Cannabis hyperemesis syndrome, or cannabinoid hyperemesis syndrome, is not well understood and seems to be a new illness that mostly affects heavy cannabis users. Since the first recorded case in 2004, much has been speculated about this mysterious and literally sickening syndrome. Is it cannabis intolerance? Is it neem oil poisoning? And what’s with the hot baths?
Cannabis hyperemesis syndrome sounds like William Randolph Hearst rose from the dead and cursed cannabis lovers with the worst thing his undead brain could conjure.
“You will vomit uncontrollably! You will assume cannabis will help because it is a proven anti-emetic, but it will make it worse! Vomiting episodes will last up to a week! Conventional anti-emetics will not work! Your doctor will not know what is causing it! BWAHAHAHAAAA!”
Joking aside, this is a gruesome condition and there’s no denying the correlation between cannabis use and the onset of cannabis hyperemesis symptoms, and the corresponding cessation of those symptoms within an average of three months of stopping cannabis use.
Cannabinoid hyperemesis should be considered in younger patients with long-term cannabis use and recurrent nausea, vomiting, and abdominal pain. Cessation of cannabis use should result in the improvement of clinical symptoms. Studies with higher rates of follow-up are needed, and validation of the proposed diagnostic criteria is required.
Symptoms of cannabis hyperemesis syndrome
The literal translation of ‘hyperemesis’ is ‘hyper-vomiting’. This is the primary symptom. It manifests as prolonged periods of violent nausea and vomiting which last one or more days per week. Severe abdominal pain accompanies the sickness.
These episodes of hyperemesis happen to the majority of sufferers about every one to four months, which causes weight loss, dehydration, and understandably a lot of stress! Many are hospitalised, and need to be given intravenous hydration and medical treatment.
This stage is preceded by what is termed the prodromal phase, where sufferers feel morning nausea, fear and as though they may vomit at any moment. This symptom is also accompanied by abdominal discomfort, despite which people usually manage to maintain regular eating.
Because these symptoms are quite vague and could have many different causes, this phase can go on for years and only be seen as part of cannabis hyperemesis syndrome once the hyperemesis stage has begun.
Hot baths, cannabis hyperemesis syndrome, and cyclical vomiting syndrome
All these symptoms are also seen in an equally rare and literally nauseating affliction, cyclical vomiting syndrome (CVS). The two conditions share one more symptom, and it’s very unusual. In both cases, people have reported finding relief by taking hot baths or showers. As neither condition responds to conventional anti-emetics, what is known as ‘compulsive bathing as learned behaviour’ is extremely common because it is one of the very few things that seem to help.
There is even an anecdotal report of a young man having plates of food next to his shower because hot showers were the only thing that made him feel well enough to eat. Almost 70% of patients diagnosed with cannabis hyperemesis syndrome or cyclical vomiting syndrome reported using hot baths or showers to alleviate their symptoms.
Cannabis hyperemesis syndrome and cyclical vomiting syndrome actually have all of the following symptoms in common:
- Repeating cycles of stomach pain, extreme nausea, and vomiting
- Periods of feeling relatively well, or only having nausea, between the vomiting episodes
- Conventional anti-emetics don’t work
- Hot showers or baths do work
- Weight loss (unsurprisingly)
- Extreme thirst, sometimes linked to vomiting up water being less painful than trying to vomit with an empty stomach
- Sufferers are under 50 years old
What’s the difference between cyclical vomiting syndrome and cannabis hyperemesis syndrome?
When it comes to making a diagnosis, physicians are beset by problems. Firstly, little is known about either syndrome. It’s common for patients to go through years of painful and invasive tests before a diagnosis is reached because many other diseases and health problems are initially suspected and then have to be ruled out.
Often, physicians may not have even heard of these afflictions, making it even harder to diagnose them! According to a 2017 German medical study, it takes about ten years for a definitive diagnosis to be made. The same study also points out the many symptoms that cyclical vomiting syndrome and cannabis hyperemesis syndrome have in common:
“…both [are] characterised by recurrent episodes of heavy nausea, vomiting … and comparative well-being between the episodes… Literature is inconsistent concerning clinical features which allow to differentiate CVS from CHS”.
