Cannabis Hyperemesis (UPDATED)

January 28, 2010

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.


Allen and colleagues (2004) reported a series of 14 consenting (of 19 approached) individuals from South Australia, 9 of whom could not be excluded for obvious confounds. The remaining 9 cases all had suffered from a cyclical pattern of sustained episodes of vomiting which remitted and then returned weeks or months later. They also comment on a case one of the authors had published in 1996 of a similar case attributed to “psychogenic vomiting”.
Roche and Foster (2005) identified a case of a 21 yr old New Zealand man who was admitted to hospital seven times over a two year period with severe vomiting. All of the usual suspects were excluded in medical tests and workups.
Sontineni and colleagues (2009) report a single case of a 21 yr old male from Omaha Nebraska in the United States who suffered from 2-3 hr bouts of uncontrolled vomiting several times per day during a symptomatic episode.
Donnino and colleagues (2009) report on three cases from the Boston area of the United States. In this case all three were males (22, 23, 51 yo) and were found to have visited the Emergency Department many times over approximately 2 year intervals with episodes of severe emesis. The striking thing about this case report is the description of extensive medical workup undergone trying to determine or rule out various causes for the vomiting. E.g.,

a 51-year-old man who presented to the ED with nausea, vomiting, and abdominal pain. The patient had experienced similar episodes over the previous 2 years (2006 -2008), involving 10 ED visits and four hospital admissions, during which he underwent a total of two EGDs, one colonoscopy, several abdominal
ultrasound examinations, and four abdominal CT scans, with no clear cause for his symptoms identified.

Not cheap!
There were two striking similarities across all these cases. The first is that patients had discovered on their own that taking a hot bath or shower alleviated their symptoms. So afflicted individuals were taking multiple hot showers or baths per day to obtain symptom relief.
The second similarity is, as you will have guessed, they were all cannabis users. The cannabis use predated the cyclic hyperemesis, typically by many months to a few years. Cannabis use was also fairly heavy with the afflicted individuals smoking multiple times per day. In those cases where individuals were able/willing to stop using cannabis, the cyclic vomiting remitted. In at least three cases (from Allen et al) individuals were unable or unwilling and the cyclic hyperemesis continued.
It will not escape your attention that one of the supposed medical indications for cannabis smoking is the prevention of nausea and emesis, particularly in those undergoing chemotherapy for cancer. Anti-emesis is an expected property of cannabis ingestion. Cyclical hyperemesis is not. The symptom relief provided by hot showers or baths only fuels additional curiosity. Consequently, there are very intriguing scientific questions arising from these Case Reports. Very intriguing indeed.
Overall this is a fascinating tale and clearly, given the timeline of the publications (this is not an exhaustive list), an association that is only beginning to be recognized. Presumably it is not a highly common syndrome because the cases are often relatively young and there have been plenty of chronic cannabis smokers around for decades. If it were a common feature of chronic cannabis you might expect it would have been identified earlier. Nevertheless, even if this is rare, if we continue to enact polices which will increase the amount of cannabis smoking or the number of chronic smokers this syndrome might be expected to rise.
UPDATE (02/18/10): I was actually motivated to do the research into this by news of another paper which has finally become available. It describes eight more cases of the syndrome.
__

Literature Cited

Allen, J. (2004). Cannabinoid hyperemesis: cyclical hyperemesis in association with chronic cannabis abuse Gut, 53 (11), 1566-1570 DOI: 10.1136/gut.2003.036350
Donnino MW, Cocchi MN, Miller J, & Fisher J (2009). Cannabinoid hyperemesis: A case series. The Journal of emergency medicine PMID: 19765941
Roche E, & Foster PN (2005). Cannabinoid hyperemesis: not just a problem in Adelaide Hills. Gut, 54 (5) PMID: 15831930
Sontineni SP, Chaudhary S, Sontineni V, & Lanspa SJ (2009). Cannabinoid hyperemesis syndrome: clinical diagnosis of an underrecognised manifestation of chronic cannabis abuse. World journal of gastroenterology : WJG, 15 (10), 1264-6 PMID: 19291829

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119 Responses to “Cannabis Hyperemesis (UPDATED)”

  1. Barn Owl Says:

    What’s known about the expression levels and types of cannabinoid receptors in the area postrema? I know there are high numbers of dopamine receptors in that “vomiting center”, but not much about any other receptors.

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  2. DrugMonkey Says:

    In a word yes, Barn Owl.
    Rats don’t vomit so the ferret is one model. Sharkey KA et al have a couple of papers showing CB1 receptor mediated inhibition of emesis in the dorsal vagal complex which includes area postrema. There are a couple of other studies in other species showing CB receptor expression and/or activation of immediate early genes in these regions
    The anti-emetic rationale is there. Question is, what sort of plasticity with chronic smoking is inducing what sort of dysregulation that leads to episodic emesis? Maybe I should drop that ferret lab a line and ask them about chronic exposure…hmmmm

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  3. Barn Owl Says:

    Yeah, I can see where simple confirmation of cannabinoid receptor in area postrema/dorsal vagal complex, in support of an anti-emetic rationale, might lead to complacency and no further investigation of receptor levels. The plasticity question, in the context of chronic exposure, would be really interesting to address … perhaps also from the standpoint of a patient who uses marijuana to ameliorate the nausea associated with chemotherapy. Are we talking years or months of chronic exposure? That might make a difference to a chemotherapy patient.
    The relief through hot shower or bath phenomenon is intriguing, and I think makes it all the more interesting to look at area postrema/dorsal vagal complex in the context of chronic exposure.

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  4. Healthdoc Says:

    “Nevertheless, even if this is rare, if we continue to enact polices which will increase the amount of cannabis smoking or the number of chronic smokers this syndrome might be expected to rise.”
    DM – This isn’t good science. It’s like Fox News saying “Some say…” then using that unsupported premis to launch a nonsensical fear based senario.
    You’ve not established a causal link before you start your therefores. You’re letting your bias interfere with your logic.

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  5. ZenMonkey Says:

    I’m curious — was the marijuana in question tested in any of these cases? I am a legal medical marijuana patient (and am happy to present my medical “bona fides” as to the Trojan Horse issues) and I receive my meds from only one dispensary, where I know and trust the people who run it legally, and where the marijuana is of top quality.
    I have had some pretty unfortunate effects from crappy weed sold by drug dealers in disguise as “compassionate” providers, before I found and stuck with my current dispensary. Is it possible that something in the marijuana was causing this problem?
    Even though cannabis has anti-emetic and anti-nausea properties, it does need to be used correctly or it can certainly cause nausea or vomiting. This isn’t news (not referring to these hyperemesis cases). It’s also worth noting that many medical marijuana patients who use it for legitimate symptom relief do not smoke it, but rather vaporize or use edibles, tinctures, etc. Smoking a joint (or several) wrapped in thick paper using a cheap lighter will definitely introduce a host of yucky chemicals that have nothing to do with the cannabis, and this might be a contributing cause as well.

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  6. PalMD Says:

    You know I heart you Zen, but that seems like a bit of a stretch. It is possible, is it not, that this syndrome exists but you happen to be one of the majority who doesn’t suffer from it, no?
    @Healtdoc: i think you need to re-read it. Your interpretation isn’t supported by DM’s text, which contained a lot of qualifications, “ifs”,etc.

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  7. ZenMonkey Says:

    By no means am I implying that this syndrome doesn’t exist. I really do find this report interesting and I don’t deny the cases. I’m only pointing out that there are associated problems with cannabis smoking that might be contributing factors, that were not examined at all in this article. (I admit I haven’t read the linked papers themselves yet.)
    Contrary to the stereotype of the overly defensive MMJ patient, I find these kinds of reports useful and important. But due both to my personal bias and my skepticism, as well as DM’s self-professed bias, I’m interested in what else might be going on. My comments are not meant to discredit the post, but rather to point out those potential contributing factors. And I additionally appreciate that DM DOES admit his feelings on the matter, even if we disagree.

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  8. DuWayne Says:

    Bad form DM, bad form indeed. I am sorry, but Healthdoc is dead on here, you are totally sounding like a FOX news report with this post. There are more than a few holes in this that make you sound very much like someone who wants this to mean what you seem to think it means.
    Come up with actual evidence that the cause is actually cannabis and not one of the myriad possible corelates – including smoking joints, smoking moldy cannabis, smoking cannabis that is covered in pesticides, smoking through water pipes that contain foul, moldy water, smoking through solid pipes that contain molds, etc. Also, come up with evidence that medical cannabis or legalization is likely to cause an increase in smoking, because in my experience, people who have not previously been smokers, tend to use other delivery methods.
    Come up with the evidence and we will talk about this rather rare syndrome. It is pointless to even try, when all you are doing is mimicking “Americas most trusted news source.”

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  9. DuWayne Says:

    Pal –
    I personally wouldn’t argue that it doesn’t exist, I just question the actual cause. Mainly because I have gotten rather ill from smoking, but when I have it was from smoking rather rank weed. The symptoms sound very much like what I have experienced.
    And I am not averse to accepting that cannabis itself is to blame, but what we have here is not very informative…

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  10. Pedro A. Ballester, M.D. Says:

    GIGO
    http://www.newscientist.com/article/mg20527446.100-its-lack-of-balance-that-makes-skunk-cannabis-do-harm.html
    Millions smoke for recreation, Marinol is supposed to stimulate appetite (mixed response in my limited clinical experience).
    Where is the EBM? Are randomized clinical trials possible? Which strain of plant would be studied, all of them?
    There won’t be any funding because there is no Big Pharma profit potential…
    In my state, pot is not legal, on what grounds can I endorse or refuse a patient request if it becomes legal with a Physician’s prescription?

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  11. bsci Says:

    Granted fewer people take Marinol, than smoke pot, but, fi this is due to cannabis, wouldn’t you expect it to have some occurance in some of the pill based users? Of course, in the pill population, they are all really sick and many have nausia for other reasons making this harder to identify.

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  12. DrugMonkey Says:

    Multiple geographically dispersed individuals, syndrome that expresses over almost two years….don’t you think it is a tad wee bit of a stretch to blame mouldy weed, DuWayne?

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  13. Dr. Ballester, there actually is profit potential for Big Pharma as evidenced by the continuing development and approval in non-US countries for a product called Sativex from GW Pharmaceuticals. DrugMonkey has written about it here somewhere.
    Sativex is one of a couple of oromucosal spray products that are made from extracts of cultivars of two kinds of Cannabis sativa, one optimized for Δ9-THC and the other for cannabidiol (CBD). Data are suggestive that CBD offsets some of the reinforcing euphoric effects of THC and contributes to efficacy against N/V of cancer and muscle spasticity in MS.
    Most interesting about this buccal spray is that it contains dozens of other related cannabinoids. Some patients complain about Marinol because it is sometimes dysphoric – one of very few examples where purifying just one compound from an herbal extract is inferior. There have been some setbacks with Sativex approval but it is about as close as one with get to a standardized Cannabis medicinal.
    All of that is to ask our blog host whether any incidence of cyclical hyperemesis has been reported in Sativex trials – I can’t seem to find any.

