Cannabinoid Hyperemesis Syndrome
Cannabinoid Hyperemesis Syndrome (CHS) is still relatively new and was first discovered less than 20 years ago. Therefore, while many questions remain as to why people develop it, there is a more specific, clear path as to how to treat it.
John’s Story: Learning Cannabinoid Hyperemesis Is ‘A Thing’
John mopped his forehead with a washcloth and steadied himself against the bathroom counter. He looked at the contents of his lunch, now being washed down the sink, and thought “this is the second time this month.” John recalled the last time, which occurred about two weeks earlier, in which he threw up for about three days between fruitless toilet visits.
Oh, how he wished he were at home instead of barricaded in a locked bathroom at work. At home, John had felt some reprieve when he hopped into the shower, hoping to feel fresher after vomiting and noticing his symptoms seemed to lessen a bit in the warm, steamy stall. It seemed odd to think he had another stomach bug. The first one ended in a late-night trip to the emergency room (ER) for intravenous (IV) fluids to rehydrate when his wife Adrienne convinced him something might be wrong.
When he got home later that evening—barely avoiding hurling his stomach’s contents across his car’s interior by luckily finding an empty convenience store bag in the back seat—Adrienne found him in the shower just like last time.
When she got John into bed to rest, she mentioned a poster they had seen at the ER. The poster had a set of three arrows arranged in a circle showing a stick-figure person holding his stomach, then a shower head, then the outside of an ER with an IV bag.
The message had some acronym he struggled to recall, but the pot leaf seemed to indicate some connection to marijuana. Both Adrienne and John were what he considered recreational users, but he partook in marijuana more frequently than his wife.
The nod to their much-appreciated marijuana had given them a brief giggle, shortened suddenly by another visit to the ER bathroom while waiting to be seen.
“What was that acronym on the ER poster?” John asked Adrienne, while she looked at him with awareness dawning across her face.
Cannabinoid Hyperemesis Syndrome Or CHS
Cannabinoid Hyperemesis Syndrome (CHS) is a condition experienced with chronic marijuana use. It is demonstrated by a cyclic period of nausea, abdominal pain, and vomiting, which a person learns can be alleviated temporarily with hot bathing.
First Diagnosis In The Land Down Under
It was first recognized as a condition in 2004 by three Australian doctors who diagnosed 19 patients with the illness. Five patients refused an option for further study of the new condition, and five more were excluded for other factors. The remaining nine patients were counseled to abstain from further marijuana use. Evidence consistently showed marijuana was used before the symptom onset and ceased upon refraining from use.
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.
Drs. J.H. Allen, G.M. de Moore, R. Heddle, J.C. Twartz, published in the international gastroenterology journal GUT, Nov. 2004
CHS strongly resembles Cyclic Vomiting Syndrome (CVS) and may be initially misdiagnosed if marijuana use is not shared with a physician. When symptoms disappear in someone who uses marijuana and then abstains, it generally indicates CHS was the cause and CVS can be categorically excluded.
One medical article published in German Medical Science, actually notes how little is known about either condition.
“…cannabinoid hyperemesis syndrome (CHS) and the cyclic vomiting syndrome in adults (CVS) are both characterized by recurrent episodes of heavy nausea, vomiting, and frequently abdominal pain. Both syndromes are barely known among physicians.”
In the case of John, above, the attending physician neither asked, nor did John offer, about marijuana use. After years of using it with no real side effects, he didn’t even think the symptoms could be related to his chronic use.
Drugs are classified by a five-level schedule of potential for misuse, with Schedule I being the highest potential and Schedule V, the least potential for misuse.
While marijuana has been legalized at various levels within different states, it remains classified as a Schedule I drug by the Drug Enforcement Administration (DEA). This status prohibits federal research for studies. Being classified as illegal makes conditions less than ideal to determine the full scope of marijuana’s long-term side effects.
How Common Is Cannabinoid Hyperemesis?
Numbers on the prevalence of CHS are difficult to find. With no synopsis of national data readily available, researchers turn to hospitals for data. A 2015 study of Colorado emergency room (ER) visits following the legalization of marijuana nearly doubled (41 per 113,262 ER visits before the law change, 87 per 125,095 ER visits after law change), supports a hypothesis that CHS by chronic marijuana users is not as rare as a lack of research may indicate.
Another questionnaire was distributed at a New York hospital ER identifying 155 people age 18-49 who admitted using marijuana at least 20 days per month. The authors of the report said 32.9% met the criteria for CHS.
The legalization of marijuana may result in more cases, according to Dr. Manisha Gupta in a 2018 article Treating Cannabinoid Hyperemesis, published by the Society of Hospital Medicine.
“Marijuana use is likely to rise, and with it may arise an increasing incidence of CHS.”
Cannabinoid Hyperemesis Syndrome Has A Multiphase Cycle
Prodromal phase (the period between symptoms and development of condition: For CHS, this period can last for years and a person suffers from abdominal pain, nausea, and worry about vomiting. Their diet remains typically normal.
