Archive for the 'Cannabis' category

Health report from Colorado: Recreational marijuana harms

Dec 15 2014 Published by under Cannabis, Drug Abuse Science

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ED visits to 87 per 125 095 ED visits (prevalence ratio, 1.92) after medical marijuana liberalization (A. A. Monte, MD, unpublished data, December 2014).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.

13 responses so far

Leegalizeetmon

Nov 05 2014 Published by under Cannabis, Public Health

Looks like both Oregon and Alaska passed initiatives to legalize the recreational use of marijuana.

Interesting.

UPDATE:
Oregon's initiative.

Alaska's initiative.


Oregon:

(1) A person commits the offense of use of marijuana while driving if the person uses any marijuana while driving a motor vehicle upon a highway.

(2) The offense described in this section, use of marijuana while driving, is a Class B traffic violation.

a related item that I like because it calls for research:

(4) On or before January 1, 2017, the commission shall:

(a)Examine available research, and may conduct or commission new research, to investigate the influence of marijuana on the ability of a person to drive a vehicle and on the concentration of delta-9 tetrahydrocannabinol in a person's blood, in each case taking into account all relevant factors; and
(b) Present the results of the research to the Legislative Assembly and make recommendations to the Legislative Assembly regarding whether any amendments to the Oregon Vehicle Code are appropriate.

weird exception:

(13) "Marijuana extract" means a product obtained by separating resins from marijuana by solvent extraction, using solvents other than vegetable glycerin, such as butane, hexane, isopropyl alcohol, ethanol, and carbon dioxide.

aha, found this part:

SECTION 57. Homemade marijuana extracts prohibited. No person may produce, process, keep, or store homemade marijuana extracts.

so you can't make solvent extractions for home use but you *can* make vegetable glycerine extractions. Weirder. If the idea is to keep people from doing dangerous stuff with explosive solvents, this would be solved short of prohibiting "keep, or store homemade marijuana extracts", no?

In case you are wondering, vegetable glycerine extracts can be used in vape pen / e-cig type devices.

Alaska:

(b) Nothing in this chapter is intended to allow driving under the influence of marijuana or to supersede laws related to driving under the influence of marijuana.

14 responses so far

Szalavitz on marijuana addiction

Oct 15 2014 Published by under Cannabis, Cocaine, Drug Abuse Science

If I'm going to bash a journalist when she writes something horrible about drug abuse, I must take pains to congratulate her when she writes something pretty good.

Maia Szalavitz' latest "Of course Marijuana addiction exists and it's (almost) all in your head" is actually not bad.
Continue Reading »

3 responses so far

Repost: The War on Drugs Didn't Work, Eh?

Sep 02 2014 Published by under Cannabis, Drug Abuse Science, Public Health

There's a strawman-tilting screed up over at substance.com from my current favorite anti-drug-war-warrior Maia Szalavitz. She's trying to assert that Trying to Scare Teens Away From Drugs Doesn’t Work.

In this she cites a few outcome studies of interventions that last over relatively short periods of time and address relatively small populations. I think the most truthful thing in her article is probably contained in this quote:

Another study, which used more reliable state data from the CDC’s Youth Risk Behavior Survey, concluded that “When accounting for a preexisting downward trend in meth use, effects [of the Montana Meth Project] on meth use are statistically indistinguishable from zero.”

This points out the difficulty in determining broad, population based outcomes from either personal introspection (where a lot of the suspicion about anti-drug messaging comes from, let's face it) or rather limited interventions. Our public policy goals are broad- we want to affect entire national populations...or at least state populations. In my view, we need to examine when broad national popular behavior shifted, if it did, if we want to understand how to affect it in the future.

The following originally appeared 21 July 2008.


If you are a reader of my posts on drug abuse science you will have noticed that it rarely takes long for a commenter or three to opine some version of "The (US) War on Drugs is a complete and utter failure". Similarly, while Big Eddie mostly comments on the liberty aspects (rather than the effectiveness) of the WoD himself, a commenter to his posts will usually weigh in, commenting to a similar effect.

Now I'm open to all the arguments about personal liberty trade offs, economic costs, sentencing disparities, violations of other sovereign nations and the like. Nevertheless, I'm most interested in the fundamental question of whether the War on Drugs worked. That is, to reduce drug use in the US. For those who believe it has not worked, I have a few figures I would like explained to me.

Continue Reading »

10 responses so far

Medical marijuana "researcher" fired by U of A

Jul 02 2014 Published by under Cannabis, Public Health, Science Politics

From the LA Times:

The University of Arizona has abruptly fired a prominent marijuana researcher who only months ago received rare approval from federal drug officials to study the effects of pot on patients suffering from post traumatic stress disorder.

The firing of Suzanne A. Sisley, a clinical assistant professor of psychiatry, puts her research in jeopardy and has sparked indignation from medical marijuana advocates.

