Pubdate: Sun, 08 Apr 2018
Source: Fresno Bee, The (CA)
Copyright: 2018 The Fresno Bee
Author: Roni Caryn Rabin, The New York Times


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

He often stayed in the shower for hours at a time. When the hot water
ran out, "the pain was unbearable, like somebody was wringing my
stomach out like a washcloth," said Hodorowski, 28, a production and
shipping assistant who lives outside Chicago.

It was nearly 10 years until a doctor finally convinced him that 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 seen 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 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.

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

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
daily or near daily may suffer from at least occasional bouts of CHS.

"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 NYU 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.

Habboushe said doctors in other parts of the country may be unfamiliar
with CHS 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. A 33-year-old veteran who
asked not to be identified described bouts of 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."

'No medication is free from side effects'

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

"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 Habboushe.

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, Sorensen's study

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

The symptoms of CHS 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 CHS has a pretty simple cure: abstinence. The
pain and vomiting episodes stop when patients quit smoking, experts
say. If they start smoking again, they are likely to have a recurrence.

Hodorowski quit smoking once he accepted that marijuana was the cause
of his problems, he said, adding that he was in denial for a long
time. He's telling his story so others 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."
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