Hyperemesis phase: CHS advances to heavy vomiting, which after a time can lead to trips to clinics or urgent care for treatment. Commonly seen during the prodromal and hyperemesis phases, someone with CHS may have situational symptoms due to high discomfort and pain, including
- Low-grade fever
- Esophageal burning sensation from repetitive vomiting
During this period, patients have reported relief, sometimes as high as 60% of them, through hot bathing. The earlier-referenced New York hospital study said patients ranked hot showers as a level five or higher on a 10-point scale in terms of helpfulness. Think here in terms of hot bath soaks or steam showers, somewhat similar to the relief sought with heating pads.
Emetic phase: Prescription medications are given intravenously such as lorazepam, proton pump inhibitors, and fluids for rehydration.
Recovery phase: Symptoms will stop with the cessation of marijuana use. If use is continued, symptoms may hold off for a few days or a month, but inevitably will re-occur.
What Causes Cannabinoid Hyperemesis Syndrome?
With the challenges of marijuana research, another condition we have limited insight into is CHS. Marijuana use disorder is a condition recognized by the American Psychiatric Association’s (APA) Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5).
Cannabis is a complex natural plant with hundreds of compounds, including cannabinoids such as tetrahydrocannabinol (THC) and cannabidiol, as well as non-cannabinoids. THC is the primary psychoactive and addictive compound due to its unique structure. With chronic use, reports have shown traces can remain in a person’s system days, weeks, and even a month after use.
An average dose of cannabis is between 5-10 milligrams. and it may take up to an hour to feel the effects if consumed as an edible versus the quicker-reacting inhaling. Edible packaging comes in 100 milligram-packs, and an inexperienced user may take the entire package, unknowingly overdosing. Cannabis overdosing can cause anxiety-related symptoms and extreme heart racing that can only be treated with a prescription drug—or time as it makes its way through the system.
A chronic user may take 25-80 milligrams to feel the same effect as someone using 5 milligrams of marijuana for the first time, according to the Los Angeles Times.
In the 2020 research article Cannabis Use Disorder, the authors noted “Chronic daily smokers can produce detectable levels of THC and its metabolites one month after its last intake.”
With that longevity in the body, perhaps there is no surprise someone’s system might feel the CHS effects through nausea, upset stomach, and vomiting, such as seen in cannabinoid hyperemesis.
Isn’t Marijuana Used Medically To Stop Nausea?
Marijuana is often used to help with the nausea side effects from some medical treatments such as cancer because THC binds to nausea receptors and stops their ability to function. The recommendations are for low doses and spaced intermittently. This avoids a need to increase dosing due to increased tolerance, risking the development of CHS, and losing all the medical benefits.
Why Do Hot Showers Help?
With the cause of why chronic use can lead to vomiting unable to be answered conclusively, what is the purpose of the hot showers? That answer is also elusive as to why they sometimes help alleviate symptoms, and seeking a hot shower also seems somewhat learned at first instinctively and then becomes compulsive.
Online science media site livescience.com interviewed Dr. Kennon Heard, a toxicologist at UCHealth’s University of Colorado Hospital, who sees the syndrome regularly, in a 2018 article where he stated any conjectures to the above questions are “pretty hypothetical.”
“Something in the pain system is disturbed by having THC around all the time,” Dr. Heard said regarding the vomiting response.
The comfort sought by hot showers may help by distracting the painful stomach sensation to another body area and stimulation.
“Your body can only process so many signals at once,” he summarized.
Characteristics Factored For At-Risk Individuals for Cannabinoid Hyperemesis Syndrome”
- Chronic marijuana use: Definitions of chronic differ, but typically long-term implies years of regular use. One study defines it as an average daily use of 3-5 times per day.
- Long medical records: Patients with CHS often have long medical records consistent with multiple visits to doctors during the emetic phase. Consideration is given for similar conditions such as gastroparesis, pancreatitis, gastritis, psychogenic vomiting due to a mental illness, or CVS. After ruling out these conditions, no other conditions are identified through testing; a psychiatric evaluation could rule out an eating disorder.
- At-risk category: In addition to that fact, one study summarized a typical CHS patient as having the following characteristics: White, male, diagnosed at 35, having possibly undergone several diagnostic measures or surgical procedures to pursue a cause, to no avail.
- Rule out CVS by sharing marijuana use with symptoms: Earlier detection and accurate diagnosis would pre-empt unnecessary medical procedures. A key factor in CHS that differentiates it from CVS, aside from marijuana use, is a delay in emptying stomach contents, where CVS typically races through the gastric tract.
Follow-up treatment suggestions include the following:
- Cease marijuana use.
- Access mental health and substance use treatments for recovery.
- Revisit the possibility of CVS if symptoms persist with no marijuana use, or a person refuses recovery treatment.
The ABCs Of Marijuana, THC
Cannabis is a plant known to grow wild in Asia from the Himalayas to the Pakistani mountains and even be on decorative display alongside public streets in China. It is not native in the western hemisphere, but wild growth in the United States has literally been spreading as seeds blow from legal and illegal cannabis farms. It is also trafficked from Mexico, Colombia, and Jamaica in the west and Thailand, South Africa, Nigeria, and Kazakhstan in the east.
