Educating Steem: Is There A Disorder Caused by Marijuana?—Cannabinoid Hyperemesis Syndrome
From reading this title, many will already have preconceived notions of my intent. For instance, am I “pro-weed” or not. To set the record straight, I am not for the “war on drugs,” and I also believe that marijuana is far safer than many legal drugs.
Take alcohol for instance, the fourth-leading cause of preventable death (1). 5.9% of all global deaths in 2012 were attributed to alcohol (2). It is also a carcinogen and is attributed to 1/30 cancer deaths. A daily binge drinker increases his or her risk of esophageal cancer by around 50% (3).
So NO, I am not writing this article to warn people about the "terrible dangers" of marijuana because it is rather benign compared to alcohol and cigarettes, which are legal. However, I do wish to inform people that most things have side-effects. If a person tells you, "there is no danger in this," he or she is probably blinded by bias sources or emotional beliefs. This post is not about why marijuana should be legal or its potential health benefits (….which there clearly seem to be many). I will tell about one condition that is strongly linked with marijuana use although it is quite rare.
Cannabinoid Hyperemesis Syndrome:
It is a vomiting syndrome only discovered in the past 12 years and very similar in presentation to cyclic vomiting disorder (CVS). It is characterized by sudden nausea, abdominal pain, and extreme bouts of vomiting that is partially relieved by taking hot showers! WEIRD…. but it is certainly occurring. I have seen it a few times and will discuss that later.
Each “attack” lasts about 24-48 hours. The trigger is usually when a chronic marijuana user stops the drug. It is a “withdrawal from the substance" kind of effect.
Marijuana is a known anti-emetic (anti-vomiting agent). It is commonplace in many states now to medicate chemo-patients with cannabinoids because it truly helps people to stop vomiting. Unfortunately, we don’t understand why marijuana helps stop vomiting fully (partly because it is a Schedule 1 substance and very limited money is available to research it properly). Why it is a Schedule 1 drug while opiates and cocaine are lower?…haha that is a great question.
One Basic Theory:
One theory on why the excessive vomiting occurs is due to the fact that marijuana controls mechanisms in the body that prevent nausea. When one is deprived of this substance, there is a “rebound” increase in nausea. Many people suffering from this syndrome “self-medicate” by smoking more marijuana. When they can’t obtain or choose to stop, it is like a viscous cycle and the vomiting intensifies.
Research into this Syndrome:
Sun and Zimmerman, two pharmacists, did a major literature review on studies to get to the bottom of this issue! They also were striving to help make a viable way to treat and diagnose this condition. They found that this condition usually occurred in chronic users of marijuana for over a year duration (4). They also believe the most probable theory is that the CB1 receptor in the brainstem, a central control for nausea, is a main culprit (4).
In the 4th link provided they also map the symptom course of the syndrome; a prodrome stage lasting months or years where the marijuana user has nausea, fear of vomiting, and abdominal discomfort. The hyperemic stage encompasses the actual vomiting, which can be debilitating. It is during this second stage where a learned behavior to bathe or shower in hot water is recognized.
There is an interesting correlation seen with the CB1 receptor in the hypothalamus of the brain and the regulation of temperature (4). The relief of these symptoms occurs in HOT water. A very interesting/believable scientific suggestion of why HOT water relieves or reduces symptoms.
Lastly there is a recovery stage which generally occurs if the user remains off of cannabis for a period of time.
Complications of this Disorder:
Cyclic type vomiting can be debilitating. Vomiting is well known to remove acid from the body and can make a person's blood more basic. In simple terms, the body needs the pH level to be well regulated and any deviation from normal values can be dangerous. These individuals lose a lot of weight due to lack of appetite/fear of eating being a trigger, which can lead to extreme malnutrition. In addition, vomiting can lead to electrolyte and volume depletion, which can always be dangerous.
Treatment:
Firstly, if the individual has lost lots of fluid, IV hydration should be administered in the hospital for 24-48 hours. In the acuteness of the issue, lorazepam, a benzodiazepine, has been the most effective. Its analgesic/anti-emetic properties were shown to cease nausea and vomiting within 10 minutes (4).
Long term success is obviously from the cessation of cannabis.
A Patient Case:
I have seen cannabinoid hyperemesis syndrome multiple times; one interesting case to report about was during one my emergency medicine rotations last year. I was seeing a patient who was in his early 20s with cyclic vomiting. He was with his girlfriend who reported that he had been vomiting for over a day and would not stop. In fact, he had vomited so much that he had nothing left to bring up. He looked dehydrated, fearful... and just miserable.
