms would not improve, and he was always admitted in the past when his symptoms were so severe. He denied fevers, chills, diarrhea, hematemesis, melena, or hematochezia.

The patient's history was significant for similar symptoms every 2 to 3 months for approximately 10 years. He reported daily cannabis use since 1992, with only short intervals of abstinence resulting in complete resolution of his vomiting. He has been admitted to our hospital from the ED 7 times and had multiple unremarkable diagnostic tests including 3 computed tomographic scans, an esophagogastroduodenoscopy, and several specialty consults. He has also been admitted to several other local hospitals for cyclical vomiting. Other than substance abuse, he has no known psychiatric history. A diagnosis of CHS was finally made in 2012, a few months before this ED arrival.

Mohammed and colleagues (2013) reported a Case (which they are at pains to point out is from the Caribbean) that resolved with abstinence.

A 26-year-old Caucasian male presented to our center with a
1-week history of severe colicky epigastric pain heralded by significant nausea for 3 weeks. He had approximately 20 episodes of bilious vomiting daily with numerous bouts of retching. He admitted to smoking 4 “joints” or marijuana cigars every day for the last 2 years, and denied alcohol and tobacco use. He had 4 similar episodes over the last 6 months. During
these admissions, he was rehydrated and abdominal imaging revealed no abnormalities. His ongoing nausea was relieved
by taking hot showers, of which he took up to 15 times per day, sometimes for more than an hour.


The diagnosis of CHS was made and he was counseled on abstinence from marijuana. Though he refused to enter a substance
abuse program, he remained cannabis-free and on follow-up at 1, 3 and 6 months revealed no recurrence in symptomatology.

Enuh and colleagues (2013)
report a case from the US.

A 47-year-old African American male with a history of epilepsy and drug addiction presented to the hospital with a seizure complicated by nausea, vomiting, and severe abdominal pain. He was known to be diabetic, hypertensive, and addicted to marijuana for 30 years. He smoked two to three “blunts” (cigar hollowed out and filled with marijuana) most days and occasionally up to eight blunts daily. The drug was last taken on the day of his admission.

He immediately went to the bathroom and remained under a hot shower with the exception of two 15-minute breaks for the rest of the day. He believed that a warm shower could relieve his nausea and vomiting. He stated that it made him feel better than medication. Intravenous ondansetron was of limited benefit. It was difficult to persuade him to exit the shower for the rounds and physical examination. Receiving medication and eating were problems because of this compulsive showering. The same event of entrenching himself in the shower had happened 2 months prior to his hospitalization for a grand mal seizure. Abstinence from marijuana during the hospital stay made the patient’s nausea, vomiting, and obsessive warm showering resolve after 3 days.

Not as satisfying as it could be with respect to the workup and the post-hospitalization followup, of course. But interesting.

Sofka and Lerfald (2013) report a series of four Cases. All had histories of chronic cannabis use, all used hot showers to alleviate symptoms and all had negative GI scans and other clinical workups. One individual was reported to have ceased cannabis use and had remained symptom free. The other three were reported as continuing their cannabis use and continuing to have symptoms. Frustratingly, the authors do not specify the followup duration for any of the cases.

Gessford and colleagues (2012) report a Case that is significant for the comment on the efforts to find a cause prior to the identification of CHS:

A 42-year-old Caucasian female, who has routinely been seen at our institution for nausea, vomiting and abdominal pain since 2003, presented with the complaint of nausea, vomiting and abdominal pain. She stated that the symptoms occurred this time after eating four bites of ice cream. ...

Her physical exam was normal except for some mild epigastric tenderness which she attributed to her excessive vomiting. Laboratory studies including a comprehensive metabolic panel, amylase, lipase, and complete blood count were normal except for anemia, which had improved since her last admission. Urine studies, including urinalysis, were normal with a urine drug screen positive for delta-9-tetrohydrocannabinol (THC), benzodiazepines and opiates. Abdominal and chest x-rays were normal.

