More cannabis hyperemesis Cases emerge

August 15, 2012

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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No Responses Yet to “More cannabis hyperemesis Cases emerge”

  1. Isabel Says:

    I am not “for” pot, I am AGAINST the harmful, unjustified (by the governments own account) prohibition.

    And really, DM? You are going on record as saying the claim that cannabis has less harmful effects than tobacco is false?????

    You are truly insane if you believe that.

    Like

  2. Isabel Says:

    Oh, your interjection was confusing- did you mean addiction and long term effects was wrong?

    As far as long term effects they are referring to major disease leading to early death, not strange diseases that may or may not affect a tiny minority.

    I think it should say it has never been proven to have long term effects and that addiction is rare and less debilitating than the other (legal) cases.

    And that it doesn’t cause users to become violent is “a distraction?” Some victims of violent alcoholics might disagree with your privileged view there, DM.

    You left some important questions unanswered once again on the other thread. 😦
    Why does this

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  3. drugmonkey Says:

    as always, your reading comprehension needs some work Isabel

    Like

  4. Isabel Says:

    Wait that’s still not right?

    If it is it is definitely your fault. Your writing at this point is gibberish. You are flailing.

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  5. drugmonkey Says:

    did you mean addiction and long term effects was wrong
    yes. our comments must have crossed.

    As far as long term effects they are referring to major disease leading to early death, not strange diseases that may or may not affect a tiny minority.
    You are just making that up. You have no idea to what this refers beyond the words themselves. Until and unless you are a judge having to decide what a bit of passed legislation actually means in implementation.

    I think it should say it has never been proven to have long term effects and that addiction is rare and less debilitating than the other (legal) cases.

    Well, perhaps next time you can write the initiative and see if it convinces 51% of voters somewhere.

    And that it doesn’t cause users to become violent is “a distraction?”
    Yes. Enumerating what some bit of policy fails to do is a distraction for the most part. far more useful to enumerate what it will actually do. I notice that there is no mention of increased automobile accidents in this clause, an obvious place to put it.

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  6. Beaker Says:

    This can’t be cannabis ‘cuz cannabis is all-natural–and safer than water!!!1111!! I think they were smoking shower salts.

    Like

  7. Isabel Says:

    “I think it should say it has never been proven to have long term effects and that addiction is rare and less debilitating than the other (legal) cases.

    Well, perhaps next time you can write the initiative and see if it convinces 51% of voters somewhere. ”

    This is disingenuous. I just provided evidence that the initiative failed because of the efforts of police union lobbyists and other interests.

    “far more useful to enumerate what it will actually do.”

    possibly decrease domestic violence if some people switch?

    ” I notice that there is no mention of increased automobile accidents in this clause, an obvious place to put it.”

    No evidence that this would occur!

    Meanwhile, Beaker thinks these attempts to end the tragic period of prohibition are freaking hilarious!

    Like

  8. drugmonkey Says:

    No evidence that this would occur!

    and you wonder why I call you a denialist…..

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  9. Isabel Says:

    ” Until and unless you are a judge having to decide what a bit of passed legislation actually means in implementation. ”

    I asked this exact question on the other thread, and as usual you did not answer me. This is just one item in a long, wide ranging list of “things we know to-date” – is its hyper-accuracy going to have major implications of some sort?

    Is your point that it will have health policy implications or that its inclusion caused voters to back off support? If the latter, do you have any evidence that it doomed the initiative?

    Like

  10. Beaker Says:

    Isabel, please stay on subject. If you did, I might bother to read more of your comments. Cannabis hyperemesis is a fascinating medical condition, and it carries no political spin.

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  11. Isabel Says:

    “Isabel, please stay on subject. If you did, I might bother to read more of your comments. ”

    Please don’t bother. I’m sure you’s have nothing of value to add to the conversation. And I was responding to an intentional mis-characterization of ME in the first fucking sentence of the OP and then an intentional omission of the facts I JUST PRESENTED on the post he links to. His whole post is an attempt to say that this bizarre syndrome should be acknowledged as an example of the long term toxic effects of using cannabis. If it wasn’t for Drugmonkey no one would even have heard of this particular syndrome. Even the real sufferers of hyperemensis are annoyed because their physicians are all saying “we have cured the mysterious condition you have had since age 7, it’s caused by your cannabis use! finally, we don’t have to search for the cause anymore! I read it on Drugmonkey, or addiction box!

