To “Green Out,” the Cannabis Hyperemesis Syndrome

Tomorrow up here they will cede

That battle they have waged against weed

A pot head flat broke

Still has money to toke

And won’t listen to me when I plead

Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, traveled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. I followed 3 years Community Health Center work with a return to traveling and adventures in temporary positions in Alaska, rural Iowa, suburban Pennsylvania, western Nebraska and northern British Columbia. I have returned to Canada now for the 4^th time.  Any identifiable patient information has been included with permission.

Tomorrow, Canada will legalize marijuana.

In the week since I returned to Canadian clinical practice, I’ve taken care of 4 patients with cannabis hyperemesis syndrome (CHS).

The active ingredient in marijuana, tetrahydrocannabidiol (or THC) usually suppresses the urge to vomit, but if a person uses too much, that effect gets reversed and the person starts to puke.

I first learned of CHS about 10 years ago. In a town I will not name, a young patient kept coming to the hospital vomiting and dehydrated.  Discharge would follow symptom cessation, after a couple of days.  Three admissions later, the complete gastrointestinal workup completed, one of the person’s parents had gone to the net and educated the entire medical community.  Cutting back from an ounce a day to just half an ounce per day solved the problem.  At the time, the doctors thought CHS a rare problem.

A lot of people use marijuana to excess, and a lot of people vomit.  A vomiting pot smoker doesn’t necessarily get the diagnosis of CHS; a craving for hot showers or baths cinches the diagnosis.  Stopping the drug will cure the disease.

I learned the local street slang for CHS this week, to “green out.” It bothers me that the syndrome has become so common that it now has a place in the language.

Given the choice, I prefer cure to treatment, and stopping the THC will cure the green out. Regretfully, application of capsaicin cream (available without a prescription) will treat the problem without curing it.

Legalizing cannabis will cut down on illegal profits by crime bosses, but those criminals will not go away and they will not turn to legal ventures; they will find other unlawful ways to make money.

Revenues generated from the sales of marijuana will not come close to the economic ruin that the increased use will cause.

I try to tell depressed, anxious people they’re making themselves worse with the drug; I meet with vigorous denial. Which leaves me two tools.

One is educational. I tell my patients that because cannabis long term drives down testosterone levels it leads to Low T, and will impair sexual function.

The other is a question: “How’s that working out for you?”  Because not only does marijuana worsen (not lessen) depression, anxiety, and pain, it ruins functionality.  A pot head’s life deteriorates slowly and steadily.  They lose their house, job, car, and relationships.  They can’t afford rent, food, transportation or a lawyer.

But they find money for weed.

 

 

Coming back from New Year’s Day

When it comes to the question of pot

And all the supporters it’s got

It just doesn’t makes sense

Because now evidence

Shows that good for depression it’s not

Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, travelled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. After three years working with a Community Health Center, I am back having adventures in temporary positions until they have an Electronic Medical Record (EMR) system I can get along with. I spent the winter in Nome, Alaska, followed by assignments in rural Iowa. The summer and fall included a funeral, a bicycle tour in Michigan, cherry picking in Iowa, a medical conference in Denver, working Urgent Care in suburban Pennsylvania, and Thanksgiving in Virginia. Right now I’m in western Nebraska. Any patient information has been included with permission.

I’ve listened to Audio Digest Family practice for 37 years. In the beginning, my aging Karmann Ghia had no place for the tape cassettes. I wore out a tape machine about every 7 years.  Last century I upgraded my vehicles and started listening over the car stereo system.  Now that cars don’t have tape cassette decks, I get the programs on CD.

Yesterday we drove east through the flat Colorado wheat country after spending the holiday with family and friends, listening to an educational CD about medical marijuana on the car stereo.

The lecturer talked slowly, leading me to wonder about his firsthand experience with the drug.

Good evidence supports the use of medical marijuana for AIDS wasting syndrome (hardly ever seen anymore) and the nausea from cancer chemotherapy. After that the quality of research falls off with small studies and poor design.

I know a doc from Colorado who supports use of medical marijuana, and points out that the sativa variety has more THC, the stuff that gets people high, whereas indica plants have more cannabidiol. He asserts that the cannabidiol has the medicinal properties.

