Prepared by Karyn Godier EEN Maruma-li Drug Treatment Unit September 2012

1. Cannabinoid Hyperemesis Cyclical vomiting in association with chronic Cannabis use. Prepared by Karyn GodierEEN Maruma-li Drug Treatment Unit September 2012

2. Introduction Cyclical vomiting in association with chronic Cannabis use. First reported in November 2004 issues of the journal “GUT”. Article published by Dr. Hugh Allen & Associates of Mt Barker Hospital SA. Symptoms occur primarily at the cessation of use: Vomiting Dehydration with possible deranged Electrolytes “Gripping” abdominal pain Frequent showering/bathing.

3. 19 participants identified for Dr. Allen’s study. • 10 of the 19 had experienced all symptoms upon cessation of use. • 7 of those 10 abstained and all symptoms resolved over a period of weeks. • 3 resumed smoking Cannabis.

4. In 2009 Sontineni and Associates publish guidelines to the clinical diagnosis of Cannabinoid Hyperemesis ESSENTIAL: • Chronic Cannabis use. MAJOR: • Severe vomiting and nausea. • Vomiting that occurs in a cyclic pattern over a period of months. • Resolution of symptoms upon cessation of use. SUPPORTIVE: • Compulsive hot baths/showers that relieve symptoms. • Colicky abdominal pain. • NO evidence of Gall Bladder or Pancreatic inflammation. • Negative laboratory. Radiographic and endoscopic results.

5. Simonetto & Colleagues of the Mayo Clinic, Minnesota published the results of the largest study to date earlier this year, 2012. • All patients were under 50 years of age. • 68% reported regular Cannabis use for at least 2 years prior to attempting cessation of use. • 86% reported severe abdominal pain. • 91% reported relief of symptoms with hot baths or showers.

6. Results • Participants identified from hospital records from Jan 2005 – June 2010. • 1571 were identified as having a history of recurrent vomiting in which NO other explanation apart from preceding Cannabis use was identified. • 98 (6%) met the clinical guidelines.

7. Treatment • Rehydration • Restoration of any electrolyte imbalances. • Medications – Anti emetics, anti spasmodics, analgesia. • Evaluate need for sedation to assist with agitation. • Allow showering/bathing as the environment allows, warm blankets may be helpful. • Explore options post cessation e.g. CBT, Cannabis Clinic, residential rehab.

8. A key feature that makes this syndrome relevant to all health care professionals is the acute nature of the nausea and vomiting which often leads to Emergency Department visits and can necessitate a number of expensive diagnostic evaluations. In many ways it could be said it is a diagnosis by omission.

9. CaseStudy • Female • D.O.B. 23/11/1978 • Employed as AIN. • Living with long term partner – supportive relationship. • Denies any significant medical or mental health history. • Previous treatment for depression following death of mother (ETOH related) but no current regular medications. • 10+ year history of regular cannabis use, Currently smoking approx. 1 gram daily.

10. 2006 • First presentation to ED 18/5, BIBA via GP, ? Viral infection. • Admitted 23/5 – 23/5 for Panendoscopy & Abdo CT, same NAD. • 25/5 BIBA reporting same symptoms, Pelvic U/S attended – NAD. • 26/5 – 2/6 BIBA admitted repeat U/S shows “sludge” in Gall Bladder. First documentation of excessive showering in nursing notes. • 3/6 – 8/6 BIBA Admitted under surgical team, Lap Chole attended. • 22/9 – 27/9 BIBA (presents twice 22/9) Admitted, further abdo CT attended – NAD.AOD consult attended, referred to Cannabis Clinic. • 2/10 – 8/10 BIBA, admitted. Renal U/S attended. Problematic showering and behaviour noted, verbally abusive, non-compliant with boundary setting.

11. 2008 • 3/10 BIBA twice as left without notice when shower was refused by ED staff on first presentation. Referred to inpatient detox. • Maruma-li Admission 5/10 – 14/10. • Admitted for Cannabis detox. Compulsive showering up to 12 times daily for up to 1 hour noted in nursing notes, found lying on the floor of shower stall on a number of occasions. Agitated and verbally abusive toward staff. Nauseated++, moaning, crying, agitated and distressed. Erratic behaviour, vomiting, nausea, and frequent showering continued unabated until day 7 when her condition improved markedly. Able to be discharged on day 10.

