Currently, 25 states and Washington, DC have varying degrees of legalization of marijuana . Most are medical marijuana but some have legalized recreational marijuana(including our home state of Maine in the last 2016 election). This has led to a rise in certain unexpected health concerns. With the reality of Maine legalizing recreational marijuana, we thought this was a good time to look at some of the early literature coming out of Colorado.
Cannabinoid Hyperemesis Syndrome (CHS)
CHS is a poorly understood variant of cyclic vomiting syndrome (CVS) that was first described in 2011. These patients present with cyclic vomiting, abdominal pain, and compulsive hot showering to relieve the symptoms. It is very difficult to differentiate from other causes of CVS. Usually, there is a history of long-standing use of marijuana. There tend to be minimal findings on lab and imaging evaluation and there is generally improvement of symptoms with cessation of cannabis. In 2015, Kim et al demonstrated that the prevalence of cyclic vomiting patients to 2 Denver-area hospitals nearly doubled after the liberalization of medical marijuana. CHS can be difficult to treat and sometimes can require multiple antiemetics. In their study, the use of promethazine was associated with admission.
Take home: It is reasonable to consider the diagnosis of CHS in patients presenting for cyclic vomiting with concomitant use of marijuana. While care is generally supportive, cessation of cannabinoid use is the definitive treatment although it is unclear if patients will heed this advice.
Injuries from Butane Hash Oil
The quest for purer and more potent THC has led to the home-chemist attempting to increase their yield. Butane hash oil (BHO) also known as “honey oil,” “shatter,” “wax,” or “dab,” is a potent concentrate, which may contain more than 90% tetrahydrocannabinol. BHO is made using a hydrocarbon, most commonly butane, as a solvent and during the extraction process, the highly flammable butane gas can be easily ignited. In Colorado, there was a dramatic increase in presentations to the burn center for injuries from explosions from the extraction of hash oil. There were 0 cases prior to medical liberalization, 19 durinag 3 years of medical liberalization, and 12 in 8 months of legalization. In a case series in California, these cases were more likely to have larger burns, multiple patients, and the patients were more likely to be positive
Take home: These injuries seem to certainly be as a direct result of trying to increase potency of THC. We may start seeing these burn patients, some with significant injury requiring grafting and multiple resources.
Accidental THC INGESTION
The final and perhaps most concerning effect was the increase in pediatric exposures and calls to a regional poison center (PC) after liberalization of marijuana. Wang et al demonstrated that marijuana exposure visits and population rates at the children’s hospital significantly increased in the 2 years following legalization compared with the 2 years prior to legalization. The PC exposure call average and population rates also significantly increased. Almost half of the patients seen in the children’s hospital in the 2 years after legalization had exposures from recreational marijuana, suggesting that legalization did affect the incidence of exposures. More than half the exposures were from edible products which highlights the ever-present concern of making things attractive to kids. Lethargy and altered mental status were the most common presenting symptoms. Many of the patients had significant workups and admissions with 2 intubated. There were no deaths.
Take home: Pediatric visits may rise as marijuana becomes more accessible. It will become increasingly more important to ask about these products during the evaluation of the altered child as this may help guide evaluation and management.
Written by Tammi H. Schaeffer, DO, FACEP, FACMT,
Medical Director Northern New England Poison Center, Portland, ME
Edited and Posted by Jeffrey A. Holmes, MD
Tired of reading? Watch Dr. Schaeffer discuss unintended ED patients after marijuana legalization
1. Bell C, Slim J, Flaten HK, Lindberg G, Arek W, Monte AA. Butane Hash Oil Burns Associated with Marijuana Liberalization in Colorado. J Med Toxicol. 2015 Dec;11(4):422-5.
2. Wang GS, Le Lait MC, Deakyne SJ, Bronstein AC, Bajaj L, Roosevelt G. Unintentional Pediatric Exposures to Marijuana in Colorado, 2009-2015. JAMA Pediatr. 2016 Sep 6;170(9)
3. Kim HS, Anderson JD, Saghafi O, Heard KJ, Monte AA. Cyclic vomiting presentations following marijuana liberalization in Colorado. Acad Emerg Med. 2015 Jun;22(6):694-9.
4. Romanowski KS, Barsun A, Kwan P, Teo EH, Palmieri TL, Sen S, Maguina P, Greenhalgh DG. Butane Hash Oil Burns: A 7-Year Perspective on a Growing Problem.J Burn Care Res. 2017 Jan/Feb;38(1):e165-e171.
5. Sorensen, C.J., DeSanto, K., Borgelt, L. et al. Cannabinoid Hyperemesis Syndrome: Diagnosis, Pathophysiology, and Treatment—a Systematic Review, J. Med. Toxicol. (2016).