Even the pro-pot lecturer said that all the commercial products come from hybrids.

I put marijuana’s long tenure as an herbal remedy at the same level as Teddy Roosevelt’s touting the unique properties of champagne for dysentery and brandy for everything else. Alcohol turns out to be alcohol and while it may have a number of physiologic properties, it comes in last place as a pharmacologic agent because it doesn’t make anything better.

Marijuana does not relieve anxiety; quite the contrary, it brings paranoia. Nor does it relieve pain though it interferes with the ability to reason through questions about the 10-point pain scale.  It predictably drives down the level of testosterone for both genders which leads to terrible sexual dysfunction.  Eventually, it makes people depressed.  It might help some sleep, but they don’t rest.

Yet I would agree that the FDA needs to take it off Schedule 1 so that we can start doing decent research on it.   The plant makes hundreds of compounds that can stimulate receptors throughout our bodies, and its potential remains basically untapped.

I ask everyone past the age of puberty about use of tobacco, alcohol, marijuana, and other drugs. While most people at my current assignment avoid excesses, those who don’t account for a disproportionate share of the ones who need medical help.  If someone uses marijuana, I ask how much, and whether they’re using legal stuff from across the border or the illegal weed purchased locally.  I hope that the Colorado product has fewer adulterants, but it remains largely unregulated.

Today I attended a patient with chronic pain (and a number of other problems); two weeks ago we decided gradually decreasing the morphine dose would be a good first step towards returning functionality. You could see the improvement from across the room, and we talked about the increasing exercise tolerance.  I let the patient decide on the pace of treatment, and two weeks from now we will look for more progress after another dosage reduction.

As always, I heavily recommended exercise.

Fourteen hours of a zoo of a day.

I don’t do this because of the pay,

Going straight into the fray

     From eight until ten

     Like the old headless hen,

It’s been a zoo of a day.

Synopsis:  I’m a family practitioner from Sioux City, Iowa.  Avoiding burnout, I’m taking a sabbatical while my one-year non-compete clause winds down, having adventures, visiting family and friends, and working in out-of-the-way places.  Currently I’m on assignment at the hospital in Barrow, Alaska, the northernmost point in the United States.

I’m writing this after fourteen continuous hours of caring for sick people trying to get better, sick people trying to stay sick, well people pretending to be sick, and a few well people just wanting to go back to work.

I tried to take care of five people who came out and said they didn’t trust me, then tried to bully me into narcotics prescriptions.  I pointed out to them that if they really didn’t have confidence in my judgment they wouldn’t accept anything I would prescribe, and the only thing they should take from me is an arrangement to see another doctor.

A recurring theme today, just like an episode of a TV doctor show, involved a schizophrenic with a horrendous medical problem that cannot be dealt with on the North Slope.  We discussed the patient at morning rounds, I made several calls to Anchorage and received varying combinations of arrogance and sympathy from the Big City.

I placed a cast with the advice to the patient for prompt follow-up if the cast got too tight.  Which it did.

Influenza and post influenza problems saturated the walk-in clinics.  People slip on the ice and sometimes break things, but mostly just hurt for a couple of weeks.  I explained to a lot of people that if it didn’t hurt bad enough to come in for the first five, six, or eight days that they didn’t narcotics today, and they should expect to be sore for several days.

The Inuit smoke a lot of marijuana, which has marginal legality here.  But they smoke it now like hippies smoked it in the sixties and a lot of folks haven’t been unstoned for decades.  Some of them hunt stoned.  I see health problems related to cannabis abuse.

Instead of eating dinner, I waited twenty minutes to talk to a pediatrician at ANMC (Alaska Native Medical Center) because the phone operator didn’t read the call schedule correctly.

When I finally connected to the surgeon/gynecologist/pediatrician, I received cogent, useful advice in a time efficient fashion.

Seventy percent of my business came from tobacco, alcohol, or marijuana. Twenty percent came from influenza.  Ten percent came from bad luck or overeating or both.

And I saw something I’d never, ever seen before.  I didn’t even ask for permission to write about it, even if the answer had been yes, I wouldn’t have written the details.