During the course of her admission, further investigation into her history revealed chronic marijuana use. She reported that long hot showers provided the only relief for her pain and nausea. She claimed that she took so many showers that her bathroom was growing excessive amounts of mold and mildew. Research into her medical records revealed an even more disturbing fact: excessive radiation exposure and medical cost. In total, she has had in excess of 97 abdominal x-rays, eight abdominal CT scans, two abdominal MRIs, an abdominal MRA, small bowel follow-through, three gastric emptying studies, four esophagogastroduodenoscopies (EGD), and three colonoscopies. Since 2003 these tests produced two abnormal findings: (1) the two most recent gastric emptying studies at 224 and 180 minutes (gastroparesis) and (2) gastritis/duodenitis on EGD. Throughout her complete sevenyear work-up, celiac sprue, peptic ulcer disease, Barrett's esophagus, porphyrias, ischemic bowel disease, appendicitis, ulcerative colitis, Crohn's disease and H. pylori infection have been excluded. The patient's medical record indicated that since 2005 she has had 97 emergency room visits. Additionally, since 2007 she has had 42 admissions.

Emphasis added. This is a feature of many of the clinical Case Reports that cannot be ignored. The lack of awareness of cannabis as the causal agent is costly. In terms of the dollar costs of diagnosis and care and in terms of the drugs and invasive diagnostic procedures administered to the patient.

I don't have access to Morris and Fisher (2013) which the Abstract states reports a single Case.

In trolling around on Google I ran across this comment in a pot user forum:

As far as symptoms are concerned, they began about 3 years ago when I would wake up feeling nauseated. Shortly after the nausea started, I'd vomit once and (after smoking) I would feel better. This continued off and on without me giving it much thought until February of this year, when I was floored by intractable vomiting for about 48 hours. I couldn't keep anything down (not even water), and the only time I felt like I didn't want to die was when I was in a hot shower. When the vomiting and nausea finally relented after that first episode, I chalked the experience up to acute gastroenteritis. However, about three days later, I woke up feeling nauseated. I went to work as usual, but by noon I was throwing up unstoppably again and had to go home. By the time evening came around, I could eat light food like white rice and slept. But as soon as I awoke the next morning, I had the same stomach pains and nausea. Again I went to work and again the unstoppable vomiting kicked in right around midday. The only thing that brought relief was a hot shower or bath. So long as I was under hot water, I felt alright.

This person details a history of medical workups and a bit of the recur/remit presentation before ending up with his conclusion:

At this point, I have been completely abstinent from ze herb for 5 days and I have already noticed improvement. Although I, too, was skeptical about CHS at first, I just do not know what else could be causing the problem. Although I absolutely love to get high, at my current weight/height (I am 6'1" and 129lbs now) I am quickly running out of options. If I can't find a solution to this problem soon, it will literally kill me. And I'll be damned if I gonna become the first known death directly related to marijuana consumption.

Naturally, the other forum users express the usual incredulity we see from the leegalizeetmon crowd. It's worth a read.

I also ran across this blog post from a person claiming to be an ER doc:

Since I have become aware of this association between marijuana use and CVS type presentations it has been my “good fortune” to care for nearly a dozen patients in the emergency department who self-reported diagnosis of CVS. Curiously, of these patients about 10 admitted active marijuana use, and the 2 who denied it had positive urine screenings for marijuana. This does not exactly make a case series, but is certainly another interesting observation. Of course, since the prevalence of marijuana use in our Emergency Department seems to approach 100% sometimes, this also may not be a statistically significant association!

I conclude with points I made in prior posts. At the moment, this syndrome is clearly quite rare considering estimates for chronic cannabis users worldwide. Some of this is due to lack of diagnosis..the Case Reports make very clear that an extended history of diagnostic investigation of more usual gastric disorders is typical prior to the identification of cannabis as the causal agent. But even so, very likely this is a rare reaction. Given that, it is not impossible that there is some as-yet-undetermined source of the chronic vomiting that is merely correlated with cannabis use. [In the event your imagination fails you, people tend to suggest moldy weed, herbicide/pesticide and/or contamination from smoking devices as causes.] Nevertheless, it appears to me to be likely that as we accumulate more and more Cases separated by time and place, which involve individual users with a variety of phenotypes and environmental circumstances, which present similar clinical pictures and which seem to have chronic cannabis smoking (not synthetic marijuana products, for example) as the only commonality.... well it becomes very difficult to sustain any alternative hypothesis.

