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Why do some victims of a cannabis vomiting syndrome avoid it after switching to legal weed?

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It was clear what was wrong with Michael Verbora’s patient.

He smoked about a gram of cannabis a day (the equivalent of two pre-rolls), which helped with insomnia, anxiety and pain.

But while it eased some problems, it created others.

“He had chronic nausea and vomiting, classic cannabinoid hyperemesis, where they show up in the emergency room and have to take hot showers,” says Verbora, a Toronto-based doctor who practices cannabis medicine.

The first step in curing cannabinoid hyperemesis syndrome is to stop consuming. But Verbora’s patient, after a break, switched from grey-market to legal cannabis and started smoking about as much as before. The nausea never came back.

WATCH: It’s a mysterious syndrome that sometimes even emergency department staff have a hard time diagnosing and it’s happening in Saskatoon.

Verbora says it’s the second patient of his for whom a switch to legal weed has worked.

“We know that the (Ontario Cannabis Store, the patient’s new source) has licenced producer cannabis which is regulated. We know that there’s no heavy metals, pesticides, fungus, pesticides. That’s really the only difference that I know of — that there are regulations in effect on medical and adult-use legal cannabis versus the black market, where there’s no regulation.

“I also have seen cases where it came from regulated products. I’m just really scratching my head a lot.”

“The pain sometimes was so bad that I couldn’t get out of bed,” says Tobias Zhuang, a 29-year-old Vancouver man who suffered from CHS for years. “Then I would finally drag myself to the ER and spend a night there hooked on IVs, getting fed painkillers, just vomiting the whole time.”

“There were days where I literally went all day puking, to the point where there’s nothing and I would eventually start puking blood. It got scary after a while.”

Before he quit, Zhuang was smoking up to eight joints a day. He didn’t connect his health problems to cannabis, and doctors didn’t suggest a connection either.

He says he largely didn’t mention his cannabis consumption at the hospital: “I didn’t want them to suddenly look down upon me,” he says. On top of that, it’s self-inflicted. Which it was – I won’t lie. It was totally self-inflicted. But it was mostly because of the fact that it was illegal.”

In a textbook symptom of CHS, Zhuang found relief in the shower.

“We would go through tanks of hot showers,” he says “I would sometimes be in the shower for hours, praying that the water does not run out. But obviously eventually it does.”

“Hot pads were a life saver. When you have no hot water, hot pads are the next best thing.”

Courtney Head, a 31-year-old Fort McMurray, Alta. woman, remembers similar compulsions.

“I would have a craving to be in hot water. Every time I would throw up, I would get in a hot shower, to the point where it was basically burning and drying out my skin.”

For Zhuang, Googling his symptoms led Zhuang to one of several Facebook groups for CHS, and a cure through quitting heavy use.

“I have smoked since I’ve (quit), and it hasn’t affected me yet, but I know if I continue in my old pattern and just keep smoking every day, it will hit me and I will return back to my old self, being hyperemetic and sick.”

WATCH: Heavy pot smokers at risk of getting cannabinoid hyperemesis syndrome

CHS isn’t well-understood. One debate has to do with whether it’s caused by THC (the main psychoactive chemical in cannabis) or by some other chemical that’s present.

“Some of the evidence tends to lend itself to THC ingredients, and that’s the predominant, prevailing hypothesis, but at the same time I have cases like this that cause me to question whether there’s a pesticide involved, or the neem oil that’s sometimes found in products,” Verbora says.

“I don’t have a clear answer yet.”

CHS is sometimes blamed on neem oil, an organic pesticide.

“A lot of people have speculated that (the cause is) a compound called azadirachtin, which is the active component of neem oil,” says B.C.-based cannabis breeder Ryan Lee.

“It’s not used in the legal system in Canada. Because it’s organic, the hippies say, ‘It must be safe to use in our practices,’ thinking that anything organic is inherently safe, which is obviously foolish.”

Neem oil can cause poisoning. It has some of the symptoms of CHS, but not all of them, Kamloops, B.C. doctor Ian Mitchell points out.

“There are some very characteristic things about cannabinoid hyperemesis — the whole hot shower thing, where people get relief. We’ve never associated that with neem oil poisoning.”

Are heavy smokers more affected because they’re consuming more THC, or whether they’re consuming more of another chemical?

“As your consumption goes up, your consumption of toxins, heavy metals and all that would also go up. Your exposure to smoke would also increase,” Verbora says.

WATCH: Everything we know about the health effects of cannabis

One problem in studying CHS is that until legalization, it’s been very difficult for doctors to learn anything about the specific cannabis that was causing the problem. Under prohibition, patients may not have known anything about how their cannabis was produced, or by whom — or if they did, they might not have been willing to talk about it.