In fact, the only initial prerequisite for a potential diagnosis of CHS disease as oppose to CVS is chronic cannabis use. Comorbidities listed as indicating cyclical vomiting syndrome instead of cannabis hyperemesis syndrome are migraines, psychiatric illnesses, and rapid gastric emptying, also called “dumping syndrome”. Those that indicate cannabis hyperemesis syndrome are delayed gastric emptying, or gastroparesis, and the cessation of cannabis use leading to the end of the hyperemesis.
In other words, if you use cannabis and have hyperemesis problems, and then you stop using cannabis and the problems stop too, this is basically what confirms the diagnosis!
What is the connection between CHS disease, cyclical vomiting syndrome, hot baths, and chili peppers?
Despite some reports that cannabis hyperemesis is unique as a syndrome in causing its sufferers to only find relief from crippling nausea by taking hot baths, cyclical vomiting syndrome shares this feature. Because conventional anti-emetics don’t work on either affliction, this is a strong indication that one of the two is present. Research published in January 2018 points to the reason why bathing becomes ‘learned behaviour’ in people suffering from CHS, and a possible cause for CHS itself.
Although far more research is needed, there is a strong hypothesis that long-term exposure to cannabinoids desensitises certain receptors, rendering them inactive. The transient receptor potential vanilloid subtype 1 (TRPV1) receptors are activated by high temperatures, cannabinoids, and capsaicin – the chemical in peppers that makes them ‘hot’ and causes a burning sensation when they are eaten.
The TRVP1 receptors are present throughout the digestive system. When activated, they exercise a strong anti-emetic effect. Exogenous phytocannabinoids can trigger this, which is why cannabis works as an anti-emetic. However, when over-stimulated by (in this case) continual exposure to cannabinoids caused by cannabis use, they can temporarily ‘burn out’ and become inactive.
The theory is that this throws the digestive system so far off balance that the symptoms of CHS result – first the (potentially years-long) prodromal phase of nausea and discomfort, eventually the excessive vomiting. In a ‘fight fire with fire’ manner, applying the other factors that stimulate TRPV1 receptors – heat and capsaicin – cause them to start working again.
Not only is this theory borne out by the common reports of hot baths taken by sufferers of both syndromes (67% of them according to research mentioned earlier) but when capsaicin cream was applied to the abdomens of cannabis hyperemesis syndrome patients, they reported a lessening of symptoms within a matter of hours.
So far only 15 patients have been treated like this and the results recorded, but this is already very promising for a problem that has so far proved resistant to solving by any other means than “give up cannabis”.
Cannabis hyperemesis syndrome – the new reefer madness
Despite the lack of hard evidence that cannabis hyperemesis is caused by cannabis (as opposed to being linked to cannabis use), the mainstream media have leapt on it as proof that cannabis is indeed the devil’s lettuce. The free UK Metro paper attempted to claim the word ‘scromiting’ was coined in US emergency rooms as they flooded with affected cannabis consumers, although this claim was effectively debunked.
In 2015 the tabloid Daily Mail, which seems to swing between being rabidly for and rabidly against cannabis depending on which stance will generate the most outraged headline, warned that cannabis hyperemesis is likely to “drain hospital resources”, despite only two cases having been reported in the UK at the time.
Several studies and quite a few news reports have said that CHS is on the rise, and linked this to the increasing number of places where cannabis is legal for recreational and medicinal use. However, this is as yet unproven.
The first case of cannabis hyperemesis in the Netherlands was reported in 2005 despite cannabis having been decriminalised there since the early 70s, and it certainly isn’t an epidemic. There are no reported cases in Portugal (decriminalised 2001), nor Uruguay (legalised in 2017).
It could be simply that there are more reported cases, specifically in the US, because more people now feel able to tell doctors about their cannabis use without fear of repercussions. However, there is one more factor that correlates to cannabis hyperemesis which should be examined.
Could neem oil cause cannabis hyperemesis?
