That was definitely vomit, I thought as I stepped in a slippery substance and caught the rail of the stretcher to avoid sliding underneath. That bilious smell does not come out of shoes.
After ordering an intravenous, a cocktail of anti-emetics, and a change of footwear for myself, I run through a mental list. What causes a 14-year-old patient to vomit like this? Appendicitis? Meningitis? Overdose? As an emergency room physician, it’s always Big Bad Diagnoses that run through my mind first.
When I return, I find my patient still slightly green, but no longer vomiting. He has a mop of brown hair and looks much older than 14 years. I perch on the edge of his stretcher and check the name on his chart: Nick.
“Hi, Nick,” I start, “how are you feeling?”
Nick has been smoking pot every day for the past two years
As I gather my initial information, I learn that Nick is a seemingly very healthy young man. No fever, diarrhea, or tropical vacations in his recent past. I run through my usual line of questioning as his mum hovers beside him, holding his hand, before asking, “Would you mind heading to the waiting room for a few minutes?”
When she leaves, the truth comes out. I learn that at 14 years old, Nick drinks alcohol casually and from his own estimate, has been smoking pot every day for the past two years.
Combined with that knowledge and a physical exam that reveals nothing of note, I think I’ve cinched my diagnosis. “Nick, I’m going to run a few tests to rule out anything worrisome. But I’m fairly confident your vomiting is because of all the pot you’ve been smoking.”
Nick was suffering from Cannabinoid Hyperemesis Syndrome (CHS) — abdominal pain, nausea and intractable vomiting due to chronic, regular cannabis use. Never heard of it? Neither had Nick’s parents. Just a short time ago, it wasn’t on most doctors’ radars either.
Nick was suffering from Cannabinoid Hyperemesis Syndrome
And this is a problem.
The legalization of recreational marijuana is upon us, and cannabis use in youth is already rampant. Surveying grade 7 to 12 students, one in five had tried cannabis, and over one in 10 had used it in the past month, with an average initiation age of 15 years. We already treat many of these patients for CHS. And, if we’re anything like the state of Colorado, we could see nearly a doubling of cases as they did following liberalization.
CHS poses serious health effects, such as dehydration. It also contributes to missed school and work, and is costly on our already faltering health-care system. Patients often present multiple times to emergency departments, undergo expensive and sometimes invasive tests, consultations and treatments before they are appropriately diagnosed. By increasing awareness amongst both the public and the health-care profession, patients can be treated promptly (with hot showers, topical capsaicin cream and firm advice to quit), and the cost savings could be significant.
Unfortunately, most youth think that using marijuana is generally safe
Unfortunately, most youth think that using marijuana is generally safe. Researchers speculate that’s thanks in part to media, which lacks coverage about potential health effects. In fact, most youth think there’s no potential for severe harm from marijuana use. We need education for youth, parents, and health-care practitioners — and we need to share more stories like Nick’s.
In the lead up to the legalization of the possession and consumption of recreational marijuana, scheduled for July 1 of next year, Health Canada has prioritized educating youth about the health effects of cannabis. The Canadian Pediatric Society (CPS) and the Canadian Psychiatric Association have come forward with position statements warning of the harms of cannabis in youth. They outline risks such as impaired brain development, increased prevalence of mental illness, and diminished school performance and lifetime achievement. However, there was no mention of CHS in either of these documents.
It will be essential for those tasked with this massive undertaking to figure out what to say by engaging stakeholders, including the Canadian Association of Emergency Physicians, in order to shed some light on CHS. We need to find out how to say it and who should say it so youth will listen. And, this all needs to be done starting now; we are on a tight timeframe, after all. July 1 is coming up fast, and we aren’t ready.
Dr. Jessica Ross is a physician practicing in Ontario.
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