“I think it would be great if we could cross-reference these cannabinoid hyperemesis syndromes to specific products in the batch,” Verbora says.

“If there’s a problem in the future with legal products, then we can look back and start to dig deeper into the specifics of it.”

For Lee, the evidence is consistent with CHS being caused by excessive amounts of THC, not some other chemical.

“Legal products are also typically low-potency. The problem with this whole thing is that it’s not a controlled experiment. When you switch source, you could also be switching source on the potency of the product.”

WATCH: Young Canadians perceive alcohol as less dangerous than cannabis while driving, study says

Reports that some users have avoided CHS by switching to home-grown organic weed — which they can be certain is free of pesticides — can also be interpreted this way, Lee argues.

“There’s a huge confounding variable in saying, ‘I’ve started growing my own and the problems have gone away,’ which is that the stuff they were buying was twice as potent as what they’re growing.

“Home growers typically don’t analyze their plants chemically: they just grow it and smoke it. Especially if it’s their first time growing their own, they’re probably not doing a very good job.”

Head says she tried switching to legal cannabis, and ended up just as sick as before.

“I stopped smoking it. I was clean for almost six months, no symptoms, no stomach issues, nothing like that. So of course I got a little cocky and thought, ‘Maybe I can have a little puff now and again. It’s not going to be an issue.’”

“It didn’t help at all. I was smoking the legalized stuff for about a month or so, and I got just as sick as when I was smoking street weed, not even knowing what’s in it.”

As for why it afflicts some heavy users but not others, Verbora thinks it may come down to individual genetic differences in response to cannabis — much as the same joint can make one person excitable and another sedated.

“Cannabis works on the endocannabinoid system, and this system is very different in each of us. The number of receptors we all have is different. How well the cannabinoid system is functioning in all of us is different.

“We know a little bit, and there’s more that we don’t understand than we know. There are a lot of areas of research that we need to really do with this condition.”

One puzzle is that CHS doesn’t seem to exist in some parts of the world, like Jamaica, that have a long tradition of cannabis consumption.

“It does kind of beg the question: if this happens to people who use cannabis all the time, why isn’t that happening in those areas?,” Mitchell says. “Why didn’t we hear about this so much from Amsterdam?”

In the meantime, Mitchell finds that patients sometimes get relief by rubbing hot pepper sauce on their abdomens.

“Capsaicin sauce helps with the pain,” he says. “You rub hot pepper sauce on your belly and that can help treat the pain for this kind of thing.”

It seems to help in much the same way hot baths do.

While doctors say they would like to know more, it seems that capsaicin (derived from hot peppers) and hot water both activate part of the nervous system called the TRPV1 receptor, which may be damaged by very heavy cannabis use.

CHS may simply work differently in different people, Verbora says. Some people are able to start using cannabis again after recovering, and others find they can’t, and have to strictly abstain.

There isn’t an overall national number of patients, but Mitchell says his hospital sees about a dozen cases a month, mostly repeats. There is about one new case a month.

“Some predicted an increase with legalization, but CHS patients usually smoke grams per day and can’t afford the legal market,” he wrote in an exchange of texts.

“In the past, patients wouldn’t believe me because everyone knows cannabis is good for nausea. Now that there are popular articles about it added to physician awareness, it can be dealt with sooner, with fewer Emerg visits.”

Both Zhuang and Head say they experienced cannabis as addictive, something it has a reputation as not being. (Health Canada says cannabis addiction is possible.)

“Most people say weed isn’t addictive,” Head says.

“For most people it’s not — not everybody has these issues. But for me, and a lot of other people going through this, one turns into two, and whatever amount of weed you’re smoking turns to more, and it gets worse and worse and then you’re back to square one, where you’re sick again.”

In her case, she says addiction led to heavy consumption, up to 10 or 15 joints a day on days off, which in turn triggered the CHS.

However, both are in favour of legalization.

“We should never have made it into an illegal thing anyway,” Zhuang says. “There are so many benefits to it. There are people who genuinely need it. I think it should have been done sooner.”

“I’m totally for the whole legalization thing. It’s my issue, right? I have to stay away from it. It doesn’t mean others have to.”

People with cannabis hyperemesis syndrome — a problem some heavy smokers get that involves chronic vomiting — are usually told to quit. But some cure it by switching to a legal supply.

News and Events

Do You Vomit When You Smoke Pot? Here’s Why.

If you experience nausea or vomiting after smoking marijuana, it may be cannabinoid hyperemesis syndrome. UW Health emergency medicine physician Marin Darsie, MD, explains.

What is cannabinoid hyperemesis syndrome (CHS)?

Cannabinoid hyperemesis syndrome (CHS) is a condition affecting regular marijuana users which involves recurrent episodes of nausea, vomiting, and crampy abdominal pain.

