When Cannabis Makes You Vomit

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As marijuana legalization has boosted use of the drug across the country, physicians are seeing an uptick in cases of cannabis, or cannabinoid, hyperemesis syndrome (CHS), experts told MedPage Today.

Earlier this month, the New York Times reported on CHS as well as other harms from marijuana that doctors are increasingly encountering.

Tucker Woods, DO, chair of emergency medicine at Lenox Health Greenwich Village in New York, told MedPage Today that he rarely saw CHS two decades ago. Now, he sees it “almost daily in our emergency department.”

While cannabis is commonly used as an anti-emetic, it can sometimes have the opposite effect, resulting in repeated bouts of nausea, vomiting, and abdominal pain after its use.

Woods said people who develop CHS tend to have an initial phase of nausea, followed by a second phase of cyclical vomiting that can last for 48 hours, then they begin to recover in the third phase.

It can also cause severe pain, he said, noting that some patients experience what Woods calls “scrominating,” where a patient screams and vomits at the same time.

CHS typically occurs in people who’ve been using it for at least 6 months, but it can also affect people who’ve been using it for far longer — even more than a decade, Helen Senderovich, MD, of the University of Toronto, told MedPage Today in an email. It has been known to occur in older people and in people with multiple comorbidities as well, she said.

Woods points to the increased use and potency of cannabis as likely culprits for the rise in cases of CHS. One estimate showed cannabis potency, defined by mean delta-9-THC concentration, rose from 9.75% in 2009 to 13.88% in 2019.

“This is not your grandparents’ marijuana anymore, and there’s a decreased harm perception,” Woods said. “As it becomes legal, people assume legal as being safe.”

Stopping marijuana or cannabinoid use “is the first line of treatment” for CHS, Senderovich said. In a systematic review, she and her colleagues found several other treatments relieved symptoms of CHS, including haloperidol, droperidol, benzodiazepines, propranolol, and aprepitant. Hot showers and topical capsaicin cream rubbed on the abdomen may also be effective, she said.

Woods said it can be especially challenging to diagnose CHS because a lot of conditions cause nausea and vomiting. Still, he encouraged clinicians to keep the diagnosis in the back of their minds because there have been “horror stories” where patients with CHS have mistakenly had their gallbladder removed.

Woods added that some patients with CHS can be identified using a urine drug screening, but he cautioned that some synthetic cannabis products don’t show up in those screenings.

“I think the most important [thing] is just to bring awareness to the community, because a lot of folks truly think that marijuana is largely nonaddictive and that it’s safe,” he said, “but for some users these assumptions are dangerously wrong.”