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  14. Pedro A. Ballester, M.D. Says:

    Abel, you can call me Pedro!
    Your response proves my point:
    “approval in non-US countries”
    Some people feel that the discrimination against pot is racially originated, it was the Mexicans and Blacks that were the most frequent users…

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  15. Isabel Says:

    Does anyone have any idea why the hot bath and shower relieve the symptoms? One thing that might be geographically neutral and result in remission with abstinence is some type of overeating or obsessive unhealthy eating caused by the munchies. Were allergies considered? Can those types of symptoms be caused by overeating the same unhealthy foods compulsively? I read about the syndrome a while ago and don’t remember diet being discussed.
    I just heard a report on the radio about some teens hospitalized for convulsions after eating brownies, and that the tests showed the only “illicit” substance found in the brownies was pot (funny that only illicit substances were looked for), and I believe the providers of the brownies were arrested, or were going to be. The announcer then immediately segued into a report about cannabis legalization qualifying for the Nov. ballot in CA. This is the 2nd time in the last few weeks I’ve heard a report on legalization immediately following a scare story. Annoying! And I’ve never heard of MJ causing convulsions.

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  16. DrugMonkey Says:

    And, Dr. Ballester, there are some that feel that constantly banging on about the alleged motivations for century old laws is a convenient emotional argument, but should have little bearing on any evaluation of adverse consequences of a drug.

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  17. cannabinoid geek Says:

    wow, i’m surprised at how little is known about AP/DVC cannabinoid signaling. i see that IPSCs and EPSCs are affected, but that’s very narrowly focused and doesn’t tell us much about overall expression patterns…
    at any rate, different cellular milieu in different types of neurons could lead to differential downstream signaling response/desensitization in response to repeated exposures. consider there are multiple known variants in the cnr1 gene and we have no idea how these might affect receptor interactions with downstream stuff, there are a lot of unknowns on the presynaptic side- and don’t even get me started on how that would affect the postsynaptic and beyond. i would also be interested to see if Sharkey et al have tried chronic exposure.
    the adulterant idea is not outside of the realm of possibility, but doesn’t seem like something that would be easily isolated to say, a bad lot of rolling papers or a field oversprayed with a particularly nasty pesticide or whatever. considering the relative value of case reports on the quality of evidence spectrum, the observations are merely suggestive and interesting. i’m familiar with having to carefully word posts of this nature, and i don’t think DM is too far out of line with the wording…

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  18. Dude, this is the dumbest shit I’ve ever heard in my life. So many bajillions of fucking people smoke weed, that of course any bizarre unexplainable medical condition is gonna have some prevalence in people who smoke weed. This is about as relevant as attributing this weird emesis shit to drinking coffee, or eating french fries.

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  19. WcT Says:

    I’m only at all familiar with this becuase we had a patient who my senior resident insisted had this syndrome. He presented a couple of the articles DM has referenced here.
    I don’t disagree that this syndrome COULD be caused by marijuana, but a few case series doesn’t really fulfil Hill’s viewpoints very well.
    I also agree with CPP – high prevalence of pot smoking in the general population. That combined with survivorship bias, and a less than rigorous definition of the clinical syndrome, makes this one seem weak at best. Certainly not a policy changer.

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  20. Adiemusfree Says:

    I can only repeat the mantra ‘correlation is not causation’, and suggest conclusions from clinical anecdotes are rather fraught with all the confounds we don’t like to see in science. I appreciate the rider you included that it is your opinion that medical marijuana is a Trojan horse for widespread decriminalisation or recreational use, but at this stage I’m inclined to support Professor Doug Sellman’s (Otago University, NZ) view that marijuana use currently poses low risk to health, and certainly by comparison with alcohol use (even in moderation).

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  21. Isabel Says:

    Certainly not a policy changer.
    It also sounds pretty bogus to me, WcT, but how do you account for the fact that those who are able to stop go into remission when they are not using? Is it psychosomatic?

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  22. Alex Says:

    Dude, this is the dumbest shit I’ve ever heard in my life. So many bajillions of fucking people smoke weed, that of course any bizarre unexplainable medical condition is gonna have some prevalence in people who smoke weed. This is about as relevant as attributing this weird emesis shit to drinking coffee, or eating french fries.

    I heard that the people with this condition have all consumed dihydrogen monoxide. Some of them even claim that they can’t live without it.

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  23. DrugMonkey Says:

    CPP, WcT et al….when even *Isabel* picks up on the cessation aspect….well….you guys aren’t even trying to make any sense are you?

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  24. mari juana Says:

    “how do you account for the fact that those who are able to stop go into remission when they are not using?…….”
    Isabel,
    That’s love or lack of it !
    “Risa o Quebranto, los dos materiales que forman mi canto……” (Mercedes Sosa)

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  25. hoots_mon Says:

    For my own (totally anecdotal!) experience, I’ve seen a lot of people smoke a lot of weed, the ONLY time I’ve ever seen anyone vomit it was of two causes. 1) what we here in Scotland call a ‘whitey’ (basically you go white as a sheet and then throw up). Pretty common from either smoking far too much weed, or mixing weed with alcohol does it to a lot of people. I’m sure that is a pretty commonly documented effect though which goes away pretty quickly. 2) smoking weed that has seeds still in it. EVERY time someone has smoked weeds with the seeds in them, they have been pretty nauseous, a lot of them being sick.
    In both cases this was not typical ‘use’ of the drug that caused it, but misuse through either not knowing your limits, or not knowing to remove any seeds in it before you smoked it. The reason I mention this is how can you possibly tell whether it is standard and correct use of the drug that caused this, or some kind of misuse? And seriously, wtf, how much do you think useage will rise because of policies, will it double? Very unlikely. Does the risk of such a rare increase really warrant a whole fuckton of money spent on policy development, is it that much of a big deal, especially if you can just tell these people not to smoke? I know people who are intolerant to dairy and it makes them vomit, but they can’t help but have a sneaky bit of cheese sometimes. Oh noes!!1! ban the cheese! seriously, whats the evidence that this is of enough risk and importance to base policy on, other than maybe a health warning?

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  26. This is just another shoddy brick in the “weed is so totally not harmless” wall, fighting the good fight against the monstrous “weed is so harmless” strawman. This fight is morally and pragmatically dubious, ignoring as it does the facts that (1) no one making serious public policy arguments is arguing that weed is completely harmless and (2) the only question relevant to the public policy dimension is comparative harm.

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  27. PabMD Says:

    “And, Dr. Ballester, there are some that feel that constantly banging on about the alleged motivations for century old laws is a convenient emotional argument, but should have little bearing on any evaluation of adverse consequences of a drug.
    Posted by: DrugMonkey | January 28, 2010 10:26 PM”
    I hope we all know and accept that the majority of drug addicts (alcoholics, pot smokers, et al..) are white Caucasians. We need to remember the history of all current events without dismissing it as “a convenient emotional argument” IMHO
    I am just a Clinician in the trenches, not a researcher, I would like to have trusted scientific evidence to guide my clinical decisions, I am still waiting…
    I am forced to continue to fly by the seat of my pants, if a terminally ill patient wants to use cannabis because it helps them relax, who am I to criticize them?

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  28. DrugMonkey Says:

    ignoring as it does the facts that (1) no one making serious public policy arguments is arguing that weed is completely harmless
    totally and utterly false. Save for an unbelievably selective definition of who you consider “serious”. Each and every source, from Nutt to NORML and gang to *the very language being used in ballot initiatives and legislative bills* makes some version of the arguments seen here in comments on my cannabis posts. Insinuation or outright statement that pot is totes harmless is rampant. Ludicrous attempts to reframe a simple scientific body or work (as you just attempted!) through ignoring a major feature of the design. Handwaving too-many-notes or some other silly critique that has nor recognition of the progress of science or the methodological approaches of a subfield. Willful abuse of correlation-is-not-causation triumphalism. Etc.
    All very much part and parcel of the debate from street all the way into legislative bodies. Your accusation of it being a straw argument doth reek, as it were, of the scarecrow itself.
    (2) the only question relevant to the public policy dimension is should be, IMO, comparative harm.
    FTFY. But even if we credit this argument, you need to evaluate what the actual harms *are*. Not constantly insist that every scientifically identified and characterized harm doesn’t exist. Nor to engage in fantasies that pot smoking won’t increase in a more legally permissive environment. Yet less to engage in ludicrous gymnastics trying to claim that increased population level use won’t scale up the clearly identified problems associated with consumption.

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  29. Dude, you’re harshing my buzz, man.

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  30. DrugMonkey Says:

    without dismissing it as “a convenient emotional argument” IMHO
    When people who are pot fans first and foremost but have no apparent interest in social justice vis a vis the browner folk start in about the racist history of the anti-weed argument…what else would you call it?
    what do you call the arguments of fundamental Christers who discover a mysterious latent affection for Jews and Israel just because they want to shore up their argument for practicing war against mutual enemies?
    Same thing. A convenient and disingenuous argument.

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  31. DrugMonkey Says:

    Dude, you’re harshing my buzz, man.
    See, now that is an honest bit of commentary about the real reasons for people getting all upset about my cannabis posts….

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  32. DuWayne Says:

    Multiple geographically dispersed individuals, syndrome that expresses over almost two years….don’t you think it is a tad wee bit of a stretch to blame mouldy weed, DuWayne?
    No, not really. Especially as that is not the only possibility I listed. The important thing about that list, is that those are common contaminants related to smoking pot. Both of them are also contaminants that one might well get consistently, using the same source. And both are capable of inducing some horrendous nausea and brutal vomiting, though the more extreme end of that reaction isn’t common.
    And again, I don’t doubt that cannabis alone may account for this. But a rare condition such as this is not something I am going to worry overmuch about.
    Nor to engage in fantasies that pot smoking won’t increase in a more legally permissive environment.
    But there is good reason to believe that pot smoking will not increase – at least by any significant factor. Given the choice, a lot of current pot smokers would prefer a different delivery method – but as far as buzz/pot ratio works out, smoking is more efficient.
    As far as more people using cannabis, I don’t see a lot of evidence that there is likely to be a massive, long term increase in use. I don’t doubt there will be an increase in use, but I think that increase will be balanced quite nicely by providing stronger tools for addiction clinicians and especially by the overall dramatic reduction in peripheral harms.
    I think it is important to understand the harms associated with cannabis use and the use of other drugs. I also think it is important to look to the possible problems that will arise specifically due to legalization – something that is considerably more challenging. But just as I think it is important to consider these issues with the understanding that drugs – including the magical cannabis – are not harmless, I also think we need to understand that legalization is not going to hearken the end of the world.
    Being realistic means just that, being realistic. Being FOX news is not realistic.