Neem oil is a natural pesticide which is certified for organic use in the US. The growth of the legal cannabis industry in the US, together with the eagerness of many licensed cultivators to produce an organic product, has led to an increase in the use of products containing azadirachtin, the substance derived from the neem tree which kills pests.
Symptoms of neem oil poisoning are somewhat similar to symptoms of CHS – and abate in the same way when the exposure to neem oil and its derivatives ceases. This hypothesis has mainly been raised by cannabis aficionados rather than doctors, and it is possible that conventional science just doesn’t know enough about how cannabis is grown to make the connection. There are currently 139 products containing neem oil that are registered with the Organic Materials Review Institute and available in the US.
However, it is not authorised for use in Canada (it’s actually illegal to use it as a pesticide there), nor in the UK, where rates of cannabis use among the population are closely comparable to the US but reported cases of cannabis hyperemesis syndrome are far fewer.
The Albanian connection
In 2013, a slew of poisonings were reported in Albania. Over 700 people “sought treatment (…) for the effects of planting, harvesting, pressing and packing the cannabis in the village of Lazarat”. Notorious at the time for its lawlessness and industrial-scale cannabis production, Lazarat hosted about 2000 people working in the cannabis fields.
The people needing treatment were almost all women and children, who were more likely to be handling and processing the cannabis than simply cutting the plants down, and far less likely to be deliberately ingesting any of it – especially when their employers only paid €8 per 10 processed kg.
Their symptoms were “bouts of vomiting, stomach pain, irregular heartbeats and high blood pressure”. At the time, this was blamed on the cannabis alone. It’s extremely unlikely that this is the case. These are also possibly the symptoms of neem oil poisoning.
It’s not possible to prove that neem oil was being used as a pesticide on the fields of cannabis in question. It is certain though that neem oil has been encouraged as an organic fertilizer throughout Albania, with 400 neem trees introduced there in 2005 as part of a ‘Raincoat Package’, along with training of local farmers in how to use it. This is circumstantial evidence, but it is evidence nonetheless.
So what next?
There are no definite answers to the questions of what causes cannabis hyperemesis syndrome, why it has only emerged in the last two decades of thousands of years of cannabis use, and whether or not it should even be called cannabis hyperemesis syndrome instead of ‘mystery emesis syndrome’ or ‘possible neem poisoning emesis syndrome’. What we can conclude, however, are the following points:
- Cyclical vomiting syndrome and cannabis hyperemesis syndrome only differ in two respects – the sufferer’s (self-confessed) use of cannabis, and the gastric emptying speeds. There is no indication that people diagnosed with CVS have been tested for cannabis use so it seems to be down to the individual to inform the doctors about it. Based on this, is it possible that some cases of CVS are actually CHS?
- Neem oil poisoning shares some symptoms with CHS. Neem oil is used on cannabis as an organic pesticide in both legal and illegal farming. If the neem oil remains on the cannabis flowers, it can be easily ingested by people who are unaware of its presence.
- The efficacy of hot baths and capsaicin cream in treating CHS suggests that the hypothesis of the TRPV1 receptors becoming over-stimulated by cannabinoids points to not all cases of cannabinoid hyperemesis syndrome being caused by neem oil, as these treatments would have no effect on neem oil poisoning.
What to do if you think you have cannabis hyperemesis syndrome
Firstly, stop ingesting cannabis. Whether it’s neem oil or not, you need to give your system a rest; cannabis hyperemesis syndrome symptoms take one to three months to abate. If you keep having symptoms after this time, it could be that something else is wrong, but the only way to rule out cannabis hyperemesis syndrome is to stop using cannabis.
Secondly, see your doctor and explain what you think is happening. You might need extra fluids and in extreme cases, an IV drip to replace lost liquids.Have you had CHS, or do you know someone who has? What do you think could be the cause? Please let us know your thoughts in the comments below.
- Disclaimer:This article is not a substitute for professional medical advice, diagnosis, or treatment. Always consult with your doctor or other licensed medical professional. Do not delay seeking medical advice or disregard medical advice due to something you have read on this website.