Hickey JL, Witsil JC, Mycyk MB.Haloperidol for treatment of cannabinoid hyperemesis syndrome. Am J Emerg Med. 2013 Jun;31(6):1003.e5-6. doi: 10.1016/j.ajem.2013.02.021. Epub 2013 Apr 10. [link]

Mohammed F, Panchoo K, Bartholemew M, Maharaj D.Compulsive showering and marijuana use - the cannabis hyperemisis syndrome.Am J Case Rep. 2013 Aug 23;14:326-8. doi: 10.12659/AJCR.884001. [PMC link]

Enuh HA, Chin J, Nfonoyim J. Cannabinoid hyperemesis syndrome with extreme hydrophilia. Int J Gen Med. 2013 Aug 19;6:685-7. doi: 10.2147/IJGM.S49701. [OpenAccess link]

Sofka S, Lerfald N. Cannabinoid hyperemesis syndrome: A case series. W V Med J. 2013 May-Jun;109(3):20-3.

Gessford AK, John M, Nicholson B, Trout R. Marijuana induced hyperemesis: a case report. W V Med J. 2012 Nov-Dec;108(6):20-2. [link]

85 responses so far

Aug 15 2012

More cannabis hyperemesis Cases emerge

Just as our most fervent defender of pot posted the most scientifically offensive clause in the legalization initiative defeated by California voters:

5. Cannabis has fewer harmful effects than either alcohol or cigarettes, which are both legal for adult consumption. Cannabis is not physically addictive, does not have long term toxic effects on the body, and does not cause its consumers to become violent.[DM- policy statement, false, false, distraction]

a comment on an older post returned our attention to the cannabis hyperemesis syndrome.

The past year I started smoking a lot more than ever before.
I'm 21, and every single morning I wake up with the worst upset stomach. It gets all the way to the point where I'm running to the bathroom to throw up and nothing ever comes out. The doctors think its in my head. Awesome. When this first began happening I would just make myself throw up but once I began it wouldn't stop for hours and I had to be taken to the emergency room. I feel like I'm dying!! But of course I feel completely better when I go smoke. It's insane!

So I trotted over to PubMed to see what is new, if anything, with cannabis hyperemesis. I found three new CaseReport publications that I had not seen before including:

Nicolson SE, Denysenko L, Mulcare JL, Vito JP, Chabon B. Cannabinoid hyperemesis syndrome: a case series and review of previous reports. Psychosomatics. 2012 May;53(3):212-9. Epub 2012 Apr 4. PubMed

Luther V, Yap L.A hot bath to calm what ails you: the Cannabis Hyperemesis Syndrome. Acute Med. 2012;11(1):23-4. PubMed

Bagdure S, Smalligan RD, Sharifi H, Khandheria B. Waning effect of compulsive bathing in cannabinoid hyperemesis.Am J Addict. 2012 Mar-Apr;21(2):184-5. doi: 10.1111/j.1521-0391.2011.00209.x. Epub 2012 Feb 7. PubMed

There are a total of 6 individuals reported (20-27 yrs of age, 2 female), all of whom presented to medical services (New York, 4; London, 1; Amarillo, TX, 1) with repeated and severe vomiting. All Cases had been smoking marijuana for many years with at least daily smoking in recent months to years. Five of the cases identify multiple uses per day, the sixth just indicates daily smoking.

Medical workups for all six indicated no other detectable gastrointestinal causes. All six Cases include multiple episodes of repeated vomiting in the past which had resulted in emergency department visits or hospitalizations for that patient.

All six had been using hot showers to control their symptoms, selected quotes from different Cases are illustrative:

he persistently demanded to use our showering facilities...He continued to demand to use the showering facilities, and oddly seemed more settled after bathing.

Several times during the interview, he went to the bathroom to put his head under the hot shower, which he said improved his

Ms. B complained that the hospital showers were not warm enough because the best way to relieve her symptoms was to take extremely hot, hour-long showers four times daily.

Three of the cases have evidence that ceasing marijuana smoking prevented further episodes of cyclical vomiting. Three show evidence that returning to marijuana smoking after abstinence led to recurrence of symptoms. Two cases had no followup evidence.

As this evidence starts to accumulate, we need to remember one thing about the Case Reports which is that there is a severe publication/selection bias in this sort of thing. Physicians' motivations to publish are not like ours and what strikes one group of physicians to bother to publish a Report is entirely opaque to me. It is, however, likely only the tip of the iceberg. As a second caution, it may also be the case that their is a bias for the publication of "clean" Cases. For only bothering when the individual Case seems to fit this growing profile to a T. Thus, it may make things about this syndrome appear more clear cut, more severe, etc. This goes both ways but one thing I would be concerned about are those Cases that are indeed caused by chronic cannabis use but are not diagnosed because they don't seem to fit the Case Report literature.

