Medical Urgent Illness Increases Among Chronic Cannabis Users
Antonia Teresa Amore-Broccoli, MSW, LCSW
Medical Clinical Social Worker and Addiction Medicine Specialist
November 16, 2024
Multiple states in America are rapidly legalizing cannabis use recreationally and medically. America has 24 states as well as Guam and Washington D.C where cannabis is legal.
It was once rare to see cannabis related medical illness in the Emergency department (ED). However, since the rise of cannabis legalization and the wide spread cannabis use among the general population, this has contributed to an increase in cannabis emergent medical occurrences. Cannabis use increase has created a medical phenomenon from multiple medical conditions and harms which are directly related to chronic cannabis use. These adverse medical conditions specifically related to cannabis use are evident by Emergency Department visits throughout the United States.
In May-June 2019, The Missouri Medicine; the Journal of the Missouri State Medical Association published by Dr Karen Randall and Dr Kathleen Hayward presented a brief medical report about the common illness that was reported following the four years of the legalization of cannabis in Colorado. Randal and Hayward state that their brief report is by no means inclusive of all the potential problems that can occur with cannabis use. (1.) While this brief study was 5 years ago the medical conditions surrounding cannabis use are still astounding and flooding the emergency departments throughout the United States and possibly the world.
Since the legalization of recreational cannabis, cannabis has been more readily accessible to the general population than any other time in history. A wide array of people across all ages and ethnicities, races and cultures are using cannabis. Daily cannabis use is now more common in the USA than daily alcohol use. This new information is reported by a new study, according to an analysis of national survey data over four decades. The addiction medicine research is based on data from the National Survey on Drug Use and Health, was published 5/22/2024 in the journal of Addiction. The survey is a highly regarded source of estimates of tobacco, alcohol and drug use in the United States. (3.)
Why is cannabis becoming even as popular as alcohol, at least in the USA? Alcohol is still more widely used, but since 2022 it was the first time this intensive level of cannabis consumption overtook high-frequency drinking, said the study’s author, Jonathan Caulkins, a cannabis policy researcher at Carnegie Mellon University. (3.) Most people's first intention is to use cannabis recreationally while others are drawn to the substance for medicinal reasons. Cannabis has become the new seductive and romantic substance, marketed as safe and effective for nearly ever mental, emotional and physical health ailment. Over the last decade, cannabis consumption modality has been a treatment trend for veterans and people with more complex mental health issues such as complex, chronic and/or severe PTSD. Due to the increased use; ‘a good 40 percent of current cannabis users are using it [cannabis] daily or near daily, a pattern that is more associated with tobacco use than typical alcohol use.’ (3)
Cannabis is more readily accessible to the general population than any other time in history. Many more people of all ages and cultures are using cannabis.
Cannabis among the general population makes it inevitable that more people are becoming dependent on cannabis as their use increases. This study and survey by the National Survey on Drug Use and Health confirms what the author is witnessing in her clinical practice and also what other Addiction Medicine colleagues are reporting from the intensive chemical dependency programs they are clinicians.
Most people's intention to use cannabis starts out very innocent: recreational use for social reasons while others are drawn to the substance for medicinal reasons. Some people will use cannabis occasionally or moderately or start and never use again. This is about 60 % of the population who consume cannabis. The other 40% as stated in the study above increase their use of cannabis to daily or near daily use.(3) People who use cannabis multiple times per day and throughout the duration of the day have a higher risk of cannabis dependence, cannabis use disorder or full blown cannabis addiction.
