CANNABINOID HYPEREMESIS SYNDROME aka SCROMITING
By Dr. Lee
WHAT IS SCROMITING?!
In the current news cycle there are a few stories about ‘scromiting,’ the loud combination of vomiting and screaming heard through ERs across the legal country. The cause? Cannabinoid Hyperemesis Syndrome, a strange illness impacting cannabis users.
In our ongoing goal to report on and de-mystify all things medical marijuana, I am happy and amused to be talking about something that I’ve personally seen in a few patients. In my younger days as an ER resident, I would occasionally see a young, healthy person vomiting their brains out. After a while, I learned how to talk to them about it.
I really like this article because the 17-year old patient highlighted is kind of representative of a Cannabinoid Hyperemesis Syndrome patient — a young and healthy person, with really no reason to be puking their brains out. The average CHS patient is, like this young guy, pretty unconvinced that marijuana is the cause. After all, marijuana makes them feel better!
These patients sometimes end up in this cycle where they continue using marijuana to treat their symptoms. Unfortunately, elevated THC is the root cause of their CHS.
WHAT IS CANNABINOID HYPEREMESIS SYNDROME?
Cannabinoid Hyperemesis Syndrome (we’ll call it CHS) is an unusual medical condition where people that have ingested marijuana have an intense urge to vomit. It can be difficult to control, and patients often take a trip to the emergency room in their confusion.
It is both caused and relieved by marijuana, and that can lead to issues diagnosing it. Marijuana education is not great in this country, and I would be surprised if CHS was frequently on many clinicians’ radar for a vomiting patient.
WHY DO WE CARE ABOUT CHS?
We care because CHS can be deadly. Well, in the sense that any form of severe vomiting can be. Severe vomiting can cause dehydration, and deaths linked to dehydration caused by CHS have been reported by reputable sources (1). We also kind of know that CHS is starting to happen more and more to kids, and that sucks (2).
Interestingly, CHS is relieved by hot water or hot showers, and patients almost always notice that over time. Asking a vomiting patient if they have their symptoms relieved by a hot shower makes you seem like Dr. House, and is also pretty much a smoking gun for CHS. Both of the patients in the paper I linked were found dead or dying in a bathtub. Cause of death? Severe pneumonia due to puking into their own lungs.
I also want to point out that the first man in this paper had nausea and vomiting symptoms for 10 years. He also pretty clearly had CHS and we probably could have saved his life if we advised him to stop smoking for a few months. That’s why we’re here — to spread the word of science. And science sometimes involves scromiting.
WHAT CAUSES CHS?
The short answer: We aren’t exactly sure.
A pretty decent theory is that of opposing effects on the brain and gut. THC appears to have pro-emetic effects (it makes you puke) on the gut, but anti-emetic (makes you not puke) effects on the brain (3). We also know pretty convincingly that the brain and gut are the two organ systems with the highest amount of THC receptors.
A large meta-analysis was able to describe common characteristics of CHS patients (4). It notes that a vast majority of CHS patients (72.9%) are men. Most studies of CHS also indicate that CHS occurs more often in regular cannabis users. They define regular as ‘weekly’ (hahaha) but the paper does note that the incidence of CHS increases with self-reported marijuana use.
HOW DO WE TREAT CHS?
The only real cure is marijuana cessation. If you have CHS, it will come and go as long as you use marijuana. In my experience, a long THC break will sometimes allow a patient to wean themselves back to using marijuana if they wish, without risk of CHS.
In the acute phase, we treat CHS like any other cause of vomiting. We administer fluids via IV to replace what a vomiting patient has lost, and we give antiemetic medications. In the ER, it’s pretty common to start with a medication called Zofran (ol’ reliable), but it almost never works in this situation. I’ve had more success with haloperidol. There’s some data out there that capsaicin cream works too (and is also over the counter), but it’s not my first choice in the ER.
If I can, I will also totally do the hot shower thing. A lot of ERs aren’t set up to give patients a hot shower, but if I can hook it up I will. It provides a great, told-you-so moment, and lets me drive home the point that the diagnosis is correct and the patient needs to stop smoking marijuana.
But, long-term, the trick is convincing the patient to stop smoking for a while. Symptoms typically abate in a day or two but recur if the patient begins smoking regularly. I’ve had patients that stepped away for a few months and were able to re-start using marijuana, and the whole situation is a decent exercise in moderation. That’s a rosy picture, but honestly my ideal scenario.
If you or someone you know has had CHS, they probably can’t ever go back to consuming high-THC products at high rates and should mix it up with some higher CBD products. I’d also advise against dabbing and any high-THC product.
- Soota, Kaartik MD1; Lee, Ye-Jin MD2; Schouweiler, Katie MD2; Keeney, Matthew MD2; Nashelsky, Marcus MD2; Holm, Adrian DO2. “Cases of Death Secondary to Cannabinoid Hyperemesis Syndrome” American Journal of Gastroenterology: October 2016 – Volume 111 – Issue – p S1063
- Zhu JW, Gonsalves CL, Issenman RM, Kam AJ. Diagnosis and Acute Management of Adolescent Cannabinoid Hyperemesis Syndrome: A Systematic Review. J Adolesc Health. 2021 Feb;68(2):246-254. doi: 10.1016/j.jadohealth.2020.07.035. Epub 2020 Oct 7. PMID: 33036874.
- Sorensen CJ, DeSanto K, Borgelt L, Phillips KT, Monte AA. Cannabinoid Hyperemesis Syndrome: Diagnosis, Pathophysiology, and Treatment-a Systematic Review. J Med Toxicol. 2017 Mar;13(1):71-87. doi: 10.1007/s13181-016-0595-z. Epub 2016 Dec 20. PMID: 28000146; PMCID: PMC5330965.