No But Really…How Much Weed Do You Smoke?

This post was peer reviewed.
Click to learn more.

Image Credit: Flickr

Author: Ashley Grigsby, DO, PGY-3
Indiana University, Emergency Medicine/Pediatrics

Case
A 21-year-old female presented with epigastric abdominal pain and severe vomiting for the last three days. She has had similar vomiting episodes before and has had a large workup that was unremarkable for the etiology. She was unable to stay hydrated during this latest episode so she presented to the emergency department (ED). She stated that the only thing that helped her vomiting has been a hot shower. Her vitals were normal except for a heart rate of 112 beats per minute; her exam was unremarkable except for mild epigastric tenderness to palpation. The patient was questioned multiple times alone in the room and denied, multiple times, any marijuana use or other drug use. She was treated symptomatically and improved. On discharge, she was again questioned about drug use and admitted to twice daily marijuana use for the past several years. She was diagnosed with cannabinoid hyperemesis syndrome, counseled on the importance of marijuana cessation, and discharged home in good condition.

Discussion
With over 16 million users, cannabis is the most commonly used illicit drug in the United States.[1] In November 2016, California, Massachusetts, and Nevada all passed laws legalizing recreational marijuana use. With these new laws passed, a total of seven states plus the District of Columbia have legalized recreational marijuana, plus several more that have legalized medical marijuana use.[2] With a growing number of states legalizing cannabis, healthcare providers need to be familiar with side effects of its use.

Cannabinoid Hyperemesis Syndrome (CHS) was first described in 2004, and is characterized by cyclic episodes of vomiting in the setting of chronic cannabis use. Most patients with CHS have a history of several years of daily cannabis use prior to the onset of recurrent vomiting, but it can rarely occur with shorter usage. Symptoms often occur cyclically, with symptom free intervals between episodes. Classically, many of these patients develop a learned behavior of taking frequent hot showers to alleviate their symptoms.[1] These patients often have a large workup and frequent ED visits prior to diagnosis. One case series found that on average, these patients present to the ED seven times before a diagnosis is made.[1]

Treatment is targeted at symptoms, including intravenous (IV) fluids, anti-emetics and pain management. Hot showers seem to be the best at controlling symptoms, but the mechanism by which this helps is not well understood.[1] There are also case reports of haloperidol 5 mg IV alleviating symptoms and preventing admission, but further studies are needed to fully evaluate the efficacy of this treatment.[3] The most important treatment is cannabis cessation in order to prevent future cyclic episodes, and patients should be counseled appropriately.[1]

CHS can mimic other gastrointestinal, central nervous system, and metabolic disorders, and thus workups should be based on history and physical exam. Differential diagnosis for vomiting should be tailored to your history, but could include a wide range of clinical entities including increased intracranial pressure, various acidotic states, intestinal obstruction, biliary disease, and cyclic vomiting syndrome, to name a few. However, as health care providers, this clinical entity should be considered in chronic cannabis abusers to help prevent future ED visits and morbidity.

References:

1. Galli JA, Sawaya RA, Friedenberg FK. Cannabinoid Hyperemesis Syndrome. Curr Drug Abuse Rev. 2011 Dec; 4(4): 241–249.

2. State Marijuana Laws in 2016 Map. Governing. Nov 2016. Available at: http://www.governing.com/gov-data/state-marijuana-laws-map-medical-recreational.html. Accessed January 3, 2017.

3. Wang GS. Cannibis (marijuana): Acute intoxication. Up to date. Dec 2016. Accessed Dec 28, 2016. Available from: http://www.uptodate.com/contents/cannabis-marijuana-acute-intoxication?source=search_result&search=marijuana+acute&selectedTitle=1%7E150