Cannabinoids: Consumption and Hyperemesis Syndrome – Drugs of Abuse

by Pravin Shukle, MD

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    00:01 Where are we in terms of cannabis consumption in the world? In a 2019 census they found that in Zambia, 70% of the general population were using cannabinoids.

    00:13 In Canada, up to 55% of people are using cannabinoids. Nigeria, 54.

    00:19 And then in the United States, up to 51% of people.

    00:22 In terms of countries with legalized pot, and this is kind of a funny definition because legalized pot is in itself a vague term.

    00:32 People would suggest that Denmark and Amsterdam are places where there's legalized pot.

    00:38 But that's not technically true just because of the ways that the laws work in Denmark.

    00:42 In South Africa in September 2008, they were really the first major country to legalize pot.

    00:51 In October 2008, Canada joins suit.

    00:54 And by May 2019, over half the population lived in states that had legalized marijuana.

    01:02 In Uruguay in 2013, which I believe is the first country to have legalized pot, pot consumption has actually fallen off since legalization.

    01:12 So what is the Canadian experience in terms of legalizing pot? Now, in terms of society, pot use may be dropping after legalization amongst university students.

    01:24 So we're starting to see fewer and fewer university students smoking pot.

    01:28 But pot use is increasing amongst high school students along the same timelines.

    01:33 It's interesting because in Canada, it's actually illegal for kids in high school to use pot.

    01:40 So, it has not been legalized for underage kids.

    01:44 Pot use is increasing in different rates in different societal groups.

    01:49 So it is increasing amongst high school dropouts, unemployed, underemployed and the minimally employed.

    01:56 So, the higher employment rate to people and people who are doing particularly well in life actually have much lower levels of pot use.

    02:04 In terms of hospital visits, since pot was legalized in Canada, I should say the decriminalized because that's a more accurate term.

    02:13 There's a small drop in opioid overdoses in ER departments.

    02:16 However, the general opioid crisis in Canada has taken off and we're seeing more fentanyl overdoses.

    02:24 And I'll deal with that in a different lecture.

    02:26 Now, overdoses of marijuana have increased about 300% since legalization.

    02:32 Now, what do I mean by overdoses of marijuana? They're certainly not as dramatic as you would see with other drugs like alcohol or cocaine, but they are problematic.

    02:42 We are seeing something called cannabinoid hyperemesis syndrome. What is that? Well, cannabinoid hyperemesis syndrome is repeated severe bouts of vomiting in patients and it's because there are cannabinoids receptors actually in the gut.

    02:57 It is an inconsistent penetrance, so some people can smoke a lot of weed and get absolutely no negative effects.

    03:04 Other people can smoke a very small amount that have a terrible time with it with nausea and vomiting. What does it present like? Well first of all, there's a prodromal phase. This is when people first start smoking pot.

    03:19 They'll have early morning nausea. They'll have abdominal cramping.

    03:23 This can happen over the first few months or perhaps even the first few years of usage.

    03:28 As they increase their marijuana usage, they'll have more and more of the symptoms.

    03:35 The hypermetic phase is occurring when they have ongoing nausea and now they start to have vomiting.

    03:40 The vomiting starts out relatively benignly at first.

    03:43 I suppose if you can call vomiting benign.

    03:45 And it becomes absolutely severe in just a short amount of time.

    03:50 These patients then start to have decreased food and nutritional intake and they have a weight loss and they also have nutritional deficiencies.

    03:59 People are terribly dehydrated because they're not drinking water and there's a tendency that - we've noticed anecdotally for these people to take a lot of hot showers.

    04:07 This is something we've noticed when we documented family histories and see that patient’s family members are complaining about them using a lot of hot water.

    04:16 So that's a clue that this could be a cause.

    04:19 These syndromes continue until marijuana use stops.

    04:23 Now, during the recovery phase after they've stopped using marijuana, there's a gradual slow return to normal.

    04:30 And when I say slow, I'm saying really slow, it can take up to six months to return back to some kind of normality.

    04:37 The symptoms resume, and they can resume with a vengeance if marijuana use is resumed.

    04:44 In terms of long-term complications of hyperemesis syndrome, you can get muscle spasms, weakness, seizures.