Addiction medicine research depicts that high-frequency users are more likely to become addicted to cannabis reported by Dr. David A. Gorelick, a psychiatry professor at the University of Maryland School of Medicine, who was not involved in the study. The number of daily users suggests that more people are at risk for developing problematic cannabis use or addiction, Gorelick said.(3)
This essay includes some of the more common medical and mental health illnesses that have been seen over the last four years of legalization of cannabis. Emergency Departments now see patients who self-report smoking 2,000 mg or more of THC in a day. (1)
Increase in THC level within the Cannabis Plant
Medical Science documents that the cannabis plant contains numerous components. The four major compounds are d-9-THC, CBD, d-8-THC and cannabinol. The phyto-cannabinoid activity is mediated by the endocannabinoid system. Cannabinoids affect the nervous system and play significant roles in the regulation of the immune system. (2)
The increase of THC as well as the increased chronic use of cannabis may be the major contributing factors which is at the root of the increase of cannabis related medical events in the emergency departments.
The tetrahydrocannabinol (THC) concentration today is much stronger than the concentration from the 90s. In the 1990s most typical cannabis ‘joints’ contained 1–3 mg of THC or 10% THC. (1) Today, plants are being raised and modified to produce a higher concentration of THC. The typical joint today contains approximately 18 mg of THC or more. THC bud purchased at a California dispensary is 28-65% THC with an average of 32% content.
Mental Health Issues and Acute Psychosis
Cannabis-related mental health adverse events precipitating Emergency Department (ED) or Emergency Medical Services presentations can include anxiety, suicidal thoughts, psychotic or attenuated psychotic symptoms, and can account for 25–30% of cannabis-related ED visits. Cannabis use is a modifiable risk factor for the development and exacerbation of mental illness. The strongest evidence of risk is for the development of a psychotic disorder, associated with early and consistent use in youth and young adults. (4.)
There is an increased risk of psychosis, with a cannabis dose-dependent response effect and greater in those who use cannabis more frequently. Emergency departments have seen more episodes of acute psychosis when cannabis is the substance being abused. (1)
Up to 50% of patients with cannabis-related psychotic symptoms presenting to the ED requiring hospitalization will go on to develop schizophrenia. (4)
Acute Cannabinoid Catatonia
Catatonia is a psychological and motor (psychomotor) condition which is characterized by physical presentations ranging from severe immobility to excessive psychomotor agitation. Catatonia is also associated with a cluster of emotional aspects. Catatonia emergency episodes are becoming more prevalent with its changing pattern and extensive use of recreational and illegal drugs. Cannabis legalization has contributed to the rise of medical conditions associated with cannabis use. Which has led to an increase of several mental health conditions, including catatonia. Catatonia has a significant morbidity and mortality rate if left untreated. Older patients are more at risk as this condition is typically seen in older patients with acute excessive ingestions of cannabis. Acute excessive ingestions are most likely to happen with edibles. Clinically canatonia is also medically presented by smoking excessive cannabis buds or vaping. (1)
ACS, Acute Coronary Syndrome Acute Pericarditis
Acute coronary syndrome (ACS) is a combination of symptoms to describe a range of conditions related to sudden, reduced blood flow to the heart. The symptoms of ACS are often associated with severe chest pain or discomfort and require a medical emergency for diagnosis and immediate care.
The goals of the medical treatment include improving blood flow, treating complications and preventing future problems.
Cannabis is known to cause elevated blood pressure. Elevated blood pressure tends to get worse over time unless it's properly managed. Uncontrolled, elevated blood pressure and hypertension increase the risks of heart attacks and strokes. Patients with chest pain, despite their age, need to have EKG, troponin blood test, and more formal evaluations when there is a history of recent and/or chronic cannabinoid use. (1)
Acute Ingestions of Cannabis
Ingestions typically occur with edibles but as stated before can also be from smoking dabs or the cannabis bud. Acute intoxication secondary to ingestion of edibles has been seen in all age populations; both the young as well as older patients. The marketing packaging appearance of the edibles (gummies, chocolate, cakes, candies, and cookies, etc.) makes the product attractive and even seductive. Cannabis appeal has led innocent people who are unaware of the dangers of acute ingestions to experience acute accidental ingestions. Acute toxic ingestions occur secondary to excess ingestion of the cannabis product. People who ingest cannabis edibles, the onset of the high (euphoria) is delayed. This is due to the fact that the substance first passes metabolism before it reaches the site of action or systemic circulation.This is specifically true when administered orally. Therefore as a result many people who take one edible do not have an immediate high feeling effect unlike with smoking cannabis bud or vaping. People get impatient for the high off the cannabis and so they ingest more edibles; believing that are harmless.