Perhaps hot bathing/showers are not always involved? Perhaps the use history is not as severe as it was for this most recent set of six cases? Perhaps there are some cases in which marginal gastro-intestinal concerns have interacted with a lesser degree of chronic cannabis smoking to push an individual over the threshold to cyclic vomiting symptoms?

There is always the unknown factor. People have proposed unknown toxins in the past...contamination of the cannabis being used. Still not impossible, especially given the apparent rarity of the syndrome. But, I would argue, as the cases occur across time and geography this becomes less likely. You would think that contamination might surround particular drug supplies (in time and space) in a way that might turn up as a geographic patient cluster.

For now, however, the evidence is reasonably strong and it is most certainly growing. Obviously, I think it is well past time for scientists with models that are relevant to emesis to get cranking and start up some studies. Unfortunately rats don't vomit so it is going to require some specialized animal models, perhaps the ferret.

33 responses so far

Apr 28 2012

Cannabis hyperemesis: A brief update

Published by under Cannabis

Dirk Hanson's post on cannabis hyperemesis garnered another pertinent user comment:

Anonymous said...

My son suffers from this cannabinoid hyperemesis. At this moment he is here at my home on the couch suffering. I have been up with him for 3 days with the vomiting and hot baths. He says this time its over for good. This is our third bout. The first two time we went to ER, they put him on a drip to hydrate him, and gave him some pain medicine and nausea medicine. After a few hours he went home and recovered. This time we went to Urgent Care, put him on a drip, pain med, Benadryl, and Zofran. He felt better. That was yesterday, today we are right back with the nausea, but the Zofran limits the vomiting. I'm hoping tomorrow will be much better. He hasn't eaten for 3 days. He let me take a video of him at Urgent Care before treatment, and in the video he was heaving and begging himself with tears never to smoke again. My son has smoked for 14 years.

I reviewed several case reports back in 2010. The comment thread was robust (this was originally posted at the Sb version of the blog) and there was considerable skepticism that the case report data was convincing. So I thought I'd do a PubMed search for cannabis hyperemesis and see if any additional case reports have been published. There seem to be at least 17 new items in Pubmed since the Soriano-Co et al 2010 that I referenced in the update.

One in particular struck my eye. Simonetto and colleagues (2012) performed a records review at the Mayo Clinic. They found 98 cases of unexplained, cyclic vomiting which appeared to match the cannabis hyperemesis profile out of 1571 patients with unexplained vomiting and at least some record of prior cannabis use. The profile/diagnosis was created from the prior Case Report literature that I reviewed but unfortunately I can't get access to this paper to tell you more.

The other thing to think about is the relative increase in case reports in the past year or two. As I think I commented at the time, this is typical of relatively rare and inexplicable health phenomena. The Case Reports originally trickle out...this makes the medical establishment more aware and so they may reconsider their prior stance vis a vis so-called "psychogenic" causes. A few more doctors may obtain a much better cannabis use history then they otherwise would have done. More cases turn up. More Case Reports are published. etc. It's a recursive process.

I think we're seeing this at work.

And as more cases emerge, separated in time and space, the denialist position of blaming a contaminated cannabis product (or bad bongs) gets harder and harder to sustain.

141 responses so far

Jan 28 2010

Cannabis Hyperemesis (UPDATED)

Published by under Cannabis

ResearchBlogging.orgMost of my readers are aware of the growing head of steam being perked up by the medical marijuana movement (and that I think it is a Trojan Horse for recreational consumption). I have also described how perceptions of the harms associated with cannabis are associated with population level use. This suggests to me that it is important to identify adverse health consequences of cannabis smoking ranging from oral health complications to paradoxical potentiation of Ecstasy-induced hyperthermia, to a dependence syndrome in some users that shares some features with nicotine dependence.
I have a new and fascinating consequence of cannabis smoking for your consideration today, Dear Reader. There is an odd syndrome of cyclical vomiting that has resulted in a series of Case Reports. One theme that runs through these is the apparently mysterious presentation at the hospital, since most of the expected causes of severe episodic vomiting were painstakingly ruled out.

Continue Reading »

121 responses so far

Apr 21 2015

The Daily Show is just plain wrong on pot being non-addictive

In the 420 bit from this week, Jessica Williams asserts that marijuana is "a non-addictive proven medical treatment".

Marijuana is most certainly addictive.

In 2012, 17.5% of all substance abuse treatment admissions had marijuana as their primary abused drug. Alcohol alone was 21.5%, heroin 16.3% and cocaine 6.9%.

