Why do some victims of a cannabis vomiting syndrome avoid it after switching to legal weed?
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It was clear what was wrong with Michael Verbora’s patient.
He smoked about a gram of cannabis a day (the equivalent of two pre-rolls), which helped with insomnia, anxiety and pain.
But while it eased some problems, it created others.
“He had chronic nausea and vomiting, classic cannabinoid hyperemesis, where they show up in the emergency room and have to take hot showers,” says Verbora, a Toronto-based doctor who practices cannabis medicine.
The first step in curing cannabinoid hyperemesis syndrome is to stop consuming. But Verbora’s patient, after a break, switched from grey-market to legal cannabis and started smoking about as much as before. The nausea never came back.
WATCH: It’s a mysterious syndrome that sometimes even emergency department staff have a hard time diagnosing and it’s happening in Saskatoon.
Verbora says it’s the second patient of his for whom a switch to legal weed has worked.
“We know that the (Ontario Cannabis Store, the patient’s new source) has licenced producer cannabis which is regulated. We know that there’s no heavy metals, pesticides, fungus, pesticides. That’s really the only difference that I know of — that there are regulations in effect on medical and adult-use legal cannabis versus the black market, where there’s no regulation.
“I also have seen cases where it came from regulated products. I’m just really scratching my head a lot.”
“The pain sometimes was so bad that I couldn’t get out of bed,” says Tobias Zhuang, a 29-year-old Vancouver man who suffered from CHS for years. “Then I would finally drag myself to the ER and spend a night there hooked on IVs, getting fed painkillers, just vomiting the whole time.”
“There were days where I literally went all day puking, to the point where there’s nothing and I would eventually start puking blood. It got scary after a while.”
Before he quit, Zhuang was smoking up to eight joints a day. He didn’t connect his health problems to cannabis, and doctors didn’t suggest a connection either.
He says he largely didn’t mention his cannabis consumption at the hospital: “I didn’t want them to suddenly look down upon me,” he says. On top of that, it’s self-inflicted. Which it was – I won’t lie. It was totally self-inflicted. But it was mostly because of the fact that it was illegal.”
In a textbook symptom of CHS, Zhuang found relief in the shower.
“We would go through tanks of hot showers,” he says “I would sometimes be in the shower for hours, praying that the water does not run out. But obviously eventually it does.”
“Hot pads were a life saver. When you have no hot water, hot pads are the next best thing.”
Courtney Head, a 31-year-old Fort McMurray, Alta. woman, remembers similar compulsions.
“I would have a craving to be in hot water. Every time I would throw up, I would get in a hot shower, to the point where it was basically burning and drying out my skin.”
For Zhuang, Googling his symptoms led Zhuang to one of several Facebook groups for CHS, and a cure through quitting heavy use.
“I have smoked since I’ve (quit), and it hasn’t affected me yet, but I know if I continue in my old pattern and just keep smoking every day, it will hit me and I will return back to my old self, being hyperemetic and sick.”
WATCH: Heavy pot smokers at risk of getting cannabinoid hyperemesis syndrome
CHS isn’t well-understood. One debate has to do with whether it’s caused by THC (the main psychoactive chemical in cannabis) or by some other chemical that’s present.
“Some of the evidence tends to lend itself to THC ingredients, and that’s the predominant, prevailing hypothesis, but at the same time I have cases like this that cause me to question whether there’s a pesticide involved, or the neem oil that’s sometimes found in products,” Verbora says.
“I don’t have a clear answer yet.”
CHS is sometimes blamed on neem oil, an organic pesticide.
“A lot of people have speculated that (the cause is) a compound called azadirachtin, which is the active component of neem oil,” says B.C.-based cannabis breeder Ryan Lee.
“It’s not used in the legal system in Canada. Because it’s organic, the hippies say, ‘It must be safe to use in our practices,’ thinking that anything organic is inherently safe, which is obviously foolish.”
Neem oil can cause poisoning. It has some of the symptoms of CHS, but not all of them, Kamloops, B.C. doctor Ian Mitchell points out.
“There are some very characteristic things about cannabinoid hyperemesis — the whole hot shower thing, where people get relief. We’ve never associated that with neem oil poisoning.”
Are heavy smokers more affected because they’re consuming more THC, or whether they’re consuming more of another chemical?
“As your consumption goes up, your consumption of toxins, heavy metals and all that would also go up. Your exposure to smoke would also increase,” Verbora says.
WATCH: Everything we know about the health effects of cannabis
One problem in studying CHS is that until legalization, it’s been very difficult for doctors to learn anything about the specific cannabis that was causing the problem. Under prohibition, patients may not have known anything about how their cannabis was produced, or by whom — or if they did, they might not have been willing to talk about it.
“I think it would be great if we could cross-reference these cannabinoid hyperemesis syndromes to specific products in the batch,” Verbora says.
“If there’s a problem in the future with legal products, then we can look back and start to dig deeper into the specifics of it.”
For Lee, the evidence is consistent with CHS being caused by excessive amounts of THC, not some other chemical.
