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A Perplexing Marijuana Side Effect Relieved by Hot Showers

By the time Thomas Hodorowski made the connection between his marijuana habit and the bouts of pain and vomiting that left him incapacitated every few weeks, he had been to the emergency room dozens of times, tried anti-nausea drugs, anti-anxiety medications and antidepressants, endured an upper endoscopy procedure and two colonoscopies, seen a psychiatrist and had his appendix and gallbladder removed.

The only way to get relief for the nausea and pain was to take a hot shower.

He often stayed in the shower for hours at a time and could be in and out of the shower for days.

When the hot water ran out, “the pain was unbearable, like somebody was wringing my stomach out like a washcloth,” said the 28-year-old, who works as a production and shipping assistant and lives outside Chicago.

It was nearly 10 years until a doctor finally convinced him the diagnosis was cannabinoid hyperemesis syndrome, a condition that causes cyclic vomiting in heavy marijuana users and can be cured by quitting marijuana.

Until recently the syndrome was thought to be uncommon or even rare. But as marijuana use has increased, emergency room physicians say they have been seeing a steady flow of patients with the telltale symptoms, especially in states where marijuana has been decriminalized and patients are more likely to divulge their drug use to physicians.

“After marijuana was legalized in Colorado, we had a doubling in the number of cases of cyclic vomiting syndrome we saw,” many of which were probably related to marijuana use, said Dr. Cecilia J. Sorensen, an emergency room doctor at University of Colorado Hospital at the Anschutz medical campus in Aurora who has studied the syndrome.

“C.H.S. went from being something we didn’t know about and never talked about to a very common problem over the last five years,” said Dr. Eric Lavonas, director of emergency medicine at Denver Health and a spokesman for the American College of Emergency Physicians.

Now a new study, based on interviews with 2,127 adult emergency room patients under 50 at Bellevue, a large public hospital in New York City, found that of the 155 patients who said they smoked marijuana at least 20 days a month, 51 heavy users said they had during the past six months experienced nausea and vomiting that were specifically relieved by hot showers.

Extrapolating from those findings, the authors estimated that up to 2.7 million of the 8.3 million Americans known to smoke marijuana on a daily or near-daily basis may suffer from at least occasional bouts of C.H.S.

“The big news is that it’s not a couple of thousand people who are affected — it’s a couple million people,” said Dr. Joseph Habboushe, an assistant professor of emergency medicine at N.Y.U. Langone/Bellevue Medical Center and lead author of the new paper, published in Basic & Clinical Pharmacology & Toxicology.

Others questioned the one-in-three figure, however. Paul Armentano, the deputy director for the National Organization for the Reform of Marijuana Laws (NORML), said that even with more widespread use of marijuana, “this phenomenon is comparatively rare and seldom is reported” and strikes only “a small percentage of people.”

And several physicians who routinely prescribe medicinal marijuana for conditions ranging from chronic pain to epilepsy said they have not seen the cyclic vomiting syndrome in their patients, but noted that they typically prescribe compounds that are not designed to produce a high and contain very low amounts of the psychoactive ingredient THC.

Dr. Habboushe said doctors in other parts of the country may be unfamiliar with C.H.S. or mistake it for a psychiatric or anxiety related syndrome. And even if they are aware of it, many regard it as a “rare, kind of funny disease,” replete with anecdotes of patients who spend hours in the shower.

But the condition can be quite serious. One 33-year-old military veteran who asked not to be identified by name described bouts lasting up to 12 hours in which he felt “like a puffer fish with sharp spikes was inflating and driving spikes into my spine from both sides. I’ve broken bones, and this blew it out of the water.”

“I know patients who have lost their jobs, gone bankrupt from repeatedly seeking medical care, and have been misdiagnosed for years,” Dr. Habboushe said.

“Marijuana is probably safer than a lot of other things out there, but the discussion about it has been so politicized and the focus has been on the potential benefits, without looking rigorously at what the potential downside might be,” he said. “No medication is free from side effects.”

Patients often arrive at the hospital severely dehydrated from the combination of hot showers and the inability to keep food or liquids down, and that can lead to acute kidney injury, said Dr. Habboushe.

But since many patients develop the syndrome only after many years of smoking pot, they don’t make the connection with their pot habit and have a hard time accepting the diagnosis.

The confusion is understandable, Dr. Sorensen said. “Marijuana is viewed as medicinal, and it’s given to people with cancer and AIDS. People know it’s used to help with nausea and stimulate the appetite, so it’s difficult to get patients to accept that it may be causing their nausea and vomiting.”

It’s unclear why marijuana can produce such discordant effects in some users. But Dr. Sorensen often tells patients that it’s similar to developing an allergy to a favorite food.

Getting the right diagnosis often takes a long time. The average patient makes seven trips to the emergency room, sees five doctors and is hospitalized four times before a definitive diagnosis is made, running up approximately $100,000 in medical bills, Dr. Sorensen’s study found.

“They get really expensive workups, lots of CT scans and sometimes exploratory surgery” to rule out dangerous conditions like appendicitis or a bowel obstruction, Dr. Sorensen said. “At the end of the day they’re told, ‘You’re smoking too much pot.’”

The symptoms of C.H.S. often do not respond to drug treatment, though some physicians have had success with the antipsychotic haloperidol (sold under the brand name Haldol) and with capsaicin cream.

The good news is that C.H.S. has a pretty simple cure: abstinence. Patients stop having pain and vomiting episodes when they quit smoking, experts say. And if they start smoking again, they are likely to have a recurrence.

Mr. Hodorowski said he quit smoking once he accepted that marijuana was the cause of his problems, but acknowledges he was in denial for a long time. Now, he says, he’s telling his story so other people can learn from his experience.