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  33. WcT Says:

    The discontinuation argument in a small case series without any epidemiology is pretty much meaningless as you’ve described it so far, Isabel or no Isabel.
    The clinical syndrome of cyclical hyperemesis described here is NOT rigorous enough to have consistently identified it across a broad population or gathered any real stats on it’s prevalence or incidence. The definition is just strict enough to cherry pick every hyperemesis case that happened to smoke pot, and then not include the cases that didn’t improve with discontinuing pot. Without comparison groups, control groups, epidemiology, much in the way of basic science, this is an interesting idea, not a well supported hypothesis.
    Put another way, if we changed every reference here about marijuana to “vaccines” and every reference about hyperemesis to autism spectrum symptoms you’d have more or less the same argument, and same level of evidence used by the “mercury in vaccines causes autism” quacks, and when they put forward small case series, I say the same thing – not enough support.
    Look noone here is trying to say weed isn’t dangerous. I don’t smoke weed, I don’t advocate people smoking weed, I don’t think we should legalize it, I don’t think medical marijuana is an evidence based therapy. Weed can be bad without being the cause of all sorts of unproven badness.
    Let’s be intellectually honest, I would ask for more evidence if DM presented this in favor of an alt-med therapy. If a woo-meister presented me articles like this, I’d criticize the methodology, the stats, the potential for cherry picking, and so on. Why does DM get a pass on this for his pet theory?
    If you go to my blog and check out my posts on vaccines and autism, you’ll see VERY similar arguments from the cranks showing case series where patients “got worse” after vaccination” and “improved” after chelation therapy, which is directly analogous to this – a high background prevalence of an unproven “risk favor” with improvement on “discontinuation” of the risk favor. I don’t accept those arguments from the cranks, why should I accept them here? DM knows better than to say a small case series should change a doctor’s practice style, so why should he think we’d consider it for public policy changes?

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  34. WcT Says:

    See, now that is an honest bit of commentary about the real reasons for people getting all upset about my cannabis posts….

    Really DM? if you look back, I’ve commented in favor of your other cannabis posts all over the place, and on PalMDs threads criticizing medical marijuana use not evidence based I commented there too. You’re just lumping people who criticize you into “pot smokers” here, not cool, nice way to avoid any legitimate discussion and poison the well.

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  35. Maia Szalavitz Says:

    Many drugs used chronically cause the opposite effect of the initial use– that this may happen rarely with cannabis would not be surprising.
    The showering relief thing suggests to me a vagus nerve component– as warm water can stimulate it to generate a parasympathetic response, no?
    I have to say your “Trojan horse” argument fails completely because in the cases where recreational use has been decriminalized or even quasi-legalized, marijuana use has either fallen (particularly amongst youth) or remained the same. There was some suggestion that commercialization in Holland resulted in higher use rates for a time– but Holland still has lower use rates than the U.S., particularly among young people.
    Philip Morris marijuana with full advertising is certainly a bad idea– but the notion that all forms of decrim stokes use rates is completely unsupported by empirical evidence, which shows the opposite.

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  36. Vicki Says:

    bsci@11–
    What that suggests to me is that if the patients are reacting to something in cannabis (which is at least a useful working hypothesis), that something isn’t the chemical in Marinol. The thing about cannabis, or any herb, is that there are a lot of chemicals in there; the patients described here could have developed a sensitivity to one of the others. “Developed” because they’re all described as long-term users with a new symptom; someone who had that reaction the first or even third time they used marijuana would probably stop. At the thousand-and-third, they might not make the association with that rather than with a hypothetical infection, or equally hypothetical new food sensitivity.
    If medical marijuana ever gets to the point of being neatly packaged, with the standard inserts I get at the pharmacy for other drugs, this should probably be on the long-form sheet which includes rare side effects. (Maybe something like “rare, but if this occurs, discontinue use, take a hot shower, and call your doctor.”) And, again, if people are pursuing this seriously, it would be worth investigating whether it ever occurs in people who eat or vaporize rather than smoking the drug.

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  37. DrugMonkey Says:

    The difference, WcT, is that around here, despite what you *think* you are reading, I make no pronouncements about what policy *decisions* should be made. What I say is that data need to be considered *for what they are*. True, i do not endlessly add the caveats that are an integral part of science but I just can’t write about papers and constantly remind people how to think about a scientific result. I do it now and again which far surpasses the standard of MSM and the vast majority of science blogging, btw.
    Here we go again: *Every* paper in science comes with a set of limitations. This set of limitations is fair game for the interpretive process but to endlessly dismiss actual extant facts as “meaningless” is denialist, pure and simple. Tell me this, why do Case Reports exist if they are “meaningless”? Are you telling me that anyone who publishes a medical Case is engaging in woo peddling? Srsly?
    Trojan Horse has to do with intent, not result. It also has nothing to do with whether medical mj (or MDMA for that matter) has a valid place, as I have specified numerous places. There was a comment on a recent thread that fully endorsed the Trojan Horse strategy as such, btw. DuWayne will recall opposing that rationale….
    I said “an honest bit” not “the only honest bit ever” WcT- unratchet dude.
    noone here is trying to say weed isn’t dangerous
    Just because you aren’t doesn’t mean others are not making this claim. You also seriously underestimate the degree to which the subject matter of my posts, generally starting with legitimate research, sets the tone so that people know they are not going to be able to get away with saying pot is totes harmless.
    maia and DuWayne, we’ve been through this before and the arguments remain. pot use in the US started back up in the early 90s. Why? legal psychoactives in general enjoy greater use than illicit ones. Why? My dumb little poll showed a significant fraction willing to claim that legal status of pot made them not smoke it. Are they lying? Illicit diversion of pharma prep psychoactives for rec use is more popular than the illicit version of the same or closely related drugs. Why? Holland municipalities are rolling back their pot-free paradise..why?
    so you can choose your favored data points but to say my arguments “fail” is just plain silly until you’ve given the same consideration to my points as I give to your favored Portugal decriminalization outcome and what not.

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  38. DuWayne Says:

    pot use in the US started back up in the early 90s. Why?
    That one is impossible to answer with more than theory. First, I think that cannabis use increased more among younger people, rather than overall. I suspect that some of this has to do with anti-drug propaganda being way overblown and a backlash against bullshit – this could also explain the resurrection of hallucinogen use.
    legal psychoactives in general enjoy greater use than illicit ones. Why?
    Ease of access and lack of fear of imprisonment for use are of course obvious and rather big reasons. But more importantly, currently legal psychoactives have a huge place in culture. Alcohol in particular actually played a huge role in social evolution, helping to pave a foundation for the development of civic/metropolitan societies. Tobacco has a shorter history, but that is in relative terms. Tobacco, like alcohol, has traditionally been a communal phenom. And caffeine is also an important cultural binder.
    Think about it this way…What happened when the U.S. tried to make alcohol illegal? Why didn’t the same thing happen when cannabis was made illegal?
    My dumb little poll showed a significant fraction willing to claim that legal status of pot made them not smoke it. Are they lying?
    The absurdity of considering your rather limited poll evidence aside, there is no reason to assume that more people wouldn’t try it out if it were legal. And as I have said, legalization would very likely cause a spike in use – but only a spike. When it settles down, I expect there will be more cannabis users – just not the masses you seem to think there will be.
    Illicit diversion of pharma prep psychoactives for rec use is more popular than the illicit version of the same or closely related drugs. Why?
    This is far easier – both accessibility and the perception of safety. Kids who are averse to/perceive the harm in the use of illicit drugs and alcohol, are not generally inclined to feel the same about pharmaceuticals until they get well into high school – some not even then.
    Why? Holland municipalities are rolling back their pot-free paradise..why?
    Honestly, I haven’t looked into it much and as such cannot provide a reasonable response. If I happen to find the time, I will look into it and get back to you on that.
    so you can choose your favored data points but to say my arguments “fail” is just plain silly until you’ve given the same consideration to my points as I give to your favored Portugal decriminalization outcome and what not.
    For the record, I don’t think your arguments are a total “fail,” I just think you have biases that push you away from objectivity in the opposite direction from the “cannabis if fucking magical” crowd. To be sure, I don’t think you go nearly as far as many of them do – but you approach this with very overt biases.
    In this particular case, I am mostly inclined to slam your characterization of the implications of this study. Even given that the conclusions are correct, something the study markedly fails to show – the idea that this should have an impact on public policy is absurd. It would be one thing if this was more widespread – like say, cirrhosis of the liver or emphysema. But this is not what we are looking at here. At worse, we are talking about a potential side effect that wouldn’t even be a detriment to getting a pharmaceutical put on the market.
    When it comes to the notion of legalization dramatically increasing use, like I have repeatedly said – I have little doubt it will – temporarily. But I doubt it will continue into the long term.
    And I have a lot of reasons to believe that what use there will be, will mostly be either ingestion or vaporizing. Expense is the major factor contributing to people smoking it. Few people who are not tobacco smokers are all that keen on smoking as a delivery system. Make it more available in alternative forms and make it easier to get vaporizers that cost more than a hundred dollars, in spite of costing about five dollars to make and people will be far less inclined to smoke it.
    While I will not claim that smoking cannabis is the source of all associated problems, I think it is important to consider that a lot of the harms are related directly to the smoking.

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  39. DuWayne Says:

    And to be clear about this paper and my attitude about it – I am not dismissing it out of hand. I just think that making specific claims or even strong assumptions based on this paper alone is a bad idea.

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  40. Healthdoc Says:

    IMO when drug use is discussed the underlying motive for use must be central. Carl Sagan suggested in his book “Dragon’s of Eden” that the psychoactives in cannibis inhibit left brain function and allow for clearer right brain perception. Since the advent of TV, right brain thinking has been on the rise. We’re bombarded daily with visual and auditory stimuli that support and encourage right brain function. People use drugs selectively, they have favorites. It seems to me that different personality types are drawn to different psychoactives based on desired effect. I think what we’re seeing is a fundemental change in perception and desire to support this world view with the drugs etc that reinforce it.

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  41. DrugMonkey Says:

    I think that cannabis use increased more among younger people, rather than overall.
    true and if you look at figure 5-3a of MtF volume II you can see a leading edge cohort wave of those who were 18 round about 93-94. But the annual trends stayed up, meaning that successive cohorts of 18 year olds were also more likely to smoke pot compared with the 90-91 nadir.
    What happened when the U.S. tried to make alcohol illegal? Why didn’t the same thing happen when cannabis was made illegal
    Size of commercial demand? but the pot demand is huge now so.. remember, we’re facing making pot just as socially acceptable as alcohol tobacco or caffeine, right? In the glorious future envisioned by the full-legal crowd anyway.
    both accessibility and the perception of safety
    I agree. I argue that unrebutted NORML type propaganda on the toobs, medical MJ, politicians introducing legislations, etc and ultimately the legalization is and will be the factor that explains those perception-of-risk data I put up before. This is what I’m saying about making predictions about what will happen. We already have hints about what the data will look like. Relying *only* on the Dutch experiment is willfully disregarding predictor information.
    you approach this with very overt biases
    Yes, the bias for looking at scientific evidence and, to some extent, the bias for FWDAOTI. You seem to feel I have some other bias however…? Don’t tell me you’ve lost faith that my political and policy positions are indeed divisible from my scientific ones.
    The absurdity of considering your rather limited poll evidence aside, there is no reason to assume that more people wouldn’t try it out if it were legal. And as I have said, legalization would very likely cause a spike in use – but only a spike. When it settles down, I expect there will be more cannabis users – just not the masses you seem to think there will be.
    Absurdity? More so than any anecdote you, I or Isabel bring to the table based on our circle of friends and acquaintences? pshaw.
    masses? I don’t think I’ve ventured an opinion on numbers but 1% or even 0.1% of the US population is a lot of people. 0.01% or even 0.001% is a lot of people to have addiction issues. but those are policy questions. My goal is to get people to leave off with the stupid assertions that, for example, all who may become dependent on pot are already smoking it so there will be zero increase in dependence post-legalization. Someone made exactly that argument on a prior post here! It is just plain idiocy.

