Cannabinoid Hyperemesis: Marijuana Puts Patients in Hot Water

CASE REPORT

A 30-year-old male, white collar worker presented 14 times between November 1999 and November 2004, to hospital emergency departments in the same area with repeated episodes of vomiting, decreased oral intake, agitation and anxiety, with diffuse abdominal pain lasting up to 8 days. The patient was admitted briefly on three occasions. Each time he recovered with antiemetics and intravenous fluids.

The patient stated that the problem began in 1999, following a family law custody dispute. He did not present to the local hospital until March 2000. At that time, he presented to the emergency department with vomiting, agitation and abdominal pain. He was given a diagnosis of ‘stress-related vomiting’. Another presentation in August 2000 led to a referral to a gastroenterologist and an upper gastrointestinal endoscopy, which was normal. Later that year, his general practitioner commenced him on venlafaxine 75 mg daily for anxiety and depression. He took it for only a few months and said he experienced little benefit. Clinical notes by hospital staff and his general practitioner described him as suffering from ‘psychogenic vomiting’. Abnormal bathing behaviour was not noted until May 2001, when his symptoms of vomiting and abdominal pain were found to be relieved by showering.

On three separate presentations in 2004, he was referred for assessment by the mental health team. In February of that year, abnormal bathing behaviour to relieve the symptoms was cited as a frequent cause of distress for his wife, as their hot water would often run out before their children had a chance to shower. In August 2004, his wife called an ambulance, complaining he had spent all day in the bathtub for “300 out of 365 days”.

At the same time, the first entry in the clinical notes on marijuana usage noted daily, long-term ingestion. He started to use cannabis at age 14 years, with regular usage from 18 to 28 years. His heaviest period of ingestion was from 18 to 20 years, when he used up to 3 g per day. Since then, he smoked up to 1 g every 1–2 days.

In early November 2004, hospital consultation-liaison psychiatry staff saw him during an overnight admission for the same problem. He was diagnosed with anxiety and depression and started on mirtazapine 15 mg nocte. Later that month, he presented again with the same symptoms. Mental health staff saw him 2 days after admission for rehydration with intravenous fluids. He described each cycle as beginning with worry and anxiety, followed by vomiting and the fear that he would become dehydrated. He would then begin to drink large amounts of fluids, followed by an overwhelming desire to have a hot bath. He stated that at these times, staying in a hot bath was the only thing that could relax him. He estimated it reduced his anxiety by about 80%. He added that he frequently ran out of hot water at home. This led him to stay in a motel on several occasions, so that he had access to an unlimited supply of hot water.

The episodes did not seem to correspond with any change in cannabis intake. He did not try to relieve the symptoms of the cyclical vomiting with increased cannabis. On the contrary, he reported a reduced intake at those times because he felt too sick, and even lacked the motivation to smoke tobacco.

The patient also described irritable and depressed mood and feeling life was not worth living sometimes, but denied any suicidal ideas. He complained of reduced energy and motivation, reduced libido and impaired concentration. He was self critical about the problem, stating that he thought the problem was all ‘in his head’. He attributed an increase in frequency of the episodes to the recent death of his mother. He estimated that he had experienced a total of 80-100 episodes.

He had continued taking mirtazapine and had increased the dose gradually to 45 mg nocte, feeling somewhat less irritable on it. He was also taking alprazolam 1 mg three times daily, prescribed by his general practitioner. In addition, he was also undergoing eye movement desensitization and reprogramming with a psychologist, which he said was helpful.

He was married with two children. He was only able to work 1–2 days a week because of his symptoms and needed to supplement his income with social security. A grandfather had suffered from schizophrenia.

Mental state examination was unremarkable. A diagnosis of major depressive disorder with secondary obsessive-compulsive disorder (OCD) was made. He was advised to cease the benzodiazepine, continue the antidepressant and accept a referral to a psychiatrist with an interest in behaviour therapy for OCD.

The patient was reviewed in the outpatient department of the mental health unit in January 2005, after the authors became aware of the cluster of symptoms known as cannabinoid hyperemesis. He had not had any further episodes since November 2004 and had remained abstinent from marijuana of his own volition since that time, citing advice from several health professionals that it was worsening his anxiety symptoms. His mood was much brighter and he felt much less anxious. He was sleeping and eating well, gaining several kilograms in body weight. He had continued to take mirtazapine 30 mg nocte and was still taking alprazolam, 1 mg daily. He had not taken up the referral for cognitive behavioural therapy. The syndrome was discussed with him at length and he was given a copy of Allen's paper. He accepted the diagnosis and resolved to abstain from cannabis.

As at October 2006, he had not suffered any further episodes of cyclical vomiting and had remained abstinent from cannabis. He reported that in September 2006, he had suffered a few days of nausea, after reducing his dose of mirtazapine from 30 to 15 mg nocte. He did not experience abdominal pain, polydipsia or an urge to bathe. He admitted that he did try bathing a few times, out of fear that the cyclical vomiting may otherwise recur.

DISCUSSION

The case described here is typical of a handful seen by the authors. Common elements observed include numerous emergency department attendances over years, producing many volumes of hospital notes, intensive gastroenterological investigation with minimal conclusive findings and frequent referral to mental health services, producing varying diagnoses. Furthermore, the patient is often showering when the mental health team arrives to assess them.

Very little has been written about the disorder. The authors conducted literature searches, most recently in July 2006. Database sources included Medline 1966–present, EMBASE, Ovid full text journals in CIAP, PSYCHINFO 1964–present, Cochrane, MD Consult, PUBMED, Science Direct, Blackwell Synergy, Journals at OVID and CINAHL. Search terms used were cannabis, cannabinoid, THC, marijuana, marihuana, nausea, vomit, emesis, cyclical, psychogenic, bath, shower, hot water and cannabinoid hyperemesis.

Prior to the work of Allen et al., only one other paper referred to a case in which all three of the characteristic features of cannabinoid hyperemesis occurred. 3 However, in that case, marijuana was not proposed as the cause of the disorder. Since Allen et al.'s paper, cases have begun to appear in the literature. Roche and Foster described a similar cluster of symptoms in a 21-year-old male presenting to a district general hospital in the UK, whose problems remitted after cessation of cannabis use. 4 Several cases have also been described in The Netherlands. Boeckxstaens reported a 36-year-old male with cyclical vomiting who had been smoking cannabis since age 14. 5 Wolfhagen detailed the case of a 45-year-old, long-term marijuana smoker with a history of some 36 episodes of abdominal pain and vomiting relieved by showering. 6 Roelofs et al. stated the condition was ‘regularly observed’ at their psychiatric clinic and recommended the use of risperidone in ‘large quantities’, as well as abstinence. 7

The aetiology of cannabinoid hyperemesis is not known. Allen et al. discussed various theories, indicating cannabis as the likely cause, particularly as the problem seems to recur within weeks of resuming the drug after significant periods of abstinence. 1 Cannabis is widely known to have an antiemetic property of benefit in some cancer patients receiving chemotherapy. 8 However, in cannabinoid hyperemesis it seems that a paradoxical reaction occurs, resulting in severe nausea and vomiting. Furthermore, it is not understood why particular persons suffer this disorder at a specific point in time and not others, who may smoke similar quantities and for similar durations. Byrne et al.'s scepticism about this putative disorder and their appeal for more evidence is entirely reasonable. 9 Nevertheless, patients with this curious cluster of symptoms do keep appearing and they do seem to improve greatly when they are able to abstain from cannabis.