Daily marijuana smokers use 3 times a day on average and have little variability from day to day.

Pregnant women are unwilling or unable to stop smoking pot almost daily. Increasing numbers of pregnant women are seeking help to discontinue pot use.

At least one woman found out her hyperemesis during pregnancy was the pot, not morning sickness.

Marijuana is addictive in adolescents.

When adolescents stop smoking weed, their memory gets better.

About six percent of High School seniors are smoking pot almost every day.

Clinical trials of medications to help people who are addicted to marijuana stop using are far from rare.

Francophones are addicted to pot.

Yes, Dutch people are addicted to pot.

Many Cases of cannabis hyperemesis syndrome are unable to stop smoking pot, even though it is severely incapacitating them.

Marijuana is addictive.

About 37% of frequent pot users will transition to dependence in three years.

Oh, and pot users are not awesome, friendly and mellow, actually nondependent users are impulsive and hostile on the day they use pot compared with nonsmoking days.

57 responses so far

Dec 15 2014

Health report from Colorado: Recreational marijuana harms

a Reader put me onto a new Viewpoint in JAMA:

Monte AA, Zane RD, Heard KJ. The Implications of Marijuana Legalization in Colorado.JAMA. 2014 Dec 8. doi: 10.1001/jama.2014.17057. [Epub ahead of print][JAMA; PubMed]

The authors are from the Department of Emergency Medicine, University of Colorado and the Rocky Mountain Poison and Drug Center. They set out to describe a few health stats from before and after the recreational legalization of marijuana.

Interesting tidbits:

However, there has been an increase in visits for pure marijuana intoxication. These were previously a rare occurrence, but even this increase is difficult to quantify. Patients may present to emergency departments (EDs) with anxiety, panic attacks, public intoxication, vomiting, or other nonspecific symptoms precipitated by marijuana use. The University of Colorado ED sees approximately 2000 patients per week; each week, an estimated 1 to 2 patients present solely for marijuana intoxication and another 10 to 15 for marijuana-associated illnesses.

This one is obviously frustratingly anecdotal in that there is no real measure of the rate before legalization.

The one on cyclic vomiting syndrome is better:

The frequent use of high THC concentration products can lead to a cyclic vomiting syndrome. Patients present with severe abdominal pain, vomiting, and diaphoresis; they often report relief with hot showers. A small study at 2 Denver-area hospitals revealed an increase in cyclic vomiting presentations from 41 per 113 262 ED visits to 87 per 125 095 ED visits (prevalence ratio, 1.92) after medical marijuana liberalization (A. A. Monte, MD, unpublished data, December 2014).

We've discussed the phenomenon of cannabis hyperemesis before on the blog. One thing we do have to be careful about is that since it has only been recently that the medical community has been alerted to the possibility of cannabis hyperemesis, we should expect the detection rate to increase. Thus, even against a stable rate of cannabis hyperemesis I would expect the reported rate to be increasing.

The University of Colorado burn center has experienced a substantial increase in the number of marijuana-related burns. In the past 2 years, the burn center has had 31 admissions for marijuana-related burns; some cases involve more than 70% of body surface area and 21 required skin grafting. The majority of these were flash burns that occurred during THC extraction from marijuana plants using butane as a solvent.

This is the e-cigarette and vape market at work people. In South Florida they apparently call it 'Budda'.

Apparently some basic pharmacology 101 would be of help to the good citizens of Colorado.

Edible products are responsible for the majority of health care visits due to marijuana intoxication for all ages. This is likely due to failure of adult users to appreciate the delayed effects of ingestion compared with inhalation. Prolonged absorption complicates dosing, manufacturing inconsistencies lead to dose variability

Interesting. I recall the language in the original initiative was very vague about product testing, labeling, etc. Looks like this is a problem.

Ten to 30 mg of THC is recommended for intoxication depending on the experience of the user; each package, whether it is a single cookie or a package of gummy bears, theoretically contains 100 mg of THC. Because many find it difficult to eat a tenth of a cookie, unintentional overdosing is common. Furthermore, manufacturing practices for marijuana edible products are not standardized. This results in edible products with inconsistent THC concentrations, further complicating dosing for users. According to a report in the Denver Post, products described as containing 100 mg of THC actually contained from 0 to 146 mg of THC.8

Oh, and the children. Don't forget about the children.