    Please, go argue about grad student stipends, please.

    “Cannabis hyperemesis is a fascinating medical condition, and it carries no political spin.”

    LOL.

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  12. J Delphinki Says:

    DM, did you see: Simonetto, D. A., Oxentenko, A. S., Herman, M. L. & Szostek, J. H. Cannabinoid Hyperemesis: A Case Series of 98 Patients. Mayo Clin Proc 87, 114–119 (2012).

    For some reason, my institution doesn’t give me access to the full text, but there’s a relatively detailed abstract.

    I must confess that cannabinoid hyperemesis is a new phenomenon to me, so I may be out of my element here, but I can’t help but think it involves 5-HT3. Perhaps chronic administration of cannabinoids, well known 5-HT3 inhibitors, induces supersensitivity to endogenous agonists in a subset of cannabis users.

    The relief with hot showers implicates a strong role for TRVP1, which is also activated by endocannabinoids. Chronic cannabis use definitely perturbs endocannabinoid systems.

    I’d be interested to see if there are any pharmacogenomic interactions–or if anyone has even looked (a quick pubmed says no). Whatever the cause, cannabinoid hyperemesis seems quite paradoxical to me.

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  13. drugmonkey Says:

    Yes, the simonetto review was the trigger for my last post on the topic. If you click the older post link you’ll find it.

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  14. drugmonkey Says:

    No one would even have heard of it? So you suspect me of ghost authoring this now continuous trail of Case Reports across several continents, Isabel?

    Honestly, how any scientist who has such a profound obsession with pot cannot djinn up even a *little* curiosity about how this works is beyond my understanding.

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  15. Isabel Says:

    “No one would even have heard of it?”

    I posted the link that credited you with spreading the word on the subject in one of the other CHS threads, should be easy enough to find.

    “So you suspect me of ghost authoring this now continuous trail of Case Reports across several continents, Isabel?”

    well that’s quite a leap, LOL. No, I don’t suspect THAT.

    “Honestly, how any scientist who has such a profound obsession with pot cannot djinn up even a *little* curiosity about how this works is beyond my understanding.”

    If you are talking about me, I have bigger fish to fry at the moment. I’m actually fairly interested in all kinds of weird diseases, but right now prioritizing the prohibition crisis. Also, I’m not obsessed with pot.

    Like

  16. Beaker Says:

    I’m actually fairly interested in all kinds of weird diseases

    LOL Look in the mirror. Focus deep into your reflection…fairly interesting, and definitely weird.

    Like

  17. Grumble Says:

    “[DM- policy statement, false, false, distraction]”

    Wow, DM. Those two posts linked to in “false, false” are the best arguments you can come up with the marijuana is physically addictive and has toxic effects on the body?

    With regard to physical addictiveness, the post you link to describes two articles that even you admit (in the comments section) are seriously flawed because the subjects self-reported as being dependent – meaning the studies oversampled from MJ users who think they have a problem, rather than the general population of heavy MJ users. So, yes, some people might become physically addicted, but it’s entirely possible that the vast majority do not.

    With regard to toxicity: is that it? A few case reports here and there of hyperemesis? If that’s sufficient to continue banning recreational MJ use, then I guess I should stay home tomorrow because I might get into a car accident.

    Like

  18. Isabel Says:

    That was an amazing contribution to the thread, Beaker. Now let’s see if you can express specifically what it is that you find so weird. Please be specific (though I doubt you will be) so we can get to the bottom of your problem. I suspect it might be ego-related πŸ™‚

    Like

  19. Beaker Says:

    Isabel, there is considerable common ground between us concerning the current legal status of drug laws in this country and its disconnect between the harm of the various drug classes. Alcohol is only the most obvious example of the current hypocrisy. What I would like to have is a cogent discussion of social benefit vs risk–with an acknowledgement of data (cannabis hyperemesis being one example) and also history (alcohol and, say, legal stimulants such as Adderall). Also, I’d like to see a recognition that certain drug classes are indeed detrimental to society and should be outlawed, full stop (PCP, for example).