    04:51 Some people can actually have some renal insufficiency and kidney failure.

    04:55 People will develop arrhythmias.

    04:57 So, we've had a couple of people come into our emergency departments locally with arrhythmia due to the marijuana.

    05:03 People can produce - sorry, show up with shock.

    05:07 And finally, and the most feared complication is cerebral edema.

    05:12 These people then develop reduced levels of consciousness.

    05:17 They may progress into a coma and these patients are at high risk for permanent brain damage.

    05:25 What are the benefits of quitting marijuana smoking? First of all, almost immediately we see an improvement in lung function.

    05:33 We also see an improvement in memory over time in about six months.

    05:37 There is also improved cognitive skills.

    05:40 It's a bimodal kind of improvement where there's a lot of improvement at first, then it levels out.

    05:45 And then over the course of years, we see improvement.

    05:48 There's also improved sleep which is kind of surprising considering its effects.

    05:52 We have a decreased risk of depression when people stop smoking pot and decreased risk of anxiety syndromes.

    06:00 Marijuana and fentanyl, I'll probably get in trouble with for this for saying this.

    06:05 But there are concerns about fentanyl being marketed in mixed - mixed in with illegal sources of marijuana.

    06:13 It's - this is a highly politicized debate.

    06:17 And there are those on one side of the debate who are saying that fentanyl overdoses are entirely the fault of, you know, doctors.

    06:24 And there are others who were saying, "No, fentanyl overdoses and the fentanyl crisis that we're seeing in North America is because of illicit trade." I favor the latter. I think that fentanyl overdoses are due to the illicit trade roots.

    06:37 And we do see some illicit manufacturers of pot putting or lazing their product with fentanyl to get a better high.

    06:49 We believe that that's where some of our overdoses are occurring.

    06:52 In the small division of Ottawa where I live, one of the kids that actually went to high school with one of my kids died of a fentanyl overdose.

    07:02 And it was believed that she was smoking weed at the time and there was fentanyl inside the joint.

    07:07 So, it's something that strikes very close to home for me because I've actually sort of experienced it in a personal level in a personal group of friends.

    About the Lecture

    The lecture Cannabinoids: Consumption and Hyperemesis Syndrome – Drugs of Abuse by Pravin Shukle, MD is from the course Toxicology.

    Included Quiz Questions

    1. University students
    2. High school students
    3. Minimally employed people
    4. Unemployed people
    5. High school dropouts
    1. It has a predictable, dose-dependent penetrance.
    2. It is thought to be due to the overactivation of cannabinoid receptors in the gut.
    3. It is marked by repeated, severe bouts of intractable vomiting.
    4. It can result in long term complications, including brain damage.
    5. Recovery can take up to 6 months after an acute bout.
    1. There is an increased risk of insomnia.
    2. There is a bimodal improvement in cognitive skills.
    3. There is a decreased risk of depression.
    4. There is improvement in memory function.
    5. There is a decreased risk of anxiety disorders.
    1. There has been a small drop in opioid overdoses in ER departments since marijuana legalization.
    2. Overdoses in marijuana have decreased since legalization.
    3. There have not been reported cases of overdose from fentanyl-laced marijuana.
    4. There has been an overall decrease in the use of marijuana since legalization, particularly among high school students.
    5. Use of marijuana is the same across all individuals, regardless of socioeconomic and employment status.
    1. Continuous use is generally required to cause the syndrome.
    2. It is a common side effect of cannabis use.
    3. It is not associated with any complications.
    4. Diagnosis requires measurement of serum tetrahydrocannabinol (THC) levels.
    5. It resolves with further Cannabis use.
    1. Taking hot showers
    2. Exercising
    3. Meditating
    4. Consumption of alcohol
    5. Increasing cannabis use
    1. Complete symptomatic relief does not occur immediately after stopping cannabis use.
    2. Renal failure is not a complication.
    3. It is also known as cyclic vomiting syndrome.
    4. Nausea upon waking may indicate the hyperemetic phase.
    5. Cold shower reduces symptoms

    Author of lecture Cannabinoids: Consumption and Hyperemesis Syndrome – Drugs of Abuse

     Pravin Shukle, MD

    Pravin Shukle, MD

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