I have done previous posts on firefighting, brain injuries, and other things seen in my various lines of work. Response to these insights into how the sausage is made have been generally positive, so I figured I would toss out another one.
Ever since Florida legalized medical marijuana, those of us who work in the emergency department have seen an alarming uptick in people coming in with complaints of nonstop vomiting. If you ask, they will usually admit to you that they smoke marijuana. Those who won’t admit it always show it on toxicology screens.
The syndrome that is responsible for this is Cannabinoid Hyperemesis Syndrome, or CHS. This is a fairly new thing that has been becoming more and more of a thing since the legalization of marijuana has gained steam across the country.
How is it spotted?
It is reported in people who are frequent (more than once per week) users of cannabis for a year or more. The signs are pretty easy to spot:
- The victims make a loud, very characteristic retching sound
- Vomiting as often as 6 to 10 times per hour
- History of frequent marijuana use within the past 24 hours and over the past year or more
- Symptoms do not respond well to standard antiemetics (Zofran, Reglan, Compazine)
- The person will seek out and even crave hot baths and showers for temporary relief, but as soon as the shower is over, the vomiting starts back up again
- The symptoms ARE well controlled with psychoactive medications like Haldol
- They will also admit that they have been having lower abdominal pain/cramps for weeks before they began vomiting.
CHS is often misdiagnosed as Cyclic Vomiting Syndrome, but note that CHS patients when questioned will tell you that they seek out hot water baths and/or showers for temporary relief of symptoms. CVS patients don’t get relief from hot bathing and showering.
Whenever I get a patient who complains of frequent bouts of vomiting, I always administer 8mg of Zofran (I have standing orders that I can give that to anyone over the age of 16 without asking the doctor) and order a urine drug screen. If the Zofran doesn’t work, I can be fairly sure that CHS is what we are looking at.
Then I ask them what they do to relieve their symptoms. They will always tell you that while they are in a hot bath or shower, they stop vomiting. Once we know for sure that they are cannabis users, I ask the doctor for an order for Haldol. I usually get it.
At the same time, we need to make sure that the frequent vomiting hasn’t been causing any mischief , so we will also do a CBC, a Comprehensive Metabolic Panel, and will also give them a liter of normal saline and possibly 2 grams of Magnesium sulfate. Expect to see elevated WBC counts in patients who have been vomiting for a while. Absent other signs of infection, this is an inflammatory response to the vomiting.
Depending on other factors found in the initial assessment, an abdominal CT with contrast, or even a head CT without contrast will also be ordered.
Prevalance
Since people are frequently dishonest about marijuana use, its impossible to know for sure, but among people who DO admit to frequent use of cannabis, between 35 and 45 percent report frequent vomiting. This is in line with my personal experience- nearly two thirds of those who come in with vomiting complaints test positive for weed, as opposed to about ten percent of general teen and adult patients.
No one is exactly sure what causes CHS. It is believed that, although cannabis calms the vomiting center in the hypothalamus, it also irritates the enteric nervous system. That theory also explains why hot bathing seems to give temporary relief, as the hypothalamus also controls body temperature.
The patients that I talk to admit to anything from “just one joint at night before I go to bed to help me sleep” all the way to “all day, every day. As many as 15 joints per day.” With edibles, I have had people say that they eat as many as 6 to 10 edible gummies per day. That’s a lot of weed.
Treatment
To stop them from vomiting, the administration of 5 mg of Haldol usually does the trick and will stop the vomiting for a few hours. Antiemetics, including Zofran and Reglan don’t work very well or at all. Even with Haldol, the next time they use, the vomiting will start right back up again. The only way to stop the vomiting on a permanent basis is for them to stop using cannabis. Within a day or two, the vomiting will stop.
The problem is that people who use marijuana don’t believe you and will continue to do so. You will see them again in a week or two. Rinse, repeat. There is also a myth that you can’t overdose on weed. We are finding out that this is not true. The more weed, the higher your odds of seeing me with your CHS. Left untreated, constant vomiting can be fatal by causing lethal electrolyte imbalances. The severe retching that comes with it can cause issues like a Mallory-Weiss tear.
*I have also heard that rubbing capsaicin cream on the abdomen provides the same temporary relief as hot showers, but I have no personal data or experience on that. I would assume that long term use of this method will become less and less effective over time.
22 Comments
Jen · February 21, 2025 at 6:18 am
This. And they Won’t. Stop. Using.
Birdog357 · February 21, 2025 at 8:38 am
But weed’s not addictive….
Exile1981 · February 21, 2025 at 3:45 pm
When Canada legalized weed the number of work site injuries increased. At work i can tell the habitual users, they are always cutting corners, its like it messed up their ability to judge danger.
