Marijuana, Vomiting, and Hot Baths

A case history of cannabinoid hyperemesis.

Cannabinoid hyperemesis, as it's known, is an extremely rare but terrifying disorder marked by severe episodic vomiting that can only be relieved by hot baths. (see earlier post). Sufferers are heavy, regular cannabis users, most of them. And hot baths? Where did THAT come from?

The syndrome was first brought to wider attention last year by the anonymous biomedical researcher who calls himself Drugmonkey, who documented cases of hyperemesis that had been reported in Australia and New Zealand, as well as Omaha and Boston in the U.S. "There were two striking similarities across all these cases," Drugmonkey reported. "The first is that patients had discovered on their own that taking a hot bath or shower alleviated their symptoms. So afflicted individuals were taking multiple hot showers or baths per day to obtain symptom relief. The second similarity is, as you will have guessed, they were all cannabis users."

The reports haven't stopped. This summer, an intriguing account appeared on the official blog of New York University's Division of General Internal Medicine, where med students offered a formal definition: "A clinical syndrome characterized by intractable vomiting and abdominal pain associated with the unusual learned behavior of compulsive hot water bathing, occurring in the setting of long-term heavy marijuana use."

Still skeptical? I received this heartfelt comment on my original post a few days ago:

Listen, doubters. My son has this. He has been cyclical vomiting and spending hours in boiling hot baths since last Autumn. It's getting worse and he has lost a hell of a lot of weight. He is 21 and an addicted, heavy cannabis user who started at 15. He has tried cutting down but every other joint of weed brings on the obsession. He refuses to co operate with medical staff who try to treat him.
He has been taken to numerous hospitals as an emergency for non-stop vomiting and begs medical staff to let him sit in a very hot bath. They try the best anti-vomiting drugs instead, to no effect, and then some let him go in a hot shower for an hour plus. He always ends up on a drip and as soon as he feels well enough, discharges himself, often the same day.

At the weekend he went to a sports event in the city with friends, realised on the way he was going to have an episode, so left friends and made his way into a hotel room and locked himself in. Police were called and got him out of a boiling hot bath against his will. Cue vomiting attack so bad police called an ambulance. Once again discharged himself from hospital, demanding drip be removed or he would do it himself. Has sat in bath at house he shares with girlfriend for at least 12 hours today, she tells me. She says water is so hot she has no idea how he bears it.

He says he has no pain in stomach, just a sensation that drives his head mad and he KNOWS it will not go, or the vomiting stop, until he gets in boiling hot bath and stays there. He has even done this while abroad on holiday and ended up on a drip before being flown home.

All of this is true. A mother.

I was intrigued, and discussed this briefly with the mother, who lives in the U.K. She added a number of details in an email exchange, and agreed to let me publish her comments:

“I am a mother in the UK whose son definitely has this, but is not officially diagnosed as he ‘escapes’ medical attention by discharging himself from various hospitals.

When it happens he is desperate to get in a hot bath. He lives with his girlfriend. I only realised what the hell was really going on when she insisted on telling me, and have since been regularly involved in the hospitals saga.

When I discovered the truth I put ‘cannabis’ ‘vomiting’ and ‘hot baths’ ‘showers’ in google and up came a perfect description of what my son does.

I am trying to get him to agree to go for counselling and psychiatric help as he has reached the stage where this obsessive vomiting and bathing is wrecking his life. But every time he gets a little better he believes he can ‘control it’ which is not the case at all.

Yes – we end up in the hospitals and the first young emergency doctor who has ever smoked a joint and/or thinks he knows everything, tells G “Oh no it can’t be that, cannabis stops vomiting, not starts it.” Of course, they have never heard of this condition and just think he is being irrational because of the constant need to vomit. They are sure it is food poisoning or some kind of spasm and take basic blood tests.

They find nothing, insist on giving him the best anti-sickness drugs usually for cancer patients and so on…, saying “this will definitely stop it” and still he vomits. He is not in pain, just rapidly dehydrating and panicking and complaining of a weird sensation in his stomach. He tells them “I know it’s in my head doing this” and desperately demands to get in a bath. Even when he has arrived at hospital because police found him in a boiling hot bath, this makes no sense to the medics who only give in when none of their drugs work. He then immediately stops vomiting but is petrified of getting out of the bath. Eventually, when he says it is under control, he agrees to get out, and is put on a drip. Approx an hour later, while the doctors are planning follow-up procedures like scans and more complex blood tests etc, he starts an argument with a nurse, insists the drip is removed and phones a friend to collect him, avoiding seeking a lift from me if he can. The over-pressed doctors here (the British system is like a cattle market) are left mystified and move onto the next emergency in their pile up of admissions. And so it goes on, and will do, until G accepts even the odd joint can set him off.”
----

Researchers speculate that it has something to do with CB-1 cannabinoid receptors in the intestinal nerve plexus--but nobody really knows for sure. Low doses of THC might be anti-emetic, whereas in certain people, the high concentrations produced by long-term use could have the opposite effect.