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  42. MattXIV Says:

    I’m guessing the cause is related to esophageal irritation. Warm, humid air provides relief form irritation hence the baths and showers, inhaling smoke obviously provides a source of irritation as well as the “dry mouth” effect of cannabis, and in Allen, J. (2004) most of the patients who had endoscopies showed errosion and many were already on PPIs.

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  43. Katharine Says:

    The entirety of my thought processes on cannabis come down to ‘stoners are hysterical to watch, but I wouldn’t smoke pot if my life depended on it’.
    I don’t understand people who get intoxicated on anything.

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  44. Adiemusfree Says:

    Whew! the response from DM to people pointing out that two swallows do not a summer make is curious! WcT makes some very valid points about the limitations of case study. Anecdotes are great to raise a curious clinical observation, but don’t in themselves represent a stable phenomenon. Maybe there is room for further exploration of a relationship between hyperemesis and cannabis use: but to draw conclusions as you have (I quote)
    Overall this is a fascinating tale and clearly, given the timeline of the publications (this is not an exhaustive list), an association that is only beginning to be recognized. …Nevertheless, even if this is rare, if we continue to enact polices which will increase the amount of cannabis smoking or the number of chronic smokers this syndrome might be expected to rise. Highlights are mine and appear to suggest (a) that there is an association (but I’d argue that these case studies could similarly identify an association with any number of other factors) and (b) that policies will lead to an increase in this supposed association.
    I’m no apologist for cannabis use, I simply want to see conclusions drawn from such case descriptions carefully prefaced with some sort of indication that this is, as yet, only a series of uncontrolled anecdotes.

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  45. DrugMonkey Says:

    I’d argue that these case studies could similarly identify an association with any number of other factors
    Right but you haven’t. And others who have attempted it in this thread have missed at least one blindingly obvious feature. By all means have at it but read. the. bloody. case. reports. to see what they’ve done to rule out other factors while you are making your case.
    It is simple to reel off complaint before you actually read the evidence as it is being presented. Harder to incorporate all the studies (there are some others, btw), view the commonalities and find some other reason that explains the phenomenon.
    Something might have been missed, sure. As mentioned in Allen, there is an earlier case where one of the authors diagnosed “psychogenic” vomiting and they obviously later modified their opinion as to the causal factor based on additional data. Could happen here too. Until you identify a plausible explanation that incorporates the existing data meaningfully, instead of simply denying it, you don’t have a point.

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  46. Rob Monkey Says:

    Wow, interesting cases and all, but this really got derailed into legalization talk huh? Guess I’ll throw in my $0.02. In terms of legalization (partial and otherwise)increasing use, my opinion has always been, “Of course it will. So what?” There are people with medical conditions that will try and possibly continue smoking pot if it’s legal, but not otherwise, so yeah, it’ll increase the amount of legal adults smoking pot. So what? Gotta say moldy weed isn’t exactly out of the realm of possibility as well, it’s a perishable item and some people won’t store it properly. As far as the idea about this possibly increasing with legalization, well then we might have a reason why it’s happening instead of just conjecture. I’m not of the “magical nonharming drug” crowd, but it seems pretty evident that it’s fairly safe when compared to some of the other over the counter drugs we allow. I know a few patients here in MI that are in much better health because of the medical program, so I guess that colors my opinion.

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  47. DuWayne Says:

    Size of commercial demand?
    So you think it really had nothing to do with the fact that alcohol has been a fundamental of civilization since someone millenia ago noticed that funny tasting rotten fruit made them feel funny? Alcohol is the most widely used enthogen out there, with the possibly exception of caffeine. It is a rite of passage in modern U.S. society and has been a staple of virtually every human culture, likely back the the dawn of modern humans, if not further.
    Do you honestly think it is legality that causes more than 95% of the population of the U.S. to try alcohol at some point? Why aren’t they all trying tobacco as well?
    but the pot demand is huge now so.. remember, we’re facing making pot just as socially acceptable as alcohol tobacco or caffeine, right? In the glorious future envisioned by the full-legal crowd anyway.
    How exactly can you even make that comparison? As though tobacco is as socially acceptable as alcohol or that either are as socially acceptable as caffeine? Whether or not it is considered as socially acceptable as alcohol or tobacco, who knows – but I sincerely doubt it will be as socially acceptable as caffeine. And for the record *I* think cannabis is more socially acceptable than alcohol or tobacco.
    You seem to have the impression that all is equal in acceptability. Given my druthers and the legalization of not only cannabis, but most everything else happens as well, I have little doubt that for the most part, social approval of these various substances won’t change all that significantly. And I think that going back to your survey, we can be assured that many of you readers who are not pot smokers won’t change their approval level – several might even try it.
    And honestly, if we actually were to turn around and legalize most everything in one swoop, I think it would send a message about legal versus approved of.
    This is what I’m saying about making predictions about what will happen. We already have hints about what the data will look like. Relying *only* on the Dutch experiment is willfully disregarding predictor information.
    At this point, I am going to have to contradict myself on the last post and admit that this is one place where I think medical cannabis can be useful. I think it would be a very good idea to run some rather in depth studies about how that has worked out. I have said before that I don’t like relying on data from other countries, because the U.S. has a different culture. Maybe not significantly different, but very plausibly different enough in certain regards.
    You seem to feel I have some other bias however…? Don’t tell me you’ve lost faith that my political and policy positions are indeed divisible from my scientific ones.
    Honestly? I have had little doubt from early in my interactions with you, that you have certain biases, beyond the science. Like I said, not extreme, but they are pretty visible. I am not saying this to be negatively critical – everyone has biases. And ultimately, I suspect that you are well aware of your biases. But there is little doubt that you have issues with the cannabis and that they influence your thinking about this issue. This post is a good example – not that you wrote it, but the implications you throw in with it.
    I will fully admit that I have my own biases in this discussion – some in one direction, others in other directions. My relationship with enthogens is complicated, something I think it pretty obvious – made more complicated by my relationship with addiction. And I expect that my own biases are pretty notable as well…
    Absurdity? More so than any anecdote you, I or Isabel bring to the table based on our circle of friends and acquaintences? pshaw.
    Not in the least. I was just trying to put you poll in it’s place, as it were…
    masses? I don’t think I’ve ventured an opinion on numbers but 1% or even 0.1% of the US population is a lot of people. 0.01% or even 0.001% is a lot of people to have addiction issues. but those are policy questions
    Sure it is, but if things are managed properly, we could well have more tools at our disposal to deal with addiction and more resources to fight it. Not to mention a host of other tradeoffs that make it so attractive – but these are, as you say, policy issues…

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  48. Alex Says:

    First, on the motives of people who have criticized DM, let the record reflect that I have never consumed, smoked, snorted, swallowed, injected, etc. any illicit intoxicating substance of any sort. I don’t even drink alcohol. My only drug is caffeine, and even there my preferences are pretty boring. So I am not motivated by a desire to protect a habit.
    Second, DM, a question: I know that your main interest in blogging about this is to argue that the public health aspect of the data is not being properly understood by some people arguing over the bigger policy issue. Would you be willing to consider the possibility that the public health aspect, while significant for some portion of the population, is not the only aspect of policy that needs to be considered? For instance, is it possible that public health concerns might be less significant than economic concerns, crime issues, social justice issues (especially in regard to disparate impacts on low-income and ethnic minority populations), etc.?
    There is some harmony between that stance and your concern over being careful with the data on the public health issue: If the public health issue really isn’t the only significant factor, then there’s less reason for people advocating a particular policy position to feel threatened by it and argue with it. People argue with things that they feel threatened by, and when they feel threatened they don’t always argue very well or treat the truth very carefully. But if the public health angle is not the only significant angle, then there’s less incentive for anybody (on either side of the issue) to misrepresent public health data.

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  49. PabMD Says:

    When people who are pot fans first and foremost but have no apparent interest in social justice vis a vis the browner folk start in about the racist history of the anti-weed argument…what else would you call it?
    what do you call the arguments of fundamental Christers who discover a mysterious latent affection for Jews and Israel just because they want to shore up their argument for practicing war against mutual enemies?
    Same thing. A convenient and disingenuous argument.

    Huh?? The evolution of Godwin’s law?
    DM, you are erecting too many straw men in your “scientific” blog. I am not an user or an advocate, when I was younger, being around 2nd hand pot smoke made me nauseous.
    My personal observation is that “it” is called dope for a reason, makes user “stupid” temporarily! Some people just like to be “impaired”, through alcohol, solvent inhalation, etc… I had a patient that worked in the commercial music business and felt that pot helped him be creative and be atuned to his musician clients, he thought he was compliant with his meds, but when he brought his bottles, the 30 days supply had been filled 3 months before the visit, obvious non-compliance, but in his mellowed mind he was following directions and the treatment plan (BTW isn’t it “harshing my mellow?”). If a cancer patient wants to get stoned, and there is no real physical harm to him/her, who I am I to prevent them from enjoying the last days of existence, or relieving any misery from their condition?
    DM, you may be playing Devil’s advocate here, or you could be a closet pothead, just like “Citizen Cohn” was a closet homosexual that bashed Gays publicly.
    I am just asking for scientific facts to counsel my patients, what is the true purpose of your blog topic?

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  50. DrugMonkey Says:

    the “scientific facts” are right there in the papers PabMD. What you do with them in deciding to counsel your patients is your job. You are a clinician apparently and I most assuredly am not. Neither do I have any public policy role beyond what I do in the voter’s booth.
    My goal is to make my readers aware of scientific findings that I think are interesting.

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  51. PabMD Says:

    It is your blog, you tend to your garden your way, you feel you make readers aware of findings you think are interesting, not unbiased?
    Specific question: Marinol is pure THC, Savitex is a combination, which should be used for cancer patients?
    Your cop out may be “I am a scientist, not a clinician”?
    The reality as I see it, is that Human Medical care, particularly when it involves cognition, psychology, human sensations among other parameters, can only involve human subjects and experimentation, at least in the USA, requires Physicians that have been trained to help other humans. You cannot devise any experiment with rats, monkeys or any other animal to find out if a given chemical will reduce nausea or improve their well-being.
    My option is to realize that your “ScienceBlog” is useless for my medical inquiries, and remove it from my RSS reader…
    Thanks for trying, I think?