There are many varieties of cannabis from sativa to indica. The dried parts of the plant are what comprise marijuana: the stems, buds, leaves, flowers, and seeds. Cannabis is made up of hundreds of compounds, or cannabinoids, one of which is delta-9-tetrahydrocannabinol (THC). This is the main compound, found in the female plant, that causes the mood-altering high by binding to the brain’s receptors.
Cannabis Use Disorder and Syndrome
The prevalence of marijuana use is rising as legalization rates rise in the United States. Colorado and Washington were the original states to first legalize recreational marijuana in 2012.
Since those groundbreaking measures, 32 more states have joined for a total of 34 states that allow marijuana for either medicinal or recreational use. More states have indicated the issue would be visited soon, and the federal government may decriminalize marijuana, meaning offenders would have to pay fines and not serve jail time.
- A November 2020 Gallup poll showed more than two-thirds—or 68%, of Americans—support legalizing marijuana. Since being tracked in 1969 with a mere 12% in favor of legalization, approval has for the most part slowly but steadily increased, before doubling in the past 20 years.
The poll further shows the most support among “men, younger adults, college graduates and those in households with incomes of at least $100,000.”
- The National Institute on Drug Abuse ranks marijuana as the most common drug behind alcohol and used by 12 million youth in grades eight through twelve.
- The 2018 National Survey on Drug Use and Health (NSDUH) results showed 43.5 million people age 12 and older used marijuana in the past year.
As with all substances such as alcohol and tobacco, there is the possibility of developing an addiction when the substance is used more frequently, in higher quantities, over extended periods, despite how it affects a person’s social, school. work, and family life.
The NSDUH survey showed 20.3 million people had a substance use disorder related to alcohol or illicit drugs; 4.4 million, or 22%, specifically had a cannabis use disorder.
Earlier, it was referenced that CHS was first recognized by Australian doctors with 19 patients, and they ultimately were only able to study cases of nine people. The five people who refused treatment will always be somewhat of a mystery as to whether they continued using marijuana despite the vomiting or were able to recognize that abstinence needed to be adopted.
So let’s consider the situation where marijuana use is negatively affecting your life, thereby contributing to the possibility of a disorder. One might gently offer forth that if the substance makes you ill to the point of repetitive vomiting, perhaps you would be better off abstaining from the use of the substance?
Marijuana Overdose Syndrome Side Effects
Overdose with marijuana is more typically seen by someone unfamiliar with how much to use at one time. The delay felt from an edible due to being absorbed through digestion is different from the quicker high seen through smoking, whether from leaves or vaporizing, which reaches the brain more quickly.
This delay may cause someone to ingest enough at once to overdose, feeling uncomfortable but unlikely fatal side effects such as
- Higher-than-normal heart rate and blood pressure or chest pain
- Panic attacks or severe anxiety
- Hallucinations, delusions, or extreme paranoia
- Uncontrollable shaking or seizures
- Either pale or flushed skin color
Marijuana and CH Syndrome Withdrawal Symptoms
Withdrawal symptoms may occur in those with long-term, daily use who abstain entirely from marijuana. These symptoms generally last for one week and include
- Anger, irritability, and/or aggressiveness
- Extreme nervousness or anxiety
- Disrupted sleep patterns, insomnia, or nightmares
- Decreased appetite leading to significant weight loss
- Feelings of fatigue, restlessness
Individuals experiencing intense withdrawal symptoms may benefit from an inpatient treatment program. Inpatient or residential treatment can provide the psychological services that may be needed when someone is addicted to marijuana, as there are no medical drugs to regulate or reduce cravings, and all cognitive behavioral therapy can be done outside of rehab.
Vertava Health Offers Healthcare Treatment Centers Across The United States for Cannabinoid Hypermesis
For people experiencing CHS, abstinence is the recommended course of treatment. Marijuana dependence typically co-occurs with other drug use, and treatment should be sought from a program that can treat all addictions that the user might have. Because adolescents are the primary users of marijuana, many addiction treatment centers will specialize in teen rehabilitation.
We offer unique treatment plans with an evidence-based combination of detoxification and behavioral therapies that help individuals break their dependence on marijuana and relieve them from their experiences with CHS.
If you or a loved one are diagnosed with CHS and are struggling to remove marijuana from your life, contact us today. Rehab Center by Vertava Health is here to help you find a treatment center that is suited to meet your specific needs in treatment. Call us today at (877.630.2970 to start on your road to recovery.
Cannabinoid Hyperemesis FAQs:
How long does it take to recover from cannabinoid hyperemesis syndrome?
After an episode, a person may need a few days to recover their strength from the fatigue of the vomiting cycle’s adverse effects. With no more marijuana use, the syndrome would effectively be resolved with no long-term effects.
Is cannabinoid hyperemesis syndrome permanent?
No, CHS is not permanent. Abstaining from marijuana use proves to effectively resolve all symptoms of the disorder.
Why do hot showers help cannabinoid hyperemesis syndrome?
It is based on speculation that showering takes the focus from the pain of the vomiting cycle and introducing warmth to stimulate the senses on other parts of the skin and aid in distraction.