Sailor Paul · February 21, 2025 at 5:09 pm
I feel as though more than 10% of 18-25 year olds are frequent weed smokers. After a few months in working as a deckhand on my company’s tugboats, my kid tried to recruit his friends. Pay is $2000 a week to start, 2 weeks on/2 off but we piss test constantly so no drugs. Only one kid even applied, and he pissed dirty… it seems as though 18 year olds can’t live without it.
Dan D. · February 21, 2025 at 10:03 pm
That. Is. Right. They. Won’t. And if you want to stop mocking addicts in the comment section of a website and understand the underlying pathophysiology watch a video or two from Dr. Alexis LaPietra. Or maybe you can dig up the deck from her “Street or Treat” seminar from ACEP 2024 (I would share my pdf but there is no simple way to).
Let me summarize from my notes: “We are not nice to these people. The ones who give them fentanyl are.”
Bad Dancer · February 21, 2025 at 7:06 am
A good friend of mine has a stepson who has CHS and refuses to believe it is a thing. Instead saying it’s his anxiety, depression, or anything else causing the vomitting and exhaustion which he of course then self medicates with more pot. The smell gives me a terrible migraine so I can’t be around it.
Do you know of any good papers discussing addiction of pot use, or the theory of addiction vs habit forming nature of people? Was CHS a thing back in yesteryear of hippies, bikers, and jazz clubs or is it a new development?
snuffy · February 21, 2025 at 6:23 pm
I smoked quite a bit of weed (a lot) from about 16 to 28 or thereabouts. Late 70s to early 90s. So did many of my friends. Never had this happen, nor ever heard of it.
Grumpy52 · February 21, 2025 at 7:55 am
Well done. I first became aware of CHS in mid-2010s. An article in the Canadian Journal of Gastroenterology (?), 2010, was the first article I’d seen on it. That paper described the hot showers as relief as being diagnostic for what is known today as CHS.
One difficulty in having doctors identify it is the older docs who “did marijuana in college”, though as I remind them, the THC content in the 1970s was around 15%, while today’s marijuana can have a THC concentration of 70% or more.
I can attest to the use of “hot sauce” (it was all we had, got it from the cafeteria) as Haldol is a no-go for pregnant women.
Grumpy52 · February 21, 2025 at 8:04 am
Re Haldol v Zofran
While I has unable to find the reason online or in my books, somewhere back in the crevices of my memory, I remember a colleague stating that Zofran, Compazine, and Phenergan blocked lower down on the pathway of CHS, below the level of cannabinol acting on the vomiting pathway. But Haldol (and Droperidol) worked above the cannibinol activation, so s complete (or almost complete) block was achieved.
Grumpy52 · February 21, 2025 at 8:10 am
Another red flag for CHS is when they tell you they’ve been to 3 different ER’s in 24-48 hrs……. without relief. 😉
Tom235 · February 21, 2025 at 8:57 am
Weed use was pretty prevalent back when – I’ve known lots of people that essentially lived on the stuff in those days – and such things you describe were never heard of. I certainly don’t deny what you report but it leads me to believe it’s a difference in the weed of the 60s/70s vs now. Is today’s legal weed modified by more than just increased THC content? Are the growers using some type of fertilizer that modifies the effects? Seems strange this effect hasn’t been noticed until recently.
SmileyFtW · February 21, 2025 at 9:28 am
Thank you for again sharing your experiences and insight. I had no idea about this.
SiG · February 21, 2025 at 9:42 am
In addition to what Grumpy52 says about THC content, I have to wonder if the modern pot sellers don’t modify their “product” by spraying it with or feeding it something to help increase yield (and profit) that is toxic in the quantities being consumed.
Let’s call them “big weed” – like the ones who proposed Florida constitutional amendment #3 last year that wasn’t what it was sold as.
WallPhone · February 21, 2025 at 10:10 am
I suffered a Mallory-Weiss tear about twenty years ago. ED nurse was all “Nevermind!” when my response to her handing over a stack of paperwork was filling my emesis bowl.
My employer just changed insurance providers and the new one refused to pay, saying that since I self-medicated Excedrin monthly for migraine it was pre-existing, and after arguing that, made me fax several of my previous years pay stubs proving I was covered by insurance the year prior.
The experience made me reluctant to even declare OTC meds during medical interviews.
oldvet50 · February 21, 2025 at 10:30 am
I’ve often wondered what the initials CVS represented at my neighborhood pharmacy.
Boneman · February 21, 2025 at 2:03 pm
This is all news to me. Thanks for the posting and insight!
Christopher · February 21, 2025 at 2:03 pm
I’ll share a couple of thoughts I feel are worthwhile here.