While the episodes generally last 24-48 hours, the symptoms tend to be very severe and lead to dehydration and even weight loss.

Patients with CHS often say the only thing that makes them feel better during these times are hot showers, but this is temporary. The episodes stop when patients stop using marijuana completely.

What are the symptoms of cannabinoid hyperemesis syndrome?

  • Recurrent episodes of nausea, very frequent vomiting, and crampy abdominal pain which typically last 24-48 hours
  • Patients frequently go to emergency departments very dehydrated and may have actually lost weigh
  • Symptoms are temporarily improved by hot showers
  • These episodes are typically separated by symptom-free periods lasting days, weeks, to months

How long does the vomiting from cannabinoid hyperemesis syndrome last?

Most episodes last 24-48 hours, but they recur by definition and the length of time between episodes of nausea, vomiting, and abdominal pain can range from days to months.

How do you treat cannabinoid hyperemesis syndrome?

The most effective long-term treatment is not using marijuana. During an episode of vomiting, the core treatments are IV fluids, intramuscular or intravenous haloperidol (Haldol), and capsaicin cream applied to the belly. It is counter-intuitive, but narcotic pain medications should be avoided as they can worsen the nausea and vomiting. Experts do not fully understand why these medications are effective, while other more traditionally accepted pain and anti-nausea meds are not effective.

How to get rid of or cure cannabinoid hyperemesis syndrome?

The only way to cure cannabinoid hyperemesis syndrome is to completely stop using marijuana. It can take several weeks of no use before the periods of vomiting stops, perhaps because some of the marijuana is stored in body fat.

I thought marijuana was a treatment for nausea, how can cannabinoid hyperemesis syndrome be caused by marijuana?

Research is ongoing regarding the exact cause of CHS, but it is likely due to the reactions of the more than 100 active compounds in marijuana. Some of these cannabinoids trigger receptors in the brain reducing nausea, whereas others trigger receptors within the stomach, gut and intestines which seem to promote vomiting. Furthermore, in animals, one THC metabolite (cannabidiol) has been shown to have an anti-nausea effect at low doses and at higher doses stimulates vomiting.

Experts believe that periods of vomiting are caused when there is a loss of balance between the anti-nausea and pro-vomiting properties of marijuana within the body. Because of confusion regarding this issue, many CHS sufferers actually increase their marijuana use thinking that it will reduce their nausea and vomiting, but it only makes the problem worse.

Will everyone who smokes marijuana develop cannabinoid hyperemesis syndrome?

No. Cannabinoid hyperemesis syndrome was first recognized in Australia in 2004, and initially it was thought to only rarely occur among people with several years of heavy marijuana use (up to 3-5 times daily). However, the number of cases of CHS seems to be increasing and more recent studies have found some cases of CHS have occurred in people who have been using marijuana heavily for less than a year and others who only use marijuana weekly. The authors of one recent study estimate that as many as 2.75 million Americans who use marijuana on a near daily basis suffer from CHS.

The rising numbers of CHS are not fully understood, but may be due to increasing awareness of the condition, increasing use with the legalization of marijuana, and/or the increasing potency of marijuana. In the early 1990s, marijuana had an average of 3.8 percent THC or tetrahydrocannibol. As of 2015 in Colorado where marijuana has been legalized, some strains containing nearly 30 percent THC are available in marijuana dispensaries, though the average THC content is 17.1 percent.

Experts still don’t know why CHS only affects some regular marijuana users and not others.

Is cannabinoid hyperemesis syndrome permanent?

Once a patient has developed cannabinoid hyperemesis syndrome, avoiding marijuana is the only known cure. Patients who have had CHS will almost always have symptoms if they start using marijuana again.

Can you die from cannabinoid hyperemesis syndrome?

In general, cannabinoid hyperemesis syndrome leads to dehydration and the other health consequences (e.g. acute kidney injury, electrolyte abnormalities) stem from the dehydration. While it is theoretically possible, a severe electrolyte abnormality could lead to a life-threatening abnormal heart rhythm, it would be very rare.

Are cyclic vomiting syndrome and cannabinoid hyperemesis syndrome the same thing?

There is definite overlap between cyclic vomiting syndrome and CHS. Cyclic vomiting syndrome can occur in patients who don’t use marijuana and there is no clear improvement when cyclic vomiting syndrome patients abstain from marijuana. Also, cyclic vomiting patients are more likely to have a personal or family history of migraines and have a reduction in their cyclic vomiting with use of preventative medications.

How difficult is it to quit using marijuana after heavy use?

Daily smokers of marijuana are more likely to exhibit withdrawal symptoms upon quitting than casual users.

Dr. Marin Dorsie, UW Health emergency medicine specialist, explains cannabinoid hyperemesis syndrome.