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  52. DrugMonkey Says:

    Specific question: Marinol is pure THC, Savitex is a combination, which should be used for cancer patients?
    You seem to be confusing a blog with some internet Q&A for doctors. I might at some point review the relevant papers…or I might not. Perhaps I have some conflict reasons that mean I don’t think it is appropriate for me to cover the topic. Or perhaps I am uninterested. It’s a blog dude.
    Your cop out may be “I am a scientist, not a clinician”?
    Why is this a cop out? If I were to assert I had some clinical advice, PalMD, Orac and who knows probably even Hoofnagle would arise from his blogging grave, and rightly come over here and rip me a new one. I can read and interpret studies, even ones featuring human subjects. But this is not the same as being a clinician. Surely you know this?
    The reality as I see it, is that Human Medical care, particularly when it involves cognition, psychology, human sensations among other parameters, can only involve human subjects and experimentation, .. You cannot devise any experiment with rats, monkeys or any other animal
    That’s nonsense. Animal research is rightly described as pre-clinical. It can inform the conduct of *clinical research* which must also be done. Both of these types of data go into the review and ultimate approval of new medications and medical devices. This is our regulatory schema and it is a damn good one.
    My option is to realize that your “ScienceBlog” is useless for my medical inquiries, and remove it from my RSS reader…
    I am wounded to the core…

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  53. Rob Monkey Says:

    PabMD, you really don’t think we measure nausea or well-being in animal studies? Jebus, get a clue man. In fact, the reason Marinol and Sativex are being used for nausea is because they succeed in pre-clinical trials! This of course is ammo in your box if you weren’t saying something so ignorant it should be coming out of an anti-vax loon. As for your question, it couldn’t even be answered by a clinician, as “cancer patients” is a hugely broad category. Are you looking to reduce pain? Marinol would probably work better, as THC is more suited for pain relief. Appetite stimulation needed? Sativex is probably the right choice. All this data was obtained with animal studies, and while I may have my differences with DM’s reasoning, at least he’s staying in the realm of science.

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  54. DuWayne Says:

    Your cop out may be “I am a scientist, not a clinician”?
    AHAHAHAHAHAHAHAHA!!!!!!!!!!!!!!
    Oh wait – you meant that seriously? Let me ask you this – would you be comfortable stepping into the lab, designing an experiment to study the effects extremely high doses of cannabis on the brain (using rat, not human brains to start)? How about phase one studies for a medication you are developing?
    The reality as I see it, is that Human Medical care, particularly when it involves cognition, psychology, human sensations among other parameters, can only involve human subjects and experimentation, .. You cannot devise any experiment with rats, monkeys or any other animal
    Seriously? You actually managed to get an MD, while buying into this fucking trope? Are you an AR nut in disguise, sent over to fuck with us?
    Off the top of my head, I can think of 7 relatively famous, groundbreaking psych studies that used animal subjects. At least two of them are famous in pop culture.
    If a cancer patient wants to get stoned, and there is no real physical harm to him/her, who I am I to prevent them from enjoying the last days of existence, or relieving any misery from their condition?
    And my question would be – who bloody well cares if it causes damage? Who cares if it knocks a whole other week off their lifespan? Personally, I am far more interested in comfort, than suffering through a few more days, though I do not intend on waiting until I am in the worst of the suffering to die – should my end work out in this manner.
    My option is to realize that your “ScienceBlog” is useless for my medical inquiries, and remove it from my RSS reader…
    NOOOOOOO!!!!!!! Don’t go Pab, we are totes going to miss you….

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  55. Isabel Says:

    “So I am not motivated by a desire to protect a habit.”
    1) Access is not a problem for me.
    2) I care very much about criminalizing 1/3 of Americans and giving enormous powers to law enforcement.
    3) I don’t think cannabis is totally harmless.
    And PalMD it does improve creativity. It is a very different experience that alcohol intoxication.

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  56. PabMD Says:

    I know this is not a Q/A service for Doctors.
    Accept it or not, Basic and Clinical Sciences are parasitic/symbiotic, Basic Science exists to direct the best clinical decisions, without basic science clinical medicine is “curanderia”, witchcraft, “faith healing”, you can come up with different names…
    I have asked the same questions in my medical forums, the “scientific evidence” is just not there to make the right decisions for marijuana. Does it shorten the life of cancer patients? I don’t know. I do have a 54 y/o female patient with metastatic breast cancer, dying with leptomeningeal carcinomatosis that had a positive drug screen in the ER when she had syncopal episodes. She tells me it helps her relax. I told her to be sure that whatever she smoked should be free of adulterants that could make her sicker. She probably has less than 6 months to live, can I honestly tell her that the toxicologists have found that pot can make her throw up? She was vomiting more in the Hospital without her weed… One case anecdotes are not irrefutable scientific evidence, only the aggregation of individual cases can be examined to be analyzed scientifically, how many? I depend on the biostatistician to give that answer, but who will pay for such a study?
    A few months ago, I did not have any interaction or even awareness of the “ScienceBlogs”, DM, was and will continue to do well without answering any of my questions. This interaction was just another random encounter in the web…

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  57. mandas Says:

    The validity of these findings is right up there with testimonials about homeopathy.
    How about someone goes away and conducts a double blind trial to see if any causal links can be established. Until then, testimonials and anecdotes like this are not worth the paper they are written on.

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  58. Recall Says:

    “Size of commercial demand? but the pot demand is huge now so.. remember, we’re facing making pot just as socially acceptable as alcohol tobacco or caffeine, right?”
    Isn’t it already?

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  59. NewDay Says:

    “Nevertheless, even if this is rare, if we continue to enact polices which will increase the amount of cannabis smoking or the number of chronic smokers this syndrome might be expected to rise.”
    Damn big if. Well beyond what the evidence supports.
    In fact introducing liberal cannabis laws is associated with a small reduction in overall use.

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  60. WMDKitty Says:

    Is it at all possible that these people were just having a bad reaction to the weed? I’ve known people who were allergic, and would vomit if exposed to cannabis.

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  61. Did they check the cannabis for ANTHRAX? I’m only asking because it looks like somebody is messing with the heroin supply, and I don’t think it would be the dealers, since that would lead to lower sales.
    FWIW, articles like this that are at best ‘anecdotal’ do nothing but spread FUD over cannabis consumption. For the record, cannabis CONSUMPTION hasn’t killed anybody, which is more than you can say about aspirin or Tylenol.
    If it made me ill, I’d probably have stopped smoking it long ago, kinda like I avoid cooked onions because they give me gas.
    http://thetimchannel.wordpress.com/2010/01/29/change-you-cant-believe-in/
    Enjoy.

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  62. leigh Says:

    How about someone goes away and conducts a double blind trial to see if any causal links can be established. Until then, testimonials and anecdotes like this are not worth the paper they are written on.

    ethics in human subjects research, anyone? we know quite a bit about stuff that’s bad for you from sources other than double-blind trials. we haven’t employed double-blind trials to demonstrate that a diet full of fatty crap is associated with heart disease.

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  63. DuWayne Says:

    Ok, I think that people are really going too far with the notion that case studies are worthless. They have very sharp limitations and should not be taken as very strong evidence in and of themselves, but neither should they simply be dismissed. Case studies are extremely valuable, in that they often provide us an important direction to investigate.
    I think I have made it clear I am not shilling for DM’s position on this one, but let’s not get carried away in our criticism.
    WMDkitty –
    If it is actually the cannabis itself, I would assume that is the case. Though I am not certain that allergy is an accurate term for that reaction. Allergy implies a specific type of reaction. But in toker parlance, people who react that way are usually identified as allergic.
    Though usually they do not react quite as violently as the papers discussed imply, I could see that…

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  64. becca Says:

    DM- are all the case reports men?
    “Don’t tell me you’ve lost faith that my political and policy positions are indeed divisible from my scientific ones. “
    I don’t have this faith in you. Or anyone else, for that matter. I question the premise. To say that political and policy positions *should* be divisible from scientific ones is basically akin to admitting we should make political and policy decisions based on something OTHER than evidence.

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  65. Merlin DuVall Says:

    A Question, with the vomiting issue in Australia, was there any indication that ingestion of the product caused the condition, it would and if the patients came from the same area it would be an indication. Also the use of any insecticides, or other chemicals would create an increased indication. I do not use that product and never intend to have anything to do with it. However a balanced analysis of the benefits and problems should be considered. It was not made illegal because of harmful affects. But rather, as a reason to deport Mexican workers.

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  66. Nemo Says:

    Clearly the take-away here is that cannabis use promotes cleanliness.

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  67. Mark Gisleson Says:

    No science here, just anecdotalism from an uncontrite chronic imbiber, but I would bet dollars to Krispy Kreme donuts with sprinkles on them that these stoners had bad eating habits. Even good food comes back up when you eat too much of it, or eat just before bedtime.
    Marijuana has been a part of the party scene all my life (I’m 56), and I have NEVER seen anyone throw up at a party unless they were really drunk. Never.
    But your logic is impeccable. Refuse to allow controlled growing and testing of a substance, then overreact to isolated case files that could as easily reflect contamination or possibly even defective paraphernalia design (lots of plastic pipes out there and cheap screens that literally melt when heated).

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  68. DrugMonkey Says:

    Who’s “logic” are you referring to? I am very much in favor of all kinds of “testing” to determine what are and are not risks associated with drugs of abuse.
    As with others here, do tell why the most likely hypothesis is contamination? If mouldy weed and melting pipes are common as you and DuWayne assert, why is this pattern not more common? What potential sources of toxins are in those that would cause several days of vomiting? It is easy to pooh-pooh, harder to come up with credible hypotheses that might actually fit the data.
    Still, when there are credible alternatives it is great to mention them. Perhaps next time a clinician has one of these patients it will occur to ask about their weed storage practices, source of material, paraphernalia, etc.

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  69. DuWayne Says:

    As a for the record, I have never even seen plastic pipes, much less considered that as a contaminant. But that may just be because I was pretty anal about what I smoked out of – brass, stainless steel, stone or glass, wood in a pinch – usually made by me on the fly.
    As far as why it isn’t more common, if we are talking about common contaminants – I ultimately think it is. It is just that the reaction is usually not as extreme. Someone who is smoking weed with these sorts of contaminants on a regular basis could easily develop more serious problems – especially if that person is especially sensitive to them.
    And I am not claiming that contaminants are a more likely hypothesis, just that they are another possible explanation. Considering that there are people who just flat out have or develop an aversion to cannabis that causes similar symptoms, I would assume that it is possible some of these cases were an overt reaction to cannabis itself. All I am saying is that the contaminants discussed fit the data just as well.
    I would also note that what I would consider one of the more likely contaminants that would cause this sort of reaction, is pesticides – the one that you seem to have ignored completely. There are growers who use them and as rinsing the bud might well rinse some of the crystallized resins, they get smoked with the weed. Coming across buds that happen to have a higher concentration of pesticides would easily explain an extreme toxic reaction.