Firstly, I live in Michigan, where we do have legalized recreational (and medical) marijuana. Working in manufacturing, and around grinders specifically, for many years has seen me develop RA. After pursuing the traditional treatment through a rheumatologist I demurred and, instead, gave THC gummies a try to treat my symptoms. The pharma menu for RA treatment was, at the time, limited to three options all of which had the risk of serious complications (and, in one case, a 6 month half life with no remedy should a complication manifest) I am happy to report that, so far, a disciplined 20mg THC gummy about an hour before bedtime has been an absolute blessing for me and costs me about thirty cents a day.
I sleep through the “high” (avoiding the “munchies” as well). I am no longer dependent on NSAID’s or scary pharma and have seen a great resolution to my inflammation symptoms. With all pun intended, my joints have never been better. I may see complications down the road and I accept that. Like our host here regarding insulin, I too will put it off as long as possible in favor or less dramatic treatment.
Secondly, as an aside, 70% THC content is not at all an accurate statement regarding current concentrations in any strain. There are several strains currently producing a skosh over 30% THC – which is still much, MUCH, higher (he-he) than any legacy weed folks remember smoking “back in the day.” Just a decade ago that number was probably closer to 20% so breeders are swiftly improving genetics. From a commercial grower’s standpoint, it makes sense to maximize the extraction yield per plant (it may vary by state but, in general, growing licenses spell out how many plants an operation can produce). For recreational purposes as source material, however, it’s clearly crossing human safety lines as Divemedic’s article explains.
Unfortunately, from my observations here in Michigan, there are just too many people lacking in any self control when it comes to cannabis consumption. I regularly see (smell) people smoking in public, vaping THC in workplaces and generally just displaying addictive behaviors and questing after higher and higher doses. I’ve spoken with folks who regularly will eat medibles amounting to literal grams of pure THC at a time. I can’t even imagine.
It seems, though, that the State is likely to put their fingers in their ears about farming addicts this way. The tax revenue stream from it is just too good – especially since there has been so much migration away from smoking cigarettes (thank goodness!) and alcohol consumption among the younger generations that, no doubt, those cashflow sources are drying up.
I will add, too, that at least here in Michigan the products being sold through dispensaries are well tracked and screened for residual pesticides and such – and recalled if needed. Unique QR codes follow the products and are kept in databases tying them to the purchaser’s identity should something dramatic sneak through. I have not seen or heard of that being an issue.
I can only hope that the political shifts we are currently watching unfold can continue expanding and, hopefully, extend to the kinds of social cohesiveness and structures that would better encourage personal accountability and responsibility, self-discipline and self-control. I would be too happy to see communities where folks do better jobs at adulting. These problems; fentanyl and addiction in general; poor work ethic, etc. would all fade away. A man can dream.
Grumpy52 · February 21, 2025 at 5:52 pm
I always appreciate new information. From what I can find, THC from 1970s marijuana was 1-2%. This has been increased to 32% in today’s marijuana.
Re -70% THC, looks like using various solvents, you can buy anything from 65-99% THC concentrates.
Skeptic · February 21, 2025 at 2:53 pm
But duuuuuddddeeeee….weed is a miracle drug! Willie Nelson said so. And look at how long he’s lived.
I swear to God, potheads are the biggest retards in the world. Can’t stand them, can’t stand the smell of weed. And I love the “It’s not addictive, I just need it to sleep/calm my nerves/etc.” people.
Or the classic, “But duuuddddeeee, it’s the same as alcohol.” The hell it is. Show me one person who tokes up for the taste. I know a lot of people – myself among them – who will drink an occasional cocktail for the taste without the intent of getting drunk. Nobody lights a joint without the intent of getting stoned.
And DM, I liked your analysis of the pot barfing. I’ve read about “scromiting,” too, which is vomiting and screaming at the same time. Is this a subset of that?
Dan D. · February 21, 2025 at 4:13 pm
This is indeed a welcome pearl and saved off to my archives! Thank you. Things have gotten pretty thin in the ED pearls area since Emergency Physicians Monthly changed everything around.
Skyler the Weird · February 21, 2025 at 4:52 pm
I read about this in a book”Every Patient Tells a Story: Medical Mysteries and the Art of Diagnosis”. written by Dr. Lisa Sanders who was the Technical advisor for tv show House, MD. She had a patient who had chronic vomiting and after weeks figured out it was CHS which was rarely seen in 2010. The patient did not believe her of course since every knew weed is harmless and healthy.
I’ve warned the potheads in my family and they don’t believe it.
you put your weed in a van down by the river · February 21, 2025 at 9:05 pm
Sometimes muh weed is coated with fentanyl. All of the flavors, you can bet that growers are juicing the product.
Calypso Louie Farrakhan says that weed is a conspiracy to feminize black men!