“Legal products are also typically low-potency. The problem with this whole thing is that it’s not a controlled experiment. When you switch source, you could also be switching source on the potency of the product.”
WATCH: Young Canadians perceive alcohol as less dangerous than cannabis while driving, study says
Reports that some users have avoided CHS by switching to home-grown organic weed — which they can be certain is free of pesticides — can also be interpreted this way, Lee argues.
“There’s a huge confounding variable in saying, ‘I’ve started growing my own and the problems have gone away,’ which is that the stuff they were buying was twice as potent as what they’re growing.
“Home growers typically don’t analyze their plants chemically: they just grow it and smoke it. Especially if it’s their first time growing their own, they’re probably not doing a very good job.”
Head says she tried switching to legal cannabis, and ended up just as sick as before.
“I stopped smoking it. I was clean for almost six months, no symptoms, no stomach issues, nothing like that. So of course I got a little cocky and thought, ‘Maybe I can have a little puff now and again. It’s not going to be an issue.’”
“It didn’t help at all. I was smoking the legalized stuff for about a month or so, and I got just as sick as when I was smoking street weed, not even knowing what’s in it.”
As for why it afflicts some heavy users but not others, Verbora thinks it may come down to individual genetic differences in response to cannabis — much as the same joint can make one person excitable and another sedated.
“Cannabis works on the endocannabinoid system, and this system is very different in each of us. The number of receptors we all have is different. How well the cannabinoid system is functioning in all of us is different.
“We know a little bit, and there’s more that we don’t understand than we know. There are a lot of areas of research that we need to really do with this condition.”
One puzzle is that CHS doesn’t seem to exist in some parts of the world, like Jamaica, that have a long tradition of cannabis consumption.
“It does kind of beg the question: if this happens to people who use cannabis all the time, why isn’t that happening in those areas?,” Mitchell says. “Why didn’t we hear about this so much from Amsterdam?”
In the meantime, Mitchell finds that patients sometimes get relief by rubbing hot pepper sauce on their abdomens.
“Capsaicin sauce helps with the pain,” he says. “You rub hot pepper sauce on your belly and that can help treat the pain for this kind of thing.”
It seems to help in much the same way hot baths do.
While doctors say they would like to know more, it seems that capsaicin (derived from hot peppers) and hot water both activate part of the nervous system called the TRPV1 receptor, which may be damaged by very heavy cannabis use.
CHS may simply work differently in different people, Verbora says. Some people are able to start using cannabis again after recovering, and others find they can’t, and have to strictly abstain.
There isn’t an overall national number of patients, but Mitchell says his hospital sees about a dozen cases a month, mostly repeats. There is about one new case a month.
“Some predicted an increase with legalization, but CHS patients usually smoke grams per day and can’t afford the legal market,” he wrote in an exchange of texts.
“In the past, patients wouldn’t believe me because everyone knows cannabis is good for nausea. Now that there are popular articles about it added to physician awareness, it can be dealt with sooner, with fewer Emerg visits.”
Both Zhuang and Head say they experienced cannabis as addictive, something it has a reputation as not being. (Health Canada says cannabis addiction is possible.)
“Most people say weed isn’t addictive,” Head says.
“For most people it’s not — not everybody has these issues. But for me, and a lot of other people going through this, one turns into two, and whatever amount of weed you’re smoking turns to more, and it gets worse and worse and then you’re back to square one, where you’re sick again.”
In her case, she says addiction led to heavy consumption, up to 10 or 15 joints a day on days off, which in turn triggered the CHS.
However, both are in favour of legalization.
“We should never have made it into an illegal thing anyway,” Zhuang says. “There are so many benefits to it. There are people who genuinely need it. I think it should have been done sooner.”
“I’m totally for the whole legalization thing. It’s my issue, right? I have to stay away from it. It doesn’t mean others have to.”People with cannabis hyperemesis syndrome — a problem some heavy smokers get that involves chronic vomiting — are usually told to quit. But some cure it by switching to a legal supply.
Is Marijuana Making You Sick?
Cannabinoid Hyperemesis Syndrome is an emerging illness affecting heavy users of marijuana.
J. Martin Stone
Feb 19 · 5 min read
Have you been a heavy user of marijuana for a few years? Do you have episodes of nausea, vomiting and belly pain every few weeks or months? You might have Cannabinoid Hyperemesis Syndrome.
Cannabinoid Hyperemesis Syndrome, or CHS, was first recognized in Australia in 2004. It affects chronic, heavy users of marijuana. (A heavy user is defined as someone who uses marijuana more than 20 days a month.)
The symptoms of CHS are episodes of abdominal pain and vomiting. In the beginning the symptoms are mild. Perhaps just a little nausea in the morning. This first stage may go on for months, or years.
Things gradually get worse. T h e next stage of the syndrome is severe vomiting, as much as five times an hour. There is also abdominal pain. Each attack lasts for 24 to 48 hours. These episodes recur every few weeks or months.