    Instead, what we get from you is hyperbolic and aggressive talk that prevents this sort of discussion. It is not news that alcohol causes more problems than pot. It is also not news that legal opiates cause more problems than pot. Your knee-jerk responses to Drugmonkey’s very reasonable points (supported by data) makes a useful discussion impossible. Add to that your defensive and often incoherent posts–and you are left with CPP’s conclusion: Loonabel. Prove me wrong, please. (I doubt you will).

    Like

  20. Isabel Says:

    Privileged Physioprof never concluded anything: anyway he’s just a prejudiced, hostile drunk and can be safely ignored. I wouldn’t go by his opinions about people.

    Look I respect your right to want to have a discussion about “….social benefit vs risk–with an acknowledgement of data (cannabis hyperemesis being one example) and also history (alcohol and, say, legal stimulants such as Adderall). Also, I’d like to see a recognition that certain drug classes are indeed detrimental to society and should be outlawed, full stop (PCP, for example)….” but none of that relevance to prohibition, which is the topic of discussion here.

    My problem with DM is he repeatedly frames his discussion as anti-anti-prohibitionist. Just like he did here (see OP), as I already explained. What does CHS have to do with the CA initiative? It sounds like YOU have a problem with his approach also. DM also repeatedly lies about my point of view, like he did with the initiative, saying I said it was harmless. I don’t think it is, and I never said so.

    Funny that no one has any observation to make about the police and prison unions and their role in all this.

    Like

  21. drugmonkey Says:

    Wow, DM. Those two posts linked to in “false, false” are the best arguments you can come up with the marijuana is physically addictive and has toxic effects on the body?

    You are seriously deluded about the purpose of my blogging. What I happen to find interesting to blog about has little to do with what I think are the “best” arguments for anything in particular.

    So, yes, some people might become physically addicted, but it’s entirely possible that the vast majority do not.

    One of my occasional themes on this blog is the conditional probability of dependence. The majority of people who sample any drug, including intravenous heroin do not end up qualifying for drug dependence under DSM criteria. So it is not “entirely possible”, it is “entirely correct” that the majority of pot users do not become dependent. “vast” we can discuss. also, this.

    With regard to toxicity: is that it?

    Nope. You probably can find PubMed as well as anyone else. There is a healthy literature on the lasting effects of cannabis and THC exposure. I invite you to read it all critically and without reflexive denialism.

    I’d like to see a recognition that certain drug classes are indeed detrimental to society and should be outlawed, full stop (PCP, for example).

    and on what basis would you be drawing your distinctions for which particular substances?

    My problem with DM is he repeatedly frames his discussion as anti-anti-prohibitionist.

    Actually I repeatedly frame my discussion as anti-science-denialism. This is a healthy tradition on the Science / Blogging internets and is part of what attracted me to blogging in the first place. I am further motivated by the fact that my topics of closest scientific interest bring out the denialist in anti-science-denialist chest thumpers themselves. It is far too hilarious a situation for me to resist.

    Like

  22. Isabel Says:

    “Actually I repeatedly frame my discussion as anti-science-denialism. ”

    The problem is that there are studies that show the opposite of what the ones you highlight show; many in fact. The evidence is simply weak. If you are a very heavy smoker for a long time there might be a small increase in the very tiny chance that you might get lung cancer. There is an even tinier likelihood that you might end up puking all day and craving super-hot showers.

    is there, I agree, and it’s not surprising. I read the studies and take caution. But lots of things are going to have some kind of long term effect. This question of degree really matters! That is why all the governmentally-appointed commissions have concluded that prohibition is not warranted.

    You seem to think the papers you bring up are relevant to the question of prohibition. They simply are not.