Cannabis and Severe Vomiting

Pot can make you puke.

For those of you who missed this, as I did, here is a belated account of a rare but altogether curious side effect of heavy marijuana use: cyclical vomiting.

Nice, eh? And yes, it goes completely against the grain of what we think we know about marijuana: Ironically, cannabis is frequently employed to prevent the nausea and vomiting frequently associated with chemotherapy.

So what gives? The answer is that, so far, nobody really knows.

First things first: It appears to be a very rare side effect of regular marijuana use, and it was not documented in the medical literature until 2004. Given the long history of pot-smoking the world over, it is reasonable to ask where the cannabis emesis syndrome has been hiding all these years.  A fair question, but one which, at this stage, has no satisfying answer.

Cannabinoid hyperemesis, as it's known, was first brought to wider attention earlier this year by the anonymous biomedical researcher who calls himself Drugmonkey. Posting on his eponymous blog, Drugmonkey documented cases of hyperemesis that had been reported in Australia and New Zealand, as well as Omaha and Boston in the U.S.

"There were two striking similarities across all these cases," Drugmonkey reported. "The first is that patients had discovered on their own that taking a hot bath or shower alleviated their symptoms. So afflicted individuals were taking multiple hot showers or baths per day to obtain symptom relief. The second similarity is, as you will have guessed, they were all cannabis users."

Heavy, regular cannabis users, most of them. And hot baths? Where did THAT come from?

More evidence was not long in coming. In February, researchers in the Division of Gastroenterology at William Beaumont Hospital in Royal Oak, Michigan, identified eight patients in their gastroenterology wards who were suffering from "otherwise unexplained refractory, recurrent vomiting." As the researchers reported in the journal Digestive Diseases and Sciences, there were two other significant features the eight patients shared: They were all chronic cannabis smokers--and they were all compulsive bathers.

The connection between uncontrolled vomiting and heavy toking seemed unequivocal: "Four out of five patients who discontinued cannabis use recovered from the syndrome," according to the published report, "while the other three patients who continued cannabis use, despite recommendations for cessation, continued to have this syndrome."

There is precious little anecdotal evidence to support this surprising finding. Occasionally, naive marijuana smokers will ingest too much and become sick to their stomach. And it is possible to incur the (brief) wrath of cyclic vomiting by eating way too many marijuana brownies, or other cannabis foodstuffs. Short of that, I am not familiar with vomiting as a documented side effect of regular cannabis use, and I venture to guess that most readers aren't, either.

However, the reports haven't stopped. This summer, an intriguing account appeared in Clinical Correlations, the official blog of New York University's Division of General Internal Medicine. Sarah A. Buckley and Nicholas M. Mark, 4th year medical students at the NYU School of Medicine, speculated on the cannabis hyperemesis phenomenon, and offered a formal definition: "A clinical syndrome characterized by intractable vomiting and abdominal pain associated with the unusual learned behavior of compulsive hot water bathing, occurring in the setting of long-term heavy marijuana use."

After reviewing 16 published papers on the syndrome, Buckley and Mark asked the obvious question: "How can marijuana, which is used in cancer clinics as an anti-emetic, cause intractable vomiting? And why would symptoms abate in response to high temperature?"

One possible mechanism involves marijuana's penchant for fats. Theoretically, this "lipophilicity" could cause increasingly toxic concentrations of THC over time, in susceptible people. "The abdominal pain and vomiting are explained by the effect of cannabinoids on CB-1 receptors in the intestinal nerve plexus," they write, "causing relaxation of the lower esophageal sphincter and inhibition of gastrointestinal motility." The authors speculate that low doses of THC might be anti-emetic, whereas in certain people, the high concentrations produced by long-term use could have the opposite effect.

As for the hot baths, Buckley and Mark note that "cannabis disrupts autonomic and thermoregulatory functions of the hippocampal-hypothalamic-pituitary system," which is loaded with CB-1 receptors. The researchers conclude, however, that the link between marijuana and thermoregulation "does not provide a causal relationship" for what they refer to as "this bizarre learned behavior."

These questions, like many questions having to do with regular marijuana use, are not likely to be answered definitively anytime soon, for a number of good reasons, some of which are delineated by the authors:

--"The legal status of marijuana makes eliciting an accurate drug history challenging."

--"The bizarre hot water bathing is likely often attributed to psychological conditions such as obsessive-compulsive behavior."

--"The knowledge of the anti-emetic effects of cannabis likely disguise cases of cannabinoid hyperemesis, leading to the erroneous belief that cannabis is treating cyclic vomiting rather than causing it."

--"The fact that this syndrome is so recently described and relatively unknown outside an esoteric subset of the GI [gastrointestinal] literature means that most clinicians are unaware of its existence."

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