12. InpatientTreatment • Day 1 – Diazepam 15mg, Maxalon 30mg, Ondansetron 12mg, IV fluids. • Day 2 – Diazepam 65mg, Maxalon 20mg, Buscopan 20mg, Ondansetron 8mg, Somac 40mg BD, IV fluids. • Day 3 – Diazepam 45mg, Maxalon 20mg, Buscopan 40mg, Ondansetron 16mg. Slow K, Temazepam 20mg. Abdo CT attended, NAD, IV fluids continue. • Day 4 – Diazepam 60mg, Maxalon 30mg, Buscopan 40mg, Ondansetron 8mg IV ceased. • Day 5 – Diazepam 30mg, Maxalon 30mg, Ondansetron 4mg. • Day 7 – Diazepam 7mg, Maxalon 20mg. • Day 8 – Buscopan 20mg. • Day 9 – Nil. • Day 10 – Discharged with follow-up at Cannabis Clinic. Patient continued with them from discharge until mid Jan 2009.

13. 2011 • 21/2 – BIBA requesting transfer to detox unit, DNW for consult. • 23/2 – BIBA but left ED due to inability to shower. • 24/2 – BIBA, seen by D&A and referral made to inpatient detox unit. • 25/2 – BIBA due to dehydration, given IV fluids then DC with symptomatic meds. • 26/2 – BIBA, dehydrated, hypokalaemic. Treated with IV fluids and oral potassium. Surgical review attended, abdo CT attended – NAD. • 28/2 – IBBA, 8th day of vomiting. Given IV fluids and IV Droperidol. Patient removed cannula and left the ED.

14. 1/3 Brought in by partner. IV fluids and symptomatic meds given. Pathology collected but DNW. • 1/3 – 5/3 – Represent and admitted to surgical ward with diagnosis of colitis. Given symptomatic meds and analgesia. IV antibiotics. • 6/3 – BIBA 1 day post DC. CT abdo and pelvis attended, findings indicated ‘NO evidence of colitic process seen. Referred for Colonoscopy as an outpatient. • 25/11 – Colonoscopy attended NAD. Patient reports no Cannabis use since previous admission.

15. 18/9 – BIBA twice in one day. • 23/9 – Admitted under gastro team for further investigation. Psych consult attended due to problematic behaviour around showering and small doses of PRN Olanzapine introduced as well as Diazepam, little response noted for each in regards to patient’s behaviour. Seen by D&A who made the following plan:- • Cease PRN Morphine and introduce simple analgesia. • Give symptomatic medications frequently including Diazepam. • Limit showers to 10 mins per hour. • The attempt by staff to limit showering proved unsuccessful and security were forced on 2 occasions to forcibly extricate the patient from the shower. • Discharged day 12 of admission.

16. 4/10 – BIBA, Represents day of DC complaining of severe abdo pain, discharged following administration of simple analgesia. • 5/10 – BIBA, DNW. • 6/10 – BIBA, DNA. • 7/10 – BIBA. Seen by D&A, given information on residential rehabs but deemed not suitable for detox at this time. • 14/10 – BIBA. Requesting further D&A consult, not seen as patient DNW. • 15/10 – 18/10 – BIBA. Admitted due to deranged pathology ? Pancreatitis, treated on ward, continued to shower excessively. NO further presentations to ED or hospital admissions are recorded since this time. Patient has remained a client of the Cannabis Clinic from Nov 2011 and continues to see a counsellor.

17. CannabisFacts • The Cannabis Sativa plant contains 80 components classified as cannabinoids; chemicals unique to this plant. • Delta-9-tetracannabinol is the substance which is responsible for the psychoactive effects of Cannabis. • Cannabis is the most widely used illicit drug in Australia. • 33.5% of Australians (approx. 5.8 million) have tried Cannabis with 1.6 million using it in the last year. Approx. 300,000 people smoke it on a daily basis. • Cost: 1 gram = $20; 1 ounce = $300 Bush is slightly cheaper.

18. It is unknown why only a small percentage of chronic cannabis users experience this syndrome and various theories have been put forward including: • Susceptible patients develop hypersensitivity following lengthy exposure. • As Cannabis has a long half life, regular use is accumulative and therefore may lead to toxicity in a susceptible patient. • As Cannabis delays gastric emptying, a toxic patient may develop gastric stasis hence hyperemesis.

19. Why showering and bathing?What we do know:- • “Cannabinoid receptions (CB1) are abundant in the brain including the Hypothalamus. The Hypothalamus plays an integral role in the thermoregulation as there are neurons sensitive to skin and blood temperature. The thermoregulatory system may become disrupted by the presence of cannabis toxicity. • “Experiments with mice have shown Cannabis lowers body temperature, also most likely related to some disruption in the hypothalamus. A lower body temperature can adversely affect the gut and lead to vomiting. This may mean by heating the body, patients are restoring normal gut motility. What we don’t yet know? A great deal!

20. Conclusion • I hope this presentation raises awareness not only of the adverse effects of Cannabis use but also the importance of obtaining a thorough patient history which includes consideration of the possibility of substance abuse especially if a patient presents with some of the more unusual symptoms discussed today. • Fact sheets and current information on Cannabis are available on line at the ncpic (National Cannabis Prevention and Information Centre).