When going though a detailed history, I remembered this condition in my differential. I asked, "do you smoke marijuana?" He said, “daily” but had not had any for the past few days….interesting. I then had to ask the bizarre questions…What makes it feel better?…I asked “do hot showers seem to make it better.” At that moment he looked at me like I was a mind reader. In surprise, he said it certainly did!!!
My diagnosis was basically clinched with this information. I told him that he likely was suffering form a vomiting disorder known to chronic marijuana use. I think he would have believed anything after I guessed hot showers made it better haha.
We gave him a benzodiazepine, and as the study suggested, within about 10-20 minutes he felt much better. His volume status was pretty good in a couple of hours, and we discharged him home.
Obviously, we educated him about the cessation of marijuana if he did not want these symptoms to return.
Discussion:
It is important to note that this is a rare condition. Many daily marijuana smokers will never face these symptoms. If one is a chronic user, one most likely will not get this, but one's risk is certainly increased. This is not to scare people away from what they choose to do, but it is meant to be informative. If these symptoms occur, one should strongly consider if he or she wants to face this for years. It is not as bad as getting cirrhosis of the liver or dying of cancer, but it is a debilitating condition.
Marijuana certainly has medical benefits and is a far safer drug than many legal ones, but that does not mean it is harmless. I have witnessed this condition and it makes people miserable! Hopefully in the future, we can learn more about this condition and how to treat it better. One thing is for sure—we need to be able to study marijuana effects more, but the federal government for whatever reason does not make it very easy!
Thank you for reading and feel free to follow me for more medical posts/music!
I am a medical student in my last two months of school
Sources:
1) http://emedicine.medscape.com/article/285913-overview#a1
2) http://emedicine.medscape.com/article/285913-overview
3) http://www.medscape.com/viewarticle/854786
4) http://europepmc.org/articles/PMC3847982
Pixabay Image Links (no sources were necessary)
1) https://pixabay.com/en/man-hippie-geek-glasses-bald-1531903/
2) https://pixabay.com/en/alcohol-hangover-event-death-drunk-428392/
3) https://pixabay.com/en/baking-cannabis-hemp-leaf-1293986/
4) https://pixabay.com/en/disgusting-man-sick-spew-vomit-1300592/
5) https://pixabay.com/en/thinking-brain-head-idea-2006869/
6) https://pixabay.com/en/capsule-drug-gelatine-medicine-158568/
7) https://pixabay.com/en/bend-bent-over-heaving-human-1296747/
8) https://pixabay.com/en/african-asian-black-brown-cartoon-2029984/
EDIT: Link 3 for sources is not working properly and brings up one of my image links. Just check out the corresponding source listed under sources
The usual Dittos! Re Steeming for sure! THIS is an excellent article. I have had some familiarity with the symptoms you're pointing out here. I became a regular cannabis user late in life and had to discover, on my own, any and all effects. I'm happy to admit, without access to cannabis I would be dead... long dead. I would have given up years ago. But it's SO important to get more Responsible Adults working with it in a medical setting. I really believe that I could have avoided many complications if more ADULTS would study this plant like the medicine that it is. It looks like THAT'S what you're doing here!
THANK YOU!
haha thank you for your honesty. It certainly doesn't happen with a majority but it is out there! Before 12 years ago, we had no idea why this was happening. Many people were in misery for years of vomiting because we were only treating the symptoms like a bandaid! Stay tuned for more articles, and I really appreciate the RE-STEEM!
Very informative!
Thanks! I thought it would be a fun post. Appreciate the read.
You speak the truth brother. Upvoted and following you. Good luck in your career and glad to have you on Steemit.
Agreed! And Ditto! Great to have you on SteemIt. I'll be pointing out this article and your work to others. Your medical review is naturally necessary but your professionalism at explaining cannabis in a rational way is sorely needed. Too many "Professionals" come off as way too ignorant to even remotely speak intelligently about a Plant that was made "Evil" by the stroke of a pen.
Followed!
Thanks for the read! Like to get some rare conditions brought to the surface. I also really want to be able to study more on this topic...but more funding is needed in America on most marijuana topics.
Look to Colorado. We're floating in Cannabis revenue! The studies are on the way : )
Colorado sold $1.3 billion worth of marijuana in 2016
Here in Indiana things are a little different haha. More research=better understanding for the pros and cons!
Any drug has its benefits and side effects. I really liked the way you put this in your post. It is way better than a usual pros versus cons fight :)
Thank you for taking the time to read! I think the truth usually is somewhere in the middle on most debates hah. What I did not mention in this article too is dose dependence. The quantity of marijuana was correlated (not sure if linearly or exponentially) to developing this as well.