The only thing that relieves a CHS attack is a very hot shower. It is a fast acting remedy, but only works while the person is in the hot water. A CHS sufferer may shower for hours at a time to keep the symptoms at bay.
The repeated episodes of vomiting caused by CHS can lead to weight loss, dehydration, kidney damage, and in rare cases, even death. To date, there have been two known cases of death from complications related to CHS.
A factor in CHS deaths is ignorance.
It is well known that marijuana is often prescribed to relieve nausea and vomiting. When a user of marijuana begins to experience the symptoms of CHS, they may increase their use of marijuana in the mistaken belief that the extra weed will relieve their vomiting.
That is exactly the wrong thing to do. CHS is not a one time event. It will cause repeating cycles of abdominal pain and vomiting until marijuana is discontinued.
If the marijuana use is resumed, the CHS will also return. Apparently, once CHS begins, the user has to quit weed permanently.
Many users have been smoking weed for decades and have a severe addiction. They don’t want to believe the marijuana is causing their problem. They continue to use, and continue to suffer the misery of CHS.
It is like some people diagnosed with lung cancer, but continue to smoke cigarettes. They don’t want to kick the addiction. They like it too much.
The choice is to live with the misery of CHS, or stop the weed. I don’t know anyone who would want to have to live with repeated bouts of vomiting, so the choice would be easy for most of us. But a person addicted to marijuana will usually have to go through a certain amount of suffering before they are convinced.
It is not publicized much, but trying to break a marijuana addiction can cause withdrawal symptoms. Get professional help, if necessary.
Diagnosis of CHS
An increasing number of people are going to hospital emergency rooms with CHS, but it is still not well known among all healthcare providers. The symptoms of abdominal pain and vomiting are similar to many gastrointestinal illnesses. Sufferers can go for years before getting a correct diagnosis.
The key warning sign of CHS is that hot showers give relief. A knowledgeable doctor will use the following information to make a diagnosis of CHS:
- Long term marijuana use,
- A cyclic pattern of vomiting and abdominal pain,
- Symptoms relieved by a hot shower.
It is likely that many people have never heard of CHS, and do not realize that it is their marijuana use causing their stomach problems. Even healthcare professionals can have difficulty with the diagnosis. CHS is often misdiagnosed as some other gastric problem.
It frequently takes years, and many visits to emergency rooms and doctors to get a correct diagnosis of CHS. So, it is important that marijuana users protect themselves by knowing the symptoms of CHS, and telling their healthcare provider about their marijuana use.
Why is marijuana suddenly causing CHS?
CHS is a relatively new syndrome, and rather unknown until recently. Not much research has been done on what causes it. The only thing known for certain is that it is linked to heavy marijuana use.
But why now, after thousands of years of marijuana use, is CHS suddenly appearing? There are theories, but large, randomized scientific studies have not been done to learn the facts about CHS.
There is some speculation that legalization of marijuana has resulted in higher grades of marijuana being available. It is much stronger than the marijuana that was used a couple decades ago. There is a theory that use of this high grade weed causes a higher than normal buildup of cannabinoids in the body.
Recovery from CHS
The good news is that cessation of marijuana seems to end the severe symptoms of CHS.
Hospitalization may be required to replace fluids lost due to vomiting. It can take much longer for a person to regain the weight lost due to CHS. Full recovery may take several months.
It is not yet known if there is any long term damage from CHS because the syndrome hasn’t been around long enough.
Should marijuana use be curtailed due to the danger of CHS?
I quit using marijuana many years ago because I felt that smoking weed was sapping my energy and ambition. My quitting had nothing to do with CHS. It was more about my inability to be responsible. All aspects of my life were going to hell because I was high all the time.
But when marijuana is used in moderation, I think it is relatively harmless. Driving a car or using power tools while stoned is a bad idea, but I don’t think occasional use is necessarily bad.
Personally, I think marijuana is similar to alcohol in some respects: An occasional drink, or joint, is harmless. But drinking a lot of booze everyday, or smoking a lot of reefer everyday, will become a problem.
I favor the legalization of cannabis
The only ones that are currently benefiting from illegal sales of marijuana are criminal gangs. Having it sold legally would provide a way for sellers to make an honest living, as well as provide the government with tax revenue.
But marijuana has to be used responsibly. Legalization has to come with regulation to avoid things like driving under the influence, use by minors, public intoxication… In other words, marijuana needs to be regulated the same as alcohol.
Legalization might also spur additional research into CHS. No one currently knows what substance in cannabis is causing it. If it was known, maybe a safer marijuana could be developed. But due to marijuana being illegal in most of the USA, research into CHS is largely overlooked by the medical establishment.
In the meantime, be aware of the possible danger of CHS. If you are diagnosed with CHS, or suspect you have it, there is good news: Quitting marijuana will cure you.
The bad news is that once afflicted with CHS, you must avoid cannabis forever. Get your high with something else, and have a good life.Cannabinoid Hyperemesis Syndrome is an emerging illness affecting long term users of marijuana. It causes repeating cycles of nausea, vomiting and abdominal pain. ]]>