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  70. Sharon Astyk Says:

    The reason I’d be inclined to at least seriously consider the possibility of contamination of marajuana is because I raise plants for a living. Most pot growers worldwide are not able, shall we say, to take full advantage of agricultural technologies that best preserve their herb. If you are drying in concealed environments without adequate ventilation, getting mold is not a rare occurrence for any dried aerial plant matter. Moreover, it is hardly an unusual thing, statistically speaking, for those selling in an unregulated market to include fillers to increase their return on a high-value investment. Such issues were rampant in the US before regulation – famously, you got plaster in your flour, gravel in your coffee beans, etc… It is simply sufficiently likely that this can’t be ruled out – and since most people who use drugs have a limited number of suppliers, it isn’t at all impossible for this to be a long-term recurrent rare phenomenon being seen elsewhere. That’s not to say “it is true” but that “it is not totally unlikely and it probably isn’t a good idea to talk policy until you’ve ruled this out.”
    This is a purely anecdotal observation, but at my high school (in Massachusetts USA in the late 80s and early 90s) pot was actually used as an inferior substitute for alcohol in some cases, because it was easier for teenagers to get. To get booze, you had to either have a good fake id, a friend over 21, or you had to steal from your parents, and the liquor stores were pretty good at iding fakes, parents tend to get cranky when their tequila starts going down, and not all 22 year olds want to hang out with 15 year olds. It wasn’t impossible – there was a lot of booze around, but pot was ubiquitous, especially when we were younger and less able to pass for 21, because they’d sell it to teenagers.
    Sharon

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  71. PabMD Says:

    DuWayne you have an amusing blog page!
    Are you a pimp or a sex worker?
    Why do you peddle eCigs?
    My serious questions are what are the solely animal studies that can evaluate medications for anxiety, depression or psychosis?
    “Inquiring Minds” want to know…

    Like

  72. orion Says:

    Sharon
    Pot an ‘inferior’ substitute for alcohol?? Pot is far superior to alcohol!!
    And I think Mark (post #67) has hit it on the head perfectly. Anecdotes and overeaction are no substitute for real science. I, like him, am in my 50s, enjoy my pot on a regular basis, and have NEVER thrown up nor have I ever seen anyone else throw up from pot. But I have seen hundreds of people throw up from alcohol (as I have also done myself on numerous occasions).
    So there you go, two anecdotes attesting to the safety of pot (I could get others if you want). And they would all carry just as much weight as the basic premise to this thread.
    I would strongly suggest that, if you want to adopt a rational position on this subject, how about you do some science and stop relying on anecdotes.

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  73. DuWayne Says:

    I “peddle” e-cigs, because I have been using them to curb my smoking to virtually nothing. I do not actually get anything for clicks over, even if someone buys. I do not advertise for profit on my blog – the only adverts are for products or (in the case of a couple of addiction links) services that I think are worthy.
    And I am sexpositive and a very strong advocate for the legalization of prostitution and most illicit drugs, as well as ending the monopolies on gambling. I am especially ardent in my support of sex workers rights, because as things currently stand sex workers are in an unsafe and easily exploitative industry. I would like to see sex work legal and safe. There is no reason that someone who is desperate or who simply would like to use their sexuality for money should be exploited, endangered or imprisoned for it.
    Unlike some people, I don’t need a vested interest in a thing to fight for it.
    As for experiments that involved animals – you did not specify drugs. There are absolutely no drugs for humans that came on teh market after only using animal testing. There are very few drugs on the market that didn’t undergo critically important animal testing. If you actually are an AR nut, this is not the thread to argue about it – DM has several and for that matter, I have several on my own blog.
    However, to address your original statement, there are a lot of behavioral experiments that involved animals. Of particular fame, would be Ivan Pavlov’s experiment that led to important breakthroughs in our understanding of classical conditioning. That research went straight from animal experimentation to clinical practice and study. Then there was also Harry Harlow’s “wire monkey” experiment, in which infant primates were exposed to a wire “mother” that provided food and a soft “mother” that did not. Based on that experiment, we learned a great deal about infant bonding and the importance of nurture for infants.
    Any more questions? Or do we actually need to move this discussion to an AR extremist thread? Or do you have some other question about my blog? If that is the case, you have my email (listed on my blog – upper right corner).

    Like

  74. DuWayne Says:

    That was not, btw, intended for Orion – it was for Pab…

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  75. PabMD Says:

    DuWayne, thanks for clarifying the blog issues.
    I am far from being an animal rights defender, we need animals to determine the toxic and lethal doses of the various chemicals that we study for human use. We need to sacrifice animals so we can improve the Human Condition.
    The topic of this blog was nausea and vomiting and possible causation by pot, there are no animal studies that can evaluate antiemetics for humans. Please provide peer reviewed publications if there are any such studies. Anxiolytics, SSRIs, other antidepressants and anti-psychotics fall in the same category. You may determine toxicity, bur to determine clinical efficacy, you need human subjects that can tell you if they are less anxious, less depressed, and on, and on…

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  76. DuWayne Says:

    Pab, you are a petty little shit who gets pissy when people respond to what you say, rather than what you thought you said. You think it is appropriate to attempt to impugn the credibility of others with irrelevant bullshit.
    Exactly what is the point in engaging with a pointless fucking asshole, such as yourself?

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  77. Dacks Says:

    Just to counter all the anecdotes about how harmless pot is, I’ve got one about how addictive it is.
    Dealing right now with a SO going through withdrawal for the second time. First time was 12 years ago, after smoking habitually for 15 years. He went into a series of acute panic attacks which culminated in admittance to the hospital psych ward to keep him from killing himself.
    He stayed clean for 10 years. Two years ago he started smoking socially, ramping up during the past 6 mos. Has been spiraling down during the past few months, and finally stopped smoking a few days ago. Again, the panic attacks are incredibly debilitating. We’re much better prepared this time, so I expect he’ll pull out without becoming suicidal. We found a wonderful psychiatrist who treated him the first time, and continues to monitor him. While the addiction was increasing he lied to her, as well as everyone else. Now that it has gotten this bad, he’s owning up.
    This is a very good man, the best there is, struggling with a difficult drug dependency. It may not be a common result of recreational use, but it does exist!

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  78. Raging Bee Says:

    Cyclical vomiting from WEED? Are you kidding me? If this was anything more than isolated reactions, it would have been worldwide news decades ago. In the ’70s and ’80s about half the country was smoking weed (including myself and nearly all of my current friends); and NONE of them reported symptoms anything like this. If any of us puked, the cause was either alcohol, bad food, or an actual stomach ailment.
    This doesn’t prove weed is too dangerous to smoke, any more than the reactions we’ve seen prove vaccines are too dangerous to use.

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  79. Mark Gisleson Says:

    As to why plastic pipes could be a part of the problem, insane paraphernalia laws have driven the price of pipes and smoking accessories sky high and many consumers are looking for cheaper gear.
    When I say plastic pipe, I mean a pipe made from plastic with a metal or wooden bowl and a metal tube. Plastic is much funkier (but cheaper) than glass, harder to clean and more conducive to mold and bacteria. Such growth would be the exception, not the rule, hence the sporadic and isolated nature of the vomiters.
    If it was the pot, then vomiting would be a reaction more of us would be familiar with. It is more likely, therefore, that the eventual cause will be identified as paraphernalia. Possibly even a cheap disposable lighter which doesn’t cause problems for cigarette smokers, but whose defect is triggered by the extended burn times involved in smoking drugs from a pipe.
    Even then I have to wonder why you have no cases of multiple individuals coming in for treatment at the same time. Pot is a social vice and many users rarely smoke alone. Why would contaminated pot or paraphernalia only affect one person, and not other users?
    I’m assuming that once the medical practitioners discovered the marijuana use, they were able to elicit truthful admissions about other drug use. ?? Were these people growers? More variables there. I grew up on a farm suffering from nosebleeds but it didn’t mean the corn was to blame (herbicides were).
    Dude, stoners don’t pitch a fit just because. You’re getting angry comments because experienced pot smokers have never heard of anyone vomiting from smoking marijuana. There’s something else going on here, and I hope you share with us whenever they figure this one out.

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  80. Dacks Says:

    “Pot is a social vice and many users rarely smoke alone.”
    Not true. Heavy users, such as the ones in the case studies, often smoke alone.
    My SO has vomited from smoking, although not in a severe way, and I experienced more than once an unsettled feeling in my stomach when I smoked, or more often, ate pot. That’s why I never quite understood the munchies.

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  81. Raging Bee Says:

    …I experienced more than once an unsettled feeling in my stomach when I smoked, or more often, ate pot.
    EATING pot causes irritation, and possibly damage, to the stomach lining — which is why lots of people are against THC pills as a substitute for smoking it. In any case, nausea from smoking pot is rare (in fact, cancer patients value it because it almost always causes the opposite effect). Your SO may have an allergy, or may be inhaling and holding too much in her lungs for too long; or you may be getting your weed from people who put the wrong stuff in/on it, knowingly or unknowingly (I’ve had pot that smelled like gasoline, and pot that smelled like other chemicals I counldn’t identify; that’s the problem with keeping it illegal — it ends up being sold by incompetent and unscrupulous people).

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  82. DuWayne Says:

    Mark –
    Pot is a social vice and many users rarely smoke alone.
    Bullshit. Pure and utter bullshit. I am very far from alone in having had absolutely no qualms about smoking alone, when there was no one about to smoke with.
    You’re getting angry comments because experienced pot smokers have never heard of anyone vomiting from smoking marijuana.
    That is a rather stupid generalization to make, when in fact some of us have not only heard of it, but witnessed it. Just because in your little world of pot smoking, you have never come across someone who had that particular adverse reaction, doesn’t mean it doesn’t happen.
    If it was the pot, then vomiting would be a reaction more of us would be familiar with. It is more likely, therefore, that the eventual cause will be identified as paraphernalia.
    While I have yet to run across vomiting to the extent discussed in this post, there are the occasional people who have the adverse reaction and vomit. I think it is just as likely to be contaminants, but there is just as much likelihood that this can be caused by cannabis alone – indeed I would be rather surprised if none of the cases discussed above were caused by cannabis alone.
    You are making the mistake of believing that your anecdote holds any more weight than the case studies discussed in this post. While case studies are only able to show correlation, not causation, there is just as much reason to believe that cannabis alone caused some or all of them, as it is to assume that contaminants caused some or all of them. There is simply not enough evidence presented to determine either way.

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  83. Mark Gisleson Says:

    Glad I checked back in. I could let this slide once but DuWayne you’re the SECOND person to read my “many users” comment as meaning ALL USERS.
    I wasn’t generalizing. My observation fits in very well with the fact that you simply do not see people puking at pot parties like you do at booze parties. There is no body of literature to support such a notion and every story I can find on google has a qualifier (hadn’t smoked before, huge pipe, too young to be smoking anything, smoked an insane amount, playing weird videogames at the time, etc.).
    I’m not saying contaminants must have caused these problem. I was simply engaging in some basic problem solving tactics by throwing out some possible solutions. Your hostility is, frankly, not typical for a marjiuana user. You must have some serious rage issues when you’re not stoned.
    One thing for sure, I wouldn’t smoke pot if it made me puke. I can’t imagine why anyone would.

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  84. DrugMonkey Says:

    Your hostility is, frankly, not typical for a marjiuana user.
    I beg to differ. The evidence of the comments whenever this blog discusses cannabis suggests that hostility is very much typical. Perhaps just for the commenting pot user. Or perhaps just for the mid-day jonesing pot user. But hostility is there all right.

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  85. becca Says:

    I beg to differ. The evidence of the comments whenever this blog discusses cannabis suggests that hostility is very much typical. Perhaps just for the commenting pot user. Or perhaps just for the mid-day jonesing pot user. But hostility is there all right.
    Well, yes, but there may also be a difference in how provocative you are with different groups. Otherwise we would obviously have to conclude that pot smokers are more violent than AR advocates, while disgruntled postdocs were the most violent of all.

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  86. DrugMonkey Says:

    hostile, becca, hostile. Not violent, I trust.