The most concerning health effects have been among children. The number of children evaluated in the ED for unintentional marijuana ingestion at the Children’s Hospital of Colorado increased from 0 in the 5 years preceding liberalization to 14 in the 2 years after medical liberalization.3 This number has increased further since legalization; as of September 2014, 14 children had been admitted to the hospital this year, and 7 of these were admitted to the intensive care unit. The vast majority of intensive care admissions were related to ingestion of edible THC products.

This Viewpoint certainly draws attention to the edibles/consumables products as being a problem. Seems pretty clear that maturation of product regulation would be a start, so that people are informed about what they are getting. This should probably be supplemented with some sort of public information campaign on the pharmacokinetics of ingested products compared with smoking marijuana. And, you know, keep it away from your kids.

16 responses so far

Jun 21 2013

Regulatory Science at NIH

One of the more fascinating things I attended at the recent meeting of the College on Problems of Drug Dependence was a Workshop on "Novel Tobacco and Nicotine Products and Regulatory Science", chaired by Dorothy Hatsukami and Stacey Sigmon. The focus on tobacco is of interest, of course, but what was really fascinating for my audience was the "Regulatory Science" part.

As background the Family Smoking Prevention and Tobacco Control Act became law on June 22, 2009 (sidebar, um...four years later and..ahhh. sigh.) This Act gave "the Food and Drug Administration (FDA) the authority to regulate the manufacture, distribution, and marketing of tobacco products to protect public health."

As the Discussant, David Shurtleff (up until recently Acting Deputy Director at NIDA and now Deputy Director at NCCAM), noted this is the first foray for the NIH into "Regulatory Science". I.e., the usual suspect ICs of the NIH will be overseeing conduct of scientific projects designed directly to inform regulation. I repeat, SCIENCE conducted EXPLICITLY to inform regulation! This is great. [R01 RFA; R21 RFA]

Don't get me wrong, regulatory science has existed in the past. The FDA has whole research installments of its very own to do toxicity testing of various kinds. And we on the investigator-initiated side of the world interact with such folks. I certainly do. But this brings all of us together, brings all of the diverse expert laboratory talents together on a common problem. Getting the best people involved doing the most specific study has to be for the better.

In terms of specifics of tobacco control, there were many on this topic that you would find interesting. The Act doesn't permit the actual banning of all tobacco products and it doesn't permit reducing the nicotine in cigarettes to zero. However, it can address questions of nicotine content, the inclusion of adulterants (say menthol flavor) to tobacco and what comes out of a cigarette (Monoamine Oxidase Inhibiting compounds that increase the nicotine effect, minor constituents, etc). It can do something about a proliferation of nicotine-containing consumer products which range from explicit smoking replacements to alleged dietary supplements.

Replacing cigarette smoking with some sort of nicotine inhaler would be a net plus, right? Well.....unless it lured in more consumers or maintained dependence in those who might otherwise have quit. Nicotine "dietary supplements" that function as agonist therapy are coolio....again, unless they perpetuate and expand cigarette use. Or nicotine exposure...while the drug itself is a boatload less harmful than is the smoking of cigarettes it is not benign.

There are already some grants funded for this purpose.

NIH administers several and there was a suggestion that this is new money coming into the NIH from the FDA. Also a comment that this was non-appropriated money, it was being taken from some tobacco-tax fund. So don't think of this as competing with the rest of us for funding.

I was enthused. One of the younger guns of my fields of interest has received a LARGE mechanism to captain. The rest of the people who seem to be involved are excellent. The science is going to be very solid.

I really, really (REALLY) like this expansion of the notion that we need to back regulatory policy with good data. And that we are willing as a society to pay to get it. Sure, in this case we all know that it is because the forces *opposing* regulation are very powerful and well funded. And so it will take a LOT of data to overcome their objections. Nevertheless, it sets a good tone. We should have good reason for every regulatory act even if the opposition is nonexistent or powerless.

That brings me to cannabis.

I'm really hoping to see some efforts along these lines [hint, hmmmm] to address both the medical marijuana and the recreational marijuana policy moves that are under experimentation by the States. In the past some US States have used state cigarette tax money (or settlement money) to fund research, so this doesn't have to be at the Federal level. Looking at you, Colorado and Washington.

As always, see Disclaimer. I'm an interested party in this stuff as I could very easily see myself competing for "regulation science" money on certain relevant topics.

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Apr 20 2010

Happy 420 Dudes!

Published by under Cannabis

Just 'cause you know I love you all pot heads....
Cannabis Archive
The Pot Potency data

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