I bet. Interestingly I see no evidence on PubMed that this Sisley person has any expertise in conducting research at all. I'm not saying I need exhaustive credentials but I'd like to see a published study or two.

Cue the usual raving about how this is all a vast right wing conspiracy to keep down miraculous medication...

Sisley charges she was fired after her research – and her personal political crusading – created unwanted attention for the university from legislative Republicans who control its purse strings.

“This is a clear political retaliation for the advocacy and education I have been providing the public and lawmakers,” Sisley said. “I pulled all my evaluations and this is not about my job performance.”

Well, this IS Arizona we're talking about. I'm going to want to see more* but I guess I am going to have to score myself as sympathetic to the notion that this was a political squelching.
Still, the University is denying the charge...

University officials declined to explain why Sisley’s contract was not renewed, but objected to her characterization.

“The university has received no political pressure to terminate any employee,” said Chris Sigurdson, a university spokesman. He said the university embraces research of medical marijuana, noting that it supported a legislative measure in 2013 permitting such studies to be done on state campuses.

Ok, "embraces", eh? We'll see if that turns out to be true.

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h/t: clbs

*if this holds true to form the University will be compelled to make a case for how she wasn't competent at the "clinical assistant professor" category of association with U of A.

4 responses so far

CPDD 2014: The XLR-11 synthetic cannabinoid is looking nastier by the day

XLR-11_structureA session on synthetic cannabinoids at the Experimental Biology meeting in April included a talk on nephrotoxicity consequent to use of synthetic cannabinoid products. I covered it in a post. As with a prior report of Cases in Wyoming, the scientist from Oregon reported being able to identify XLR-11 in two of the cases presented. There is not much available on PubMed at the moment regarding the effects of this cannabimimetic. (The XLR-11 structure at the right is courtesy of "meodipt" who submitted it to the Wikipedia page for free use.)

New data presented by Michael Gatch at the recent meeting of the College on Problems of Drug Dependence in San Juan, PR (lovely venue, btw) caught my eye because of an unusual property of XLR-11. Previously, Gatch has looked at a lengthy series of synthetic cathione ("bath salt") drugs in mouse locomotor and rat drug-discrimination assays. This new work is similar, save for the different drug class, so if you want some background reading, that prior paper would be a good complement.

The key, for me, was the drug-discrimination data. This is an assay in which animals are trained to discriminate saline from a reference drug, in this case good old Δ9Tetrahydrocannabinol (THC). In essence the rat is reinforced for responding on one lever if it has received saline just prior to the operant session and on the other lever if it has received THC. Then, on critical test days, you can substitute a dose of some other drug and determine the extent to which the rat responds on the drug-paired versus saline-paired lever. As I've mentioned before, this seems imprecise to the newcomer since seemingly any intoxicant would be scored as "drug" to a rat. Not so. They are actually highly specific in categorizing drugs of similar pharmacological activity.

The interesting thing in the presentation by Gatch was that he showed time-course with bins of about 5 minutes after the start of the session. One drug, XLR-11, popped out as having rapid onset of activity (i.e., full THC responding at 5 min when it takes maybe 10 or 15 for this to occur for THC itself) and a short duration of action (THC-lever responding disappeared after about 15 minutes). I say it popped out because out of a series of cannabimimetic drugs he presented, this one was the only one to have this profile (to my recollection).

This is interesting because in a general sense this tells me two things. First, this is the profile of a drug that is going to engender rapid on/off subjective effects and therefore very likely frequent re-dosing. From a comparative perspective this sounds like enhanced abuse liability to me...i.e., better chances of causing addiction.

The second aspect only hit me when I recalled that XLR-11 was the compound associated with nephrotoxicity. Now, admittedly, it may be the case that XLR-11 itself has a pyrolosis product produced during the smoking of plant matter containing it. But it also strikes me that this rapid on/off pharmacological profile might lead to recreational users simply using more of the products containing this compound than they ever would of products containing some longer acting synthetic cannabinoid. And that might get us back to thinking about what is contained in the various plants used in the products being sold to users.

8 responses so far

Hyperemesis associated with synthetic cannabinoid products

Mar 07 2014 Published by under Cannabis, Drug Abuse Science

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.

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*more likely Scooby Snax?

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Marijuana use rates in 12-17 year olds is highest in medical marijuana states

Dec 18 2013 Published by under Cannabis, Drug Abuse Science

The ONDCP twitter account just posted a very interesting graph on past-month marijuana use rates in the 12-17 year old adolescent population.
TeenMJbyState

This dovetails very nicely with a factoid being twittered today in the #MTF2013 hashtag which is covering the release of the mid-term data from the Monitoring the Future project.

this actually surprised me. That it was so low.

Of course, one's first suspicion is that states which are liberal enough to pass medical marijuana laws might have adolescent populations that are more likely to smoke marijuana anyway, i.e., regardless of the medical legalization. Be nice to see a workup on teen marijuana use in these states before and after they legalized medical marijuana.