The biological reason for this delayed cannabis high has to do with drug metabolism at a specific location in the body. This leads to a reduction in the concentration of the active cannabinoid, before it reaches the site of action or systemic circulation which results in unpredictable onset and quality of the effects felt. Once ingested, the person is on an unalterable course until the THC is metabolized. This can lead to a sudden onset of acute alteration in consciousness and acute changes in behavior. In other words people get very very high and/or intoxicated. The associated behavior can be manifested as erratic, unpredictable, and bizarre. Some people are very uncomfortable and afraid the high won't end; like a bad acid trip. Sometimes this leads to delusions, extreme paranoia and sometimes full on psychosis episodes.
Cannabinoid Hyperemesis Syndrome
Cannabinoid hyperemesis syndrome (CHS), once thought to be rare, is now being seen almost daily in emergency departments throughout the United States. (1)The specific etiology for the cause of CHS symptoms is unclear. However, medical research has led to the belief that this is due to the endocannabinoid receptors in the GI tract. Most people who are commonly affected are heavy and chronic cannabis users. Patients present with the combination of loud vomiting and screaming which has led to the term “scromiting.” Symptoms are temporarily relieved by hot showers which have been reported by many patients. Many patients with these often unexplained signs and symptoms endure multiple medical diagnostic tests, such as CTs, GI evaluations, and endoscopy; testing results are usually negative. An Endoscopy may show gastritis or esophagitis from the repeated vomiting. Dehydration is usually confirmed and treated w/ IV fluids due to the vomiting episodes. However, this significant dehydration can be serious as patients are at risk for acidosis, decreased serum bicarbonate, and acute renal failure Significant alterations in electrolytes can be recognized. Many patients have difficulty accepting that their CHS diagnosis is a direct result of their cannabis consumption. This is for a variety of reasons namely denial and rationality and deflection of blame that is associated with cannabis addiction. Cannabis has long been thought to be an effective treatment for nausea and vomiting and many people are very reluctant to stop using it. The treatment of choice is abstinence for a prolonged period of time (typically over several weeks, months and years).
Summary (1)
Since the legalization of cannabis in America , the THC potency has dramatically increased. Cannabis consumption is often in the grams as opposed to milligrams previously. (One gram is equal to 1000 milligrams.)
More people from the mass population including all ages are consuming higher quantities of cannabis thus higher levels of THC on a daily basis. As a result of this increased use pattern, there are increased adverse harms and side effects seen in emergency departments. Baffling new medical problems such as cannabinoid induced hyperemesis, acute ingestions, psychosis, chest pain – myocarditis, and are being seen more frequently.(1)
References:
(1) Emergent Medical Illnesses Related to Cannabis Use by. Karen Randall, DO & Kathleen Hayward, May 2019
Randall K, Hayward K. Emergent Medical Illnesses Related to Cannabis Use. Mo Med. 2019 May-Jun;116(3):226-228. PMID: 31527946; PMCID: PMC6690288.
https://pmc.ncbi.nlm.nih.gov/articles/PMC6690288/
More information: Changes in self-reported cannabis use in the United States from 1979 to 2022, Addiction (2024). DOI: 10.1111/add.16519 onlinelibrary.wiley.com/doi/10.1111/add.16519
Journal information: Addiction (4) Crocker CE, Carter AJE, Emsley JG, Magee K, Atkinson P, Tibbo PG. When Cannabis Use Goes Wrong: Mental Health Side Effects of Cannabis Use That Present to Emergency Services. Front Psychiatry. 2021 Feb 15;12:640222. doi: 10.3389/fpsyt.2021.640222. PMID: 33658953; PMCID: PMC7917124.
Antonia Teresa Amore Broccoli, LCSW ©