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  87. DR Says:

    Marijuana has a legitimate medical purpose, in case you haven’t seen people starving to death from chemotherapy nausea. Angel Raich won her battle to smoke in the supreme court, and the list goes on and on. The government and medical community’s credibility was shot. You had the past 40 years to speak up and didn’t. So people with real legitimate needs (and recreational) are all plowing forward.
    Meanwhile, 400,000 people die each year from tobacco use, and 100,000 from alcohol related deaths. Why don’t you focus on a real menace to society and stop wasting everybody’s time putting nonviolent offenders in prison?

    Like

  88. DuWayne Says:

    To reiterate your stupid generalization;
    You’re getting angry comments because experienced pot smokers have never heard of anyone vomiting from smoking marijuana.
    That said nothing about most. At best it was a generalization, at worse it could be taken as an implied absolute
    My observation fits in very well with the fact that you simply do not see people puking at pot parties like you do at booze parties.
    Certainly not like you do with drinking, but no one was claiming that.
    There is no body of literature to support such a notion and every story I can find on google has a qualifier (hadn’t smoked before, huge pipe, too young to be smoking anything, smoked an insane amount, playing weird videogames at the time, etc.).
    Yet we have for case study reports above that do not have qualifiers. People who were consistent smokers, who had rather extreme cyclic bouts of vomiting. While there is not enough evidence to tell us exactly what the cause was, it was most certainly not one of your “qualifiers.” And shy of a fairly extreme bout of nausea – or for that matter even if it is fairly extreme, most adults aren’t all that big on talking about their negative experience.
    I’m not saying contaminants must have caused these problem. I was simply engaging in some basic problem solving tactics by throwing out some possible solutions.
    But that is not what you are doing – whether it was your intent or not. You are making an argument that leaves absolutely no room for the possibility that cannabis alone might have been the cause. Re-read your last comment and you might understand why someone would take you to be arguing that cannabis alone cannot cause nausea.
    Your hostility is, frankly, not typical for a marjiuana user.
    You are mistaking hostility for a rather pronounced lack of patience for people who try to take a reasonable argument to an extreme. I am a very strong advocate for legalization of illicit drugs and while I am unwilling to tolerate propagandizing that tries to make various drugs seem worse than they are, I am just as unwilling to tolerate the same in the other direction.
    I believe very strongly in people making evidence based decisions. And as someone who has functioned as a lay substance abuse counselor, who is studying to research and treat substance abuse, an evidence based understanding of enthogens is even more important to me.
    And while I was just as prone to impatience with people who try to equate anecdote as reasonable evidence when I was smoking pot on a daily basis, I am not really much of a toker anymore. I’m in school and taking meds to manage my neurological issues – I do not need to throw weed onto that, as I am rather fond of 4.0s.
    You must have some serious rage issues when you’re not stoned.
    Only when I am driving.
    One thing for sure, I wouldn’t smoke pot if it made me puke. I can’t imagine why anyone would.
    Two reasons.
    First, a lot of people who smoke everyday don’t make the connection. One of my oldest friends became prone to a mild rash on his temples and was nauseous (with occasional vomiting) in the mornings – sometimes extending further into the day. Honestly – a lot like a pregnant woman with moderate morning sickness. He had no idea what the problem was – he tried process of elimination to figure it out, but even after cutting alcohol, cigarettes, sugars and caffeine it was still happening. Spent a week visiting his parents and didn’t smoke – the problem was almost entirely gone in three days, cleared entirely by the time he left.
    I.e – people are not always aware of what is causing this sort of problem.
    Second, there are people who are flat out addicted. They will happily deny that cannabis or any substance of abuse is causing a problem. And/or they just don’t fucking care. Addiction causes people to do really stupid things and often pretend that it isn’t a problem…

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  89. Isabel Says:

    “I beg to differ. The evidence of the comments whenever this blog discusses cannabis suggests that hostility is very much typical. Perhaps just for the commenting pot user.”
    Hahaha just while commenting you mean!
    I think YOU are the hostile one here, in a weird passive aggressive way.

    Like

  90. Dacks Says:

    Second, there are people who are flat out addicted. They will happily deny that cannabis or any substance of abuse is causing a problem. And/or they just don’t fucking care. Addiction causes people to do really stupid things and often pretend that it isn’t a problem…
    Amen to that!

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  91. PabMD Says:

    http://www.psychiatrictimes.com/display/article/10168/1507650?verify=0
    This link is more educational than the original “Research Blogging” (!!!???) post.

    Like

  92. WIll Says:

    Oh is that why I can’t stop vomiting?

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  93. DuWayne Says:

    Ummm, Pab? That link isn’t the least bit educational, unless one is more interested in the law than they are medical use. It certainly doesn’t provide anything as informative as this post – which is indeed a research blogging post.
    This post lists four different studies, which, correlational as they are, are none the less part of the body of literature on cannabis. DrugMonkey, a scientist who does research into this field, wrote a post about these studies. While there are plenty of reasons to argue about the nature of the studies, there is no doubt that this is in fact, a research blogging post.
    The research being discussed in this post, however, has nothing to do with law and has limited applicability to medicine. If you would like to find more research, including studies into medical cannabis, there is a link to the MAPS database in DM’s sidebar (though that is mostly slated to MDMA). Even better, for cannabis info, see my blog sidebar with links to Erowid, Lycaeum and the Harm Reduction Coalition.
    Erowid and the HRC probably will have the best information – though you will have to dig a bit with the HRC. Lycaeum tends to let their biases get in the way of linking to real science. Erowid has it’s biases as well, but neither they nor the MAPS folks allow those biases to interfere with posting good science. The HRC provides more concise information that is backed by hard science.
    This post was not intended to provide information to support medical decisions. DM would be acting extremely irresponsibly and unethically, were he to dispense medical advice. He is not a doctor, he is a research scientist. Those resources I listed however, are entirely geared towards helping people make informed decisions. They have their biases, but at least Erowid and MAPS are upfront about it, while the HRC has the least bias as an addiction treatment organization.
    Now I would recommend you go screw, before you embarrass yourself further with your incessant whining. Whining because someone isn’t writing about exactly what you want to know is beyond ridiculous and makes you look like a petulant child.

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  94. PabMD Says:

    The research that I am interested in pertains to scientific facts.
    I expect Pharmacologists to tell me what is the lethal dose of a drug, what is the incidence of any toxicity, its severity, any interactions with other chemicals, you know, boring numbers that can be examined by other scientists and descriptions of experiments that can be replicated by other scientists.
    What is the incidence of cannabis hyperemesis? (how many experimental subjects, controls?)
    At what dose?
    Smoked or ingested orally?
    What kind of cannabis?
    Who grew it? Under what conditions? Soil or hydroponics? Which fertilizers? Any pesticides?
    How was it processed after harvest?
    Where was it stored?
    What was the chemical analysis of the pot?
    My initial post started with GIGO- garbage in, garbage out; I still stand behind my initial assessment.
    I just see anecdotes and personal attacks, not research…

    Like

  95. DrugMonkey Says:

    I expect Pharmacologists to tell me what is the lethal dose of a drug,
    But nobody can tell you this. We can get at approximations of lethal doses, under certain conditions. For the most part if you want the kind of specificity that you are seeking in the comment, you are going to have to get those answers from controlled animal studies. Which then give you fits trying to translate back to human. There is simply no escape from doing the hard work of maintaining the miasma of evidence, strength and weakness, statistical probability and doing your best to distill that into a clinical judgment. Nobody is going to be able to give you the answer key to the test questions.
    what is the incidence of any toxicity, its severity, any interactions with other chemicals, you know, boring numbers that can be examined by other scientists and descriptions of experiments that can be replicated by other scientists.
    What makes you think that Case Studies cannot be replicated? Indeed I link to several cases with similar phenotype and there are a few more I haven’t bothered to include in the OP. These can be replicated. Eventually, someone will bother to do a more formal study. If there is still something that needs to be answered, more studies will result. Maybe someone will think to try chronic exposure in the ferret model or something. Ongoing evidence, imperfect and incomplete, will allow moving on to the next logical inferences, conclusions and future experiments. This is the progress of science.
    Insisting that some part of the puzzle is nonsense just because it is only a part of an answer is a failure to understand how science works.

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  96. PabMD Says:

    I remember concepts like LD50, LD95 [lethal dose where 50% or 95% of the subjects(experimental animals of course!)?]
    Are those concepts outdated?
    What percentage of potheads get nauseated?
    How many continue to use it even when it is “demonstrated” to them that the pot is the cause of the nausea?
    Are the case subjects “normal”?

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  97. DrugMonkey Says:

    Of course the concept of LD50 is not outdated. How do you translate it from a rat to a person when you are making your clinical recommendation?
    With respect to the rest of your questions is there a particular reason you can’t just read the papers yourself?
    If you are talking about the subject of the post we are talking about something a little different than “nausea”. And the cases report discontinuation and failure to discontinue..it is one of the strengths that the cyclic vomiting remitted with cannabis discontinuation. Percent? how would we know? As you can see from what I said and from the Case Reports, doctors went to endless lengths to rule out other causes- obviously the pot smoking is not high on anyone’s radar as a causal factor.
    “Normal”? Pretty clearly not or there would be a lot more of these reactions to chronic cannabis smoking. So what? As a clinician is this your major focus for rare complaints? Asking the patient if she or he is “normal”? Then what? Sorry, can’t do anything for you if you are insufficiently “normal”?

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  98. PabMD Says:

    From the source:
    Background and aims: To explore the association between chronic cannabis abuse and a cyclical
    vomiting illness that presented in a series of cases in South Australia.
    Methods: Nineteen patients were identified with chronic cannabis abuse and a cyclical vomiting illness.
    For legal and ethical reasons, all patients were counselled to cease all cannabis abuse. Follow up was
    provided with serial urine drug screen analysis and regular clinical consultation to chart the clinical course.
    Of the 19 patients, five refused consent and were lost to follow up and five were excluded on the basis of
    confounders. The remaining nine cases are presented here and compared with a published case of
    psychogenic vomiting.
    Results: In all cases, including the published case, chronic cannabis abuse predated the onset of the
    cyclical vomiting illness. Cessation of cannabis abuse led to cessation of the cyclical vomiting illness in
    seven cases. Three cases, including the published case, did not abstain and continued to have recurrent
    episodes of vomiting. Three cases rechallenged themselves after a period of abstinence and suffered a
    return to illness. Two of these cases abstained again, and became and remain well. The third case did not
    and remains ill. A novel finding was that nine of the 10 patients, including the previously published case,
    displayed an abnormal washing behaviour during episodes of active illness.
    Conclusions: We conclude that chronic cannabis abuse was the cause of the cyclical vomiting illness in all
    cases, including the previously described case of psychogenic vomiting.
    Compelling evidence? Next you will tell me you believe in the power of intercessionary prayer…

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  99. DrugMonkey Says:

    Compelling evidence? Next you will tell me you believe in the power of intercessionary prayer…
    Who said anything about “compelling” evidence? Do you really not grasp the way we arrive at a compelling body of evidence in support of an observation? Do you really not understand that you can criticize each and every bit of evidence as “not compelling” in isolation?
    And what, pray tell, does whether I believe in the power of “intercessionary prayer” or not have to do with evaluating these case reports?