8 responses so far

Transitioning to cannabis dependence

Nov 04 2013 Published by under Cannabis, Drug Abuse Science

The conditional probability of dependence on a given drug is a question that is of substantial interest to users, parents of users, public policy makers and heath care providers. After all, if people simply stopped using a drug once a problem arises then many of the negative effects could be avoided. There is a fair degree of correlation between meeting diagnostic criteria for dependence and someone failing to stop using a drug despite clear and growing negative consequences. (Indeed this is one of the dependence criteria). Therefore, we must consider dependence to be a target of substantial interest.

It can be difficult to estimate the conditional probability of dependence in humans because we mostly have cross-sectional data to work with. And so we must infer conditional probability from dividing the currently dependent population by some denominator. Depending on what one uses for the denominator, this estimate can vary. Obviously you would like some population that uses the substance but what represents a level of "use" that is relevant? One time ever? Use in the past 12 months? Use in the past 30 days?

A new paper by van der Pol and colleagues uses a prospective design to provide additional data on this question.

The authors recruited 600 frequent cannabis users, aged 18-30, and assessed them for cannabis dependence at start, after 18 months and after 36 months using the:

Composite International Diagnostic Interview (CIDI) version 3.0 (Kessler and Ustun, 2004), and required the presence of three or more of seven symptoms within the 12-month period since the previous interview (without requiring the presence of all symptoms at the same time). It should be noted that the CIDI includes a withdrawal symptom, which is not included in the DSV-IV manual.

The study defined "frequent" use as 3 or more times per week for 12 months or more. This is important to remember when trying to assess the conditional probability. It all depends on what you construe as an at-risk population. Here, I'd say these were already rather confirmed cannabis fans.

The authors were interested in the very first incidence of dependence and so therefore excluded subjects who had ever met criteria, this left 269 subjects at intake (retention in the study left N=216 at 18 mo and N=199 at 36 mo). This is another point of interest to me and affects our estimation. Three or more times per week for 12 months or more and 45% of them had never previously met criteria for dependence. There are two ways to look at this. First, the fact that a lot of similarly screened users had already met criteria for dependence suggest that this remaining population was at high risk, merely waiting for the shoe to drop. Conversely it might be the case that these were the resistant individuals. The ones who were in some way buffered from the development of dependence. Can't really tell from this design....it would be nice to see similar studies with various levels of prior cannabis use.

There were 73 cases of cannabis dependence of the 199 individuals who were followed all the way to 36 months, representing a conditional probability of transitioning to dependence of 36.7% within 3 years.

Now, of course the authors were interested in far more than the mere probability of meeting dependence criteria. They assessed a number of predictor variables to find differences between the individuals that met criteria and those that did not. Significant variables included living alone, mean number of prior cannabis use disorder symptoms, a continual smoking pattern per episode, using [also] during the daytime, using cannabis to "cope", child abuse incidents, motor and attentional impulsivity and recent negative life events. For this latter, followup analysis identified major financial crisis and separation from someone important as driving events.

As the authors point out in the discussion, the predictors differ from those identified from a more general population. This makes sense if you consider that the range on numerous variables has been seriously restricted by their catchment criteria. The amount of cannabis exposure, for example, did not predict transition to dependence in this study--perhaps because it was well over the "necessary if not sufficient" threshold. This underlines my theme that the denominator matters a lot to our more colloquial estimates of the risks of dependence on cannabis.

Another issue identified in the discussion was the choice to start at 18 years of age for the captured population. Cannabis use frequently starts much earlier than this and many studies of epidemiology suggest that initiation of drug use in the early teens, mid teens, late teens and early twenties confers substantially different lifetime risk of dependence. "The earlier someone starts using, the more likely to become dependent" is the general findings. The authors cite a study showing that the mean age of meeting cannabis dependence criteria for the first time is 18. This is at least consistent with the fact that 65% of their collected sample had previously met criteria for dependence. No study is perfect or gives us the exact answer we are looking for, of course.

A final note on estimating the conditional probability of dependence in the population that uses cannabis 3 or more times per week for over a year. Of the original sample, 331 had already met dependence criteria and were excluded because the interest here was on the first time dependent. If we ignore those 70 people lost to followup during the study, and add the 73 to the 331 then we end up with 76% of those individuals smoking that much cannabis who have already, or will soon, meet dependence criteria.

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van der Pol P, Liebregts N, de Graaf R, Korf DJ, van den Brink W, van Laar M. Predicting the transition from frequent cannabis use to cannabis dependence: A three-year prospective study. Drug Alcohol Depend. 2013 Jul 22. pii: S0376-8716(13)00228-7. doi: 10.1016/j.drugalcdep.2013.06.009. [Epub ahead of print]. [Publisher, PubMed]

26 responses so far

More cannabis hyperemesis Cases

Oct 28 2013 Published by under Cannabis, Drug Abuse Science

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.

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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.
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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]

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