    The disagreements you have are also minor, at least from another’s view. I’m not surprised that your take on the question of addiction is more sophisticated than others, so what? You still haven’t explained why it matters in the case of the CA initiative, nor provided any evidence that either this alleged misconception about harm, or “dope fans”, doomed the initiative.

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  23. drugmonkey Says:

    Isabel,

    For teh millyunth tyme…it is *you* that insists on bringing up public policy issues vis a vis legalization every time something health-related is raised. Not I.

    Like

  24. Isabel Says:

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

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

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

    Like

  25. Grumble Says:

    What I happen to find interesting to blog about has little to do with what I think are the “best” arguments for anything in particular.

    and

    it is *you* that insists on bringing up public policy issues vis a vis legalization every time something health-related is raised. Not I.

    Both of those statements are incompatible with the opening lines of your blog post:

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

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

    So, given that you are, in fact, blogging about political arguments: my point was simply that if you want to assert that the CA initiative proponents’ arguments are “false, false”, then those links contained particularly weak evidence in support of that assertion. In evaluating the proponents’ claims, I am much less interested in a handful of examples showing physical addictiveness and emesis, and much more interested in knowing whether the drug is broadly dangerous in ways similar to nicotine, cocaine and heroine.

    The link in your response is much more informative (1.6% of population is dependent on marijuana, and 4% of people who have tried it are dependent). However, the next question is whether that dependence syndrome is as severe as for all the other nasty addictive drugs out there. One thing that struck me about the comparison of cannabis to nicotine is that the measure of craving was much lower in cannabis-dependent than nicotine-dependent abstainers. Hmm. Presumably this means that even dependent pot users don’t feel (and maybe just plain aren’t) controlled by their need to find and use pot. Whereas we know that cocaine, heroine et al addicts’ behavior is controlled by this need, and that this is a large part of what ruins their lives.

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  26. Austin Says:

    my name is Austin and i was one of the statistics for CHS at the Mayo Clinic I’m 23 yrs old now (21) at the time constant smoker for 2 plus years woke up one morning throwing my guts up worst pain I’ve ever experienced i found that very hot showers and smoking more weed fixed the problem only for a day or so i had to be taken to the ER hundreds or times over the next year and half when the DR finally gave up they sent me to the Mayo Clinic and that is the first time anyone had told me abut CHS so i gave up smoking to give it shot and by GOD they were right haven’t had a problem since i gave up smoking I wont lie I sneak one in there sometimes just very very very spaced out and not much in quantity I’m all for marijuana and its uses but CHS is very real and people need to be educated about it so hopefully no one has to endure to pain and suffering my family and i went through just from smoking weed!

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  27. drugmonkey Says:

    Thanks for stopping by and commenting. Glad your symptoms remitted.

    Like

  28. kedge1221 Says:

    As someone who was recently diagnosed with this, it kills me to see people comment that this condition isn’t really or as someone suggested people were smoking something else. For two years I’ve been in and out of the hospital and never got an answer for what was wrong with me. I feel relieved to find an answer and to know I’m not alone

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  29. […] really hoping to see some efforts along these lines [hint, hmmmm] to address both the medical marijuana and the recreational marijuana policy moves that are under […]

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  30. BRAD Says:

    Maybe funding for cannabinoid research would be better spent on clinical trials to assess the potential use of these compounds in TREATMENT OF CANCER, EPILEPSY, AND AUTOIMMUNE DISEASE? In vitro and mouse model studies clearly show that cannibinoids mediate selective apoptosis in many cancer cell lines via cross talk between autophagy and apoptosis, in addition via a separate mechanism these drugs seem to down regulate pathways that lead to aggressiveness and invasiveness of cancer cells. In short, use of cannabis may lead to greater likelihood of remission and decreased probability of an isolated neoplasm developing the ability to metastasize.

    The only utility I see in studying cannabis hyperemesis syndrome (if it exists) is that this syndrome may ultimately be a limiting factor in administration of some cannibinoids to cerain patient populations (particularly considering the high doses that may be needed for cancer treatment). If this does turn out to be a legitimate syndrome, effort should be directed at developing treatment/prevention strategies for patient’s who may need to use cannabis on a daily basis.

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