Well written and informative on this odd condition. You first mentioned this to me a while back and it was interesting when I read up on it. I'm glad you put together a post on it.
I've been super-busy in the hospital this month. 1 day off a week so I thought this would be a fun one I could put together more quickly. I am still thinking of doing one on diet coke but that will take more resources and time. I have gathered some sources for that one too!
Thanks for reading. I like to talk about odd conditions haha!
Diet coke would be a great focus. I have worked with dietitians who have referenced studies that show an increase in sugar craving and the eventual binge.
The brain is too smart to be tricked by artificial sweetener . It will seek what it requires, even the most "disciplined" restrictive eater will ruminate and crave. Diet soda is linked to increased weight gain. Studies have proven that.
I hope my discussion here didn't put you off, I am a great advocate for informed use of any medication.
I have just seen devastating results from both long term anti-emetics, THC, and benzo's.
I have worked in mental health for 20yrs.
But I do support the sharing of knowledge, especially of unusual or rare conditions. You just never know, your post may radically change someone's life.
Thanks
I really appreciate your thoughts. While I have learned a lot and seen a lot, my experience has only began. I for sure think my decesions will change as my experience increases. Great field you are in. I have a passion for psych and family medicine will give me great insight into the field of mental health as well.
I think my stance on artificial sweeteners will be a good one. I will try to put the most evidence based research out there. It may have to be a couple of posts because I also like the views of our biochemist in medical school that actually debunked a lot of misnomers out there about aspartame. However, I will look at the points of weight gain. There are for sure studies out there that do show this sugar craving.
PLEASE! Do one on Diet Coke!
And thank you again!
Will do! Not sure if it will be my next medical post but it is on the horizon!
I like reading about it, lots for me to learn about and I appreciate you taking the time to share your expertise and experiences with these things.
Many people also think of it as a calming drug. But when used for instance by someone with paranoid schizophrenia, it can most definitely exacerbate the symptoms of this very debilitating illness.
There are definitely many benefits to it, but like all medication it's no suitable for everyone.
You speak of anti-emetic medication. The most commonly used anti-emetic in the past is metaclopramide. It can cause dystonic reactions, akathisia and even tardivedyskinesia , which can be an irreversible movement disorder.
Thank you for reading! Certainly, I believe Zofran now is the most common anti-emetic I see prescribed in the hospital. In the 4th source I provided, benzos seemed to be the best acutely for this condition. The other anti-emetic drugs were more refractory.
Zofran is most definitely a better drug (although it is relatively new in comparison) and remains very expensive in some countries, and is only approved for subsidised use for people receiving chemotherapy treatment, and benzos seems to be a very strange suggestion when discussing such things .
Benzos dependence is well known and documented . Lorazapam has a very short half life second only to alprazolam.
I wish you all the best in your career. When you see your first case of acute benzos withdrawal maybe you will rethink its endorsement.
Stopping thc is tough, ceasing benzos can be deadly.
I must add, I'm not at all a thc user, I personally don't like it. But I am not apposed to its use.
I agree with your remarks on benzodiazepines. My advice for use was in the emergency room setting. Benzos are never a drug I would want to prescribe for chronic use. Obviously, you can die from its withdrawal just like alcohol. I am thinking more in the acute setting of perfuse vomiting where other concerns such as volume/electrolyte status are taking precedence.
As for the case of lorazepam, I was going off an evidence based source (number 4). I agree that it does seem odd that a longer acting agent wouldn't be initiated. Very good point!
Unfortunately, zofran is refractory in these cases.
What would you recommend? Replete the fluid and put them in a hot shower? haha.
Thank you for your feedback and for your interest in the topic.
Hyperemesis is a tough one for sure. I'm sure you are quoting evidence based practices. I am always cautious when promoting benzo's as treatment. I know you speak of it being administered in an inpatient setting, but the reality of people self administering is something to be cautious about.
I wouldn't want a young keen and obviously passionate doctor who is only just embarking on his career, to be held liable for someones interpretation of your treatment advice.
For sure noted. I agree that a short acting one seems more dangerous and potentially unnecessary. I wish zofran worked for this condition.
Very nice blog my friend, i enjoyed reading it.
You have the ability to simplified complicated medical concept, i like how you discussed PH level.
keep up good work @tfeldman
Thanks! I really like acid-base stuff. I will consider making an article about its clinical utility. Thanks for reading as always!