about cannabis hyperemesis syndrome
The main reason our company exists is because, as emergency room doctors, we are tired of seeing the destruction that the opiates-for-profit model of pain treatment has created in our country. With narcotics being the leading cause of nontraumatic death under the age of 50 in our country, I have seen as many overdoses as I ever need to. Marijuana remains the least likely medicine to kill you that I’m aware of and works well for chronic pain. So, a big part of our goal with Stillwater Medicine is to say over and over to as many people as possible, “Stop taking narcotics and start using cannabis.” It may not take away as much pain as big pharma’s latest version of heroin, but it won’t kill you or leave you unable to stop using it.
One other interesting intersection of my job as a medical marijuana doctor and my job as an emergency room doctor is a condition called cannabis hyperemesis syndrome, a disabling form of cyclic vomiting that results from prolonged, high-dose marijuana use in susceptible individuals. Not much is known about cannabis hyperemesis syndrome (CHS). It was discovered to be a distinct form of cyclic vomiting syndrome by Australian researchers less than 20 years ago. Patients with CHS typically have intermittent bouts of severe nausea and vomiting that is only relieved with hot showers or hot baths. There are no specific tests for the condition. The diagnosis is confirmed by the absence of symptoms after stopping marijuana use. It remains relatively rare and appears that only certain people are susceptible to it at all.
The mechanism of the disorder is not completely known. THC is known to be an excellent anti-nausea medicine, so it seems counterintuitive that it would cause vomiting, and often people who suffer from CHS end up steadily increasing their use of marijuana to try to prevent the nausea that THC is paradoxically causing. The most plausible theory suggests that, because THC also slows down the rate of stomach emptying, it can cause vomiting in people who have become immune to its other anti-nausea effects. An interesting study based on this model found that the nausea and vomiting could be treated by applying capsaicin cream (made from hot peppers) to the abdomen and that symptoms improved considerably because the capsaicin stimulates the receptors that have become attenuated to THC.
The nausea and vomiting associated with CHS can be disabling and the only treatment known right now is complete cessation of marijuana use. This is obviously not an ideal option for someone who uses marijuana regularly for medicinal reasons.
So, how do we prevent CHS, and are there strategies for dealing with it other than giving up the medical benefits of cannabis? This next statement is pure speculation, so take it with a grain of salt. My suspicion is that cannabis hyperemesis syndrome results from the use of high potency recreational marijuana which usually contains little or no CBD. The low-CBD indica hybrids that have become the mainstays of recreational cultivars in the last 40 years are very different from the cannabis that our ancestors relied on as medicine. Some animal studies indicate that CBD, unlike THC, can cause nausea and vomiting. Nevertheless, I know of one patient that developed CHS after regularly ingesting high-potency THC oils for chronic pain who was able to restart THC use after a short course of CBD-only therapy. My suspicion is that marijuana works best as a medicine when used in small amounts regularly and when it has at least a 1:1 CBD:THC ratio. Regardless, if you or someone you know is affected by CHS and reliant on cannabis for medicine, It may be worth trying a 4 week period without marijuana and then introducing a CBD only product. If this doesn’t lead to a recurrence of symptoms, then the patient can try introducing small amounts of THC.
In a state with medical or legal marijuana, it is easy to know how much THC you are ingesting and keep track of daily doses. While Ohio’s marijuana prices are currently absurd, I would argue that well-tested and labeled medical marijuana is worth a little more than recreational marijuana because it allows the patient to choose the strain and concentration that works best for them and to keep track of their usage patterns. Currently the prices of medical marijuana in Ohio are preventing access to marijuana in a way that is contrary to the intent of the program and we can expect legitimate patients to be be forced to use recreational marijuana due to its affordability. This, unfortunately, may lead to an increased frequency of cannabis hyperemesis syndrome and it’s something that medical marijuana patients should be aware of.