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  100. PabMD Says:

    From the source:
    CONCLUSION
    All 10 patients described in this paper were cyclical vomiters
    and chronic cannabis users. All long term sufferers (nine of
    10) also exhibited an abnormal bathing behaviour during the
    acute phase of their illness. Symptoms resolved in seven
    patients with cannabis abstention, confirmed by urine drug
    screening. Three patients rechallenged themselves by resuming
    marijuana and relapsed within months. Two of these
    three abstained again and got better, while the third did not,
    and remains sick. These observations suggest a causative role
    for chronic cannabis abuse. Simultaneous induction of
    cyclical hyperemesis and compulsive bathing behaviour
    suggests a toxic response to one or more of the active
    ingredients of cannabis, presumably acting, at least in part,
    on the limbic system of the brain. Elucidation of the
    responsible pathways will require further research.
    The compulsion to have multiple hot showers or baths
    exhibited by these chronic cases is not trivial. It is clinically
    important to both nurse and doctor as it ‘‘flags’’ these
    patients on the ward. Their ready identification should lead
    to a reduction in morbidity for the patient and cost to the
    health service. The consequences of this discovery bear
    further consideration. The paradoxical effect of its action
    must raise concerns about the long term tolerability of
    marijuana. Furthermore, it would also appear clinically
    prudent to exclude cannabis as an underlying cause in other
    cyclical illnesses, such as atypical abdominal and pelvic pain.
    Cannabis abstention, with urine drug screen monitoring, can
    be titrated against a clinical course. Finally, we feel that this
    disorder is an important differential diagnosis for unexplained
    vomiting, particularly in communities tolerant of
    cannabis. The diagnosis can be considered or discounted with
    the aid of an inexpensive consented drug screen.
    What is the percentage of potheads that get nausea? Only the ones that feel a compulsion to bathe?
    Thank you for resurrecting an obscure medical article, I will certainly pass it on to the ER staff…

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  101. DrugMonkey Says:

    What is the percentage of potheads that get nausea? Only the ones that feel a compulsion to bathe?
    Again, this is not “nausea”. Are you seriously a clinician and you think this sounds like mere nausea?
    Thank you for resurrecting an obscure medical article
    Why is it “obscure” exactly? What, pray tell, makes for a case report of a rare or underidentified phenomenon that lacks obscurity?
    I will certainly pass it on to the ER staff
    As I’ve said to you before, I’m not a clinician and venture no strong views on clinical matters. Personally I would think that clinicians would want to read up on rare stuff so that should they happen across a tough diagnosis their memory would broaden their space of consideration. But that could just be the scientist in me talking, as I said, I have no specific training and perhaps there is a very good reason for clinicians to remain as ignorant as possible. Of “obscure” reasons for what appear to be clinically distressing symptoms, of course. Or perhaps it is difficult for clinicians such as yourself to operate outside of the med school type of environment in which there is always a pat “answer” in the back of the book. Like I said, I really don’t know much about being a clinician.

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  102. PabMD Says:

    notes to self:
    Never wrestle with a pig: You both get all dirty, and the pig likes it.
    Never argue with an idiot.
    They drag you down to their level then beat you with experience.

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  103. Whether you agree or not with marijuana, I think we can all agree that we should allow access to medical marijuana for patients with really bad illness. A friend of mine has Crohn’s Disease and he finds that it helps him cope with the disease. He is really looking forward to NJ rolling out their policy this year. With any medical drug, recreational use is always a possibility but the harm is small compared to the good of showing compassion to the ill.

    Like

  104. DuWayne Says:

    The research that I am interested in pertains to scientific facts.
    Then you are shit out of luck, because in this context they don’t exist. The results of a hell of a lot of studies exist, but those do not provide us with facts, they provide us with the best understanding we have about cannabis. And if you go to the links I suggested, you will find links to those sorts of studies.
    I just see anecdotes and personal attacks, not research…
    What the fuck do you think case studies are? Do you have even the foggiest understanding of science? Case studies are correlational studies, which are sharply limited. Sharply limited does not equal useless. Correlational studies show us patterns that may or may not be worth exploring for causation.
    It frightens me that a doctor knows less about science than a sophomore undergrad…

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  105. DrugMonkey Says:

    I’ve updated the post with a link to this paper which has eight more cases to report. It was news of this paper which motivated me to delve into the hyperemesis syndrome in the first place.

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  106. PabMD Says:

    Wow!!! 8 cases…
    How many million if users?
    We have to remain vigilant of the Zebras.
    Thanks for your effort to spread the truth…

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  107. Cashmoney Says:

    Your patients must love it when you tell them to go away untreated because after all there are millions of people walking around without wtfever they came to see you about.

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  108. Cashmoney Says:

    Wasn’t that an episode of ‘Weeds’? I love that show!

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  109. COPRO Says:

    Some of you may feel this is a joke, my son now does not. He suffers from this “allergy”. He has had every test imaginable with all coming back negative. Please continue with your research so this “fun drug” can also be proven to be dangerous if abused.

    Like

  110. PabMD Says:

    FYI:
    Cannabis product ineffective for diabetic peripheral neuropathy
    Clinical question
    Is a marijuana derivative effective in decreasing pain associated with diabetic peripheral neuropathy?
    Bottom line
    A standardized, botanical derivative of cannabis is no more effective than placebo — though both produce marked relief — in the treatment of diabetic peripheral neuropathy. (LOE = 1b-)
    Reference
    Selvarajah D, Gandhi R, Emery CJ, Tesfaye S. Randomized placebo-controlled double-blind clinical trial of cannabis-based medicinal product (Sativex) in painful diabetic neuropathy. Diabetes Care 2010; 33(10):128-130. [PubMed Abstract]
    Study design: Randomized controlled trial (double-blinded)
    Allocation: Concealed
    Setting: Outpatient (specialty)
    Synopsis
    In the early part of the last century, medical use of alcohol was the way in which the then-illicit substance was available to the masses (Lydia E. Pinkham’s Vegetable Compound, marketed for “female complaints,” was 18% alcohol by volume.) Today, the illicit substance that has been medicalized is cannabis. This study evaluated the effect of a spray containing tetrahydrocannabinol 27 mg/mL and cannabidiol 25 mg/mL (Sativex; not available in the United States) in the treatment of painful diabetic neuropathy. A total of 38 patients with neuropathic pain despite treatment with tricyclic antidepressants were randomly allocated (allocation concealment unknown) to receive treatment or placebo sublingually up to 4 times per day, the dose titrated to response over 10 weeks. Pain scores, measured using 10-cm visual analog scales evaluating superficial, muscular, and deep pain, improved markedly and similarly in both groups. Patients with depression had greater pain scores at baseline that improved regardless of the intervention.
    Copyright © 2010 John Wiley & Sons, Inc. http://www.essentialevidence.com
    I have to wonder how much of the smoked weed medical benefit is placebo…

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  111. drugmonkey Says:

    An example of why poor scientific understanding can lead to insufficient healthcare- took awhile for the medical community to realize it was the chronic pot exposure at work in these poor people.

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  112. […] reviewed several case reports back in 2010. The comment thread was robust (this was originally posted at the Sb version of the […]

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  113. […] I've discussed the evidence for a cyclical vomiting syndrome associated with cannabis use here, here and here. Also see Dirk's […]

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  114. selena Says:

    i have been told by my doctor yesterday that Cannabinoid induced vomiting, is a study that came out about 5 years ago… My doctor diagnosed me with this and gastritis… i understand why…. the way i usually smoke is half marijuana half tobacco in a bong… i was told tobacco raises acid levels… i cant stop with the vomiting, abdominal pain, and major headaches. The hot shower did work for me earlier.
    Zofran somewhat works, I have anxiety from the pain, but I feel like none of my medication is working.

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  115. Isabel Says:

    “…. the way i usually smoke is half marijuana half tobacco in a bong… i was told tobacco raises acid levels..”

    Interesting….do you smoke large amounts of the stuff?

    Have you tried cannabis only, without the tobacco, in small quantities?

    How is your diet? Has your doctor checked for nutritional deficiencies?

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  116. Anonymous Says:

    Has anyone even considered questioning grow methods and genetic modification to the plant. I thought of the many equine friends I have that now have thyroid mid brain problems from genetically mod soy. There no free lunch people. Gov poison us then points the finger.

    Like

  117. ataraxia Says:

    Cannabis has more than 80 bioactive compounds. As with so many plant medicines, some compounds have effects in opposition to one another. CBD is an excellent antiemetic and antipsychotic, and it blocks the THC high. Given the latter two effects, doesn’t it seem plausible that THC caused nausea and vomiting, in opposition to CBD’s antiemesis ? Given the several known ways they act in opposition, it seems quite possible. Perhaps the strains smoked contained insufficient CBD to block the emetic effects of THC (or another cannabinoid), or insufficient for these subjects, anyway, since this obviously isn’t a widespread phenomenon.

    The two different types of cannabis will also have different effects.
    Indicas are more commonly used for pain/other medicinal use, sativas to get high, for creative stimulation, etc. Unfortunately the gold rush on THC means that in breeding for max THC they’ve probably created strains that are more likely to cause effects like hyperemesis — whether because THC is being boosted or because something else is as well.

    I once heard a friend vomit right after smoking too much really potent weed, and a brief moment of nausea right after taking a large hit has been reported to me several times. It’s possible that these subjects were simply more generally prone to nausea and vomiting, as is my friend who vomited. We just don’t know.

    Were the subjects checked for parasites? I have a friend who got sick in Hawaii. Vomiting, intense gastric pain, rash etc. She informed the docs she was using a pure CBD extract, and (after doing all the usual, CT and etc.) they made a call of cannabis hyperemesis syndrome. We couldn’t bridge the language barrier to explain about CBD being antiemetic — in their ignorance, it was all just “pot” to them.
    We her friends had already determined based on her symptoms that it was leptospirosis. We had to repeatedly insist the hospital test for it, even though she’d been in a region where lepto is endemic, so it’s unlikely that these subjects were so tested. They finally tested her for it, and hey presto, it was in fact lepto.

    These subjects may not have had an obvious exposure like going to Kauai and swimming in the water, but they may still have been exposed to some parasite. They’re more widespread than they used to be, and it’s likely that despite all of the expensive tests they did perform, parasite testing was not done. And probably will not be with future cases, unless strongly requested.

    Personally, I suspect it was in fact the cannabis that made these subjects vomit — discontinuation stopping the vomiting indicates that pretty strongly. As for the hot shower helping, I suspect the idea of vagus/parasympathetic stimulus might be on the right track.

    —-

    Will legalisation/decrim cause many to indulge who previously hadn’t? Initially, yes, of course. There will be a spike. Then use will drop. Use among the young will drop even further, because the forbidden fruit aspect will be gone. This has been the pattern. Portugal sees the same following decrim.

    The Dutch are rolling up cannabis users because of a general shift to the right politically combined with pressure from the US, which is trying not to look stupid by being so draconian by comparison — it’s tired of bloggers and writers who go to Amsterdam and send back glowing, awestruck reports. Plus Dutch annoyance with the very few pot tourists who behave badly — and the overall increase in those coming since cannabis got big in the American public eye. So the changes there have nothing to do with the effects of cannabis itself, and are entirely due to human factors.

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