“I hope they’ll be honest with themselves so they don’t have to go through what I’ve been through,” he said. “I’m very lucky to have survived this.”

Emergency room doctors are seeing a growing caseload of nausea and vomiting in marijuana users whose only relief is a long, hot shower.

Pot pains: Why marijuana can become toxic for some

Marijuana is having a moment. The once recreational-use-only drug is now considered by many as a medicine, an anti-nauseant and pain reliever, even an epilepsy medication.

But some long-term “pot heads” are finding the drug they once loved can suddenly turn on them and become almost toxic.

These users are developing a little-understood condition called cannabinoid hyperemesis syndrome that brings on unrelenting vomiting, nausea and stomach pain.

Standard medications do not relieve it, smoking more marijuana only seems to worsen it, and some doctors say they are seeing a lot more cases of it.

It was intense stomach pains that brought Dave to his doctors four months ago. The 45-year-old from southern Ontario (who’d prefer not to use his full name) knew he needed help when intense cramping left him balled up on the sofa, unable to work.

“I really wasn’t able to function much at all. I was constantly having to lie down with a constant pain,” he told CTVNews.ca by phone.

Even after Dave’s doctor ordered reams of ultrasounds, CT scans, and colonoscopies, no one could find anything wrong with him, leaving Dave frustrated.

“It was starting to take a toll on me after a few months. I was doing all these tests and not knowing what was wrong with me or who to turn to,” he says.

Dave finally turned to the internet, where he stumbled on discussions about cannabinoid hyperemisis, a condition he had never heard of.

History of hyperemesis

The first mention of the syndrome appeared in 2004, when a doctor in Australia published an article in the journal Gut describing several patients with a “cyclical vomiting illness” (or hyperemesis). All the patients had a history of “chronic cannabis abuse” and all seemed to find relief from their symptoms by taking multiple hot showers or baths a day.

“Everything I read about this CHS fit the picture,” Dave says.

“The only thing I didn’t have was the vomiting. But I had nausea and constant stomach pain and I was getting relief with hot baths and showers,” he said.

Dave also had a 25-year history of daily pot smoking. He had recently switched to smoking “shatter,” a marijuana concentrate high in THC, that he believes made things worse. Though Dave had told his doctor about his drug use, he connect his symptoms to CHS. In fact, the physician may have never seen another patient with CHS.

Emergency room doctors such as Dr. Raj Waghmare are seeing them, however. Waghmare recently wrote a blog post about the first time he diagnosed a patient with CHS, just under two years ago.

The well-dressed man had come into his ER with non-stop vomiting and abdominal pain. Like Dave, this man’s blood and urine test came out normal, yet no matter what drug Waghmare offered him, nothing seemed to quell his nausea.

Then the man mentioned that hot baths helped to dull the pain.

That’s when Waghmare recognized CHS from an article he had read about in a Canadian medical journal.

It’s a condition that can’t be easily diagnosed, since there is no one test that can spot it. It’s only after everything else has been ruled out and a history of pot use has been established that doctors are left with CHS.

Waghmare says he’s since seen dozens more patients with CHS come through the doors of Southlake Regional Health Centre where he works.

“I probably see this every week in the ER,” he says. “if we were to go through all the charts from a full week, I’m sure we’d see at least a case of day among all the doctors.”

Most of the patients Waghmare sees had no idea that the drug they used every day could suddenly become toxic to them.

“People don’t know that this exists,” he says.

What actually causes CHS remains a mystery. The THC (tetrahydrocannabinol) in marijuana causes the drug’s high by stimulating the brain’s cannabinoid receptors, but one theory is that in some patients, those receptors eventually become overloaded.

“So it will work for nausea in the beginning, but then it will totally desensitize the receptors so that people will just feel nauseated all the time,” says Waghmare.

Why some patients develop the syndrome and others don’t remains a mystery; the condition hasn’t been the subject of rigorous scientific study. It appears to develop in those who smoke weed several times a day for a decade or so. But there is some evidence that people who begin daily pot use at a young age are more at risk.

The majority of CHS patients coming to see Waghmare are young men who have been smoking marijuana since high school. By the time they reach their mid-20s, they have a decade of use under their belts.

And yet many refuse to believe the pot is the problem.

When Waghmare tells young pot users the only thing that will end their vomiting and pain is to quit smoking weed for good, they often stop listening.

“A lot of these patients who come in are ‘frequent flyers,’ They’ve heard it before and they refuse to believe it. They refuse to give it up,” he says.

But older patients often take his advice and quit cold turkey, as the patient who Waghmare wrote about promised he would do. As an ER doc, however, he has no way of following up.

At least one Facebook group has also been formed in which users discuss their symptoms and experiences.

As for Dave, he says has stopped smoking both marijuana and shatter. In fact, he wishes he never tried shatter at all, since he suspects that is what triggered his symptoms. Now, after three months of pain, he’s finally beginning to feel better. He’s also found a new doctor and has begun a new drug regimen for his Type 2 diabetes, which is also helping him feel better.

But doctors like Waghmare says there needs to be more awareness that this syndrome can develop in some pot users.

With all the recent discussions about the medicinal uses for marijuana, and the ongoing discussion about legalization, Waghmare says many pot users assumes the drug is benign, that it relieves pain and nausea, that there’s no way it could cause it.

“There’s this belief that (marijuana) is totally safe, a miracle drug, Not true,” he says.

In this Feb. 17, 2016 photo, plants grow at the home of Jeremy Nickle, in his backyard in Honolulu, Hawaii. (AP / Marina Riker)

Medical marijuana users insist that using pot does their bodies good, but doctors are seeing an increasing number of long-time smokers discovering that the drug they once loved because it took away their pain is now making them sick.