Patients arrive in the emergency department (ED) doubled over in pain and retching uncontrollably, a brew of symptoms physicians have nicknamed “scromiting” — a combination of screaming and vomiting. The problem: an underrecognized consequence of cannabis use called cannabinoid hyperemesis syndrome (CHS), and emergency medicine physicians say few conditions leave patients more obviously miserable.
“My heart breaks for them,” says Kathleen Clem, MD, an emergency medicine physician at Dartmouth Health in Lebanon, New Hampshire, and interim associate dean for faculty affairs at the Geisel School of Medicine at Dartmouth. “They come in because they absolutely cannot keep anything down. They’re dehydrated and their belly is sore from vomiting so much. Sometimes they vomit so much, they’ll break little blood vessels in their esophagus, and little bits of blood come up with that.”
The leading cause of marijuana-related ED visits, CHS is associated with the chronic and long-term use of marijuana products, and it is becoming more prevalent, likely due to the increased legalization of marijuana. Some 24 states have legalized recreational marijuana use since 2012, and 40 states allow its use as a medicinal treatment. An additional eight states allow “limited-access” medical cannabis, which refers to low-THC (tetrahydrocannabinol) products and CBD (cannabinoid) oil.
In the United States, cannabis use has nearly doubled in the past decade, with 22.3% of individuals 12 years and older — 64.2 million people — reporting its use in the past year, up from 12.6% in 2013, according to data from the Substance Abuse and Mental Health Services Administration. And research shows a 15-fold increase in the number of people reporting daily or near daily cannabis use from 1992 to 2022.
In addition, products containing THC, the primary psychoactive component of cannabis, are not only more accessible; they also are much more potent.
“This is not your parents’ weed,” says Clem. “It’s been really amped up and much stronger in potency, and you don’t necessarily know what you’re getting.”
A recent analysis of products purchased in dispensaries and convenience stories by the Laboratory for Forensic Toxicology Research at Virginia Commonwealth University found that the package labels of cannabis products rarely reflected their actual content. One product was found to contain 34 times the stated amount of THC.
Increased cannabis use, along with increased potency, has resulted in an enormous spike in ED visits for CHS, experts say. Last year the World Health Organization gave CHS a diagnostic code that the Centers for Disease Control and Prevention has now adopted. (Cannabis intoxication, cannabis use disorder, cannabis-induced psychosis, and other related disorders are on the rise as well.)
CHS is characterized by excruciating abdominal pain and repeated bouts of vomiting that can last from 24 to 48 hours, says Sean McGann, MD, an emergency medicine physician and director of emergency medicine quality and safety at Jefferson Health in Philadelphia. In rare cases it causes heart-rhythm problems, seizures, kidney failure, and even death. It typically recurs weeks or months later in susceptible people and often requires admission to the hospital.
“Not every patient who uses marijuana will get CHS, but there are certainly some patients who are more prone to it. If patients continue using marijuana products, they often will have repeat episodes," says McGann.
Emergency medicine doctors can frequently ameliorate moderate symptoms with medications and IV hydration to replace lost fluids. But the only real cure for CHS is to stop using cannabis altogether.
A CHS surge
According to an analysis of data from the University of Illinois in Chicago, the prevalence of CHS increased more than fivefold, from 4.4 reports per 100,000 ED visits in 2016 to 22.3 per 100,000 in 2022. One study has estimated that approximately 2.75 million people in the United States have been affected.
CHS can affect anyone with a history of chronic cannabis use (at least four days a week). “I see it all the way from teens to people in their 60s and 70s,” says Clem.
Research suggests that the syndrome is rising fastest among adults ages 18 to 34. And it is increasingly being reported in adolescents. Researchers saw a nearly 50% spike in CHS-related ED visits among people ages 13 to 21 between 2016 and 2023, data show.
While some data find that CHS is more common among younger populations, Hispanic and Black individuals, and men, a 2025 study showed that Caucasian women were more likely than other groups to be affected.
“When we look at the cyclic vomiting disorders, which include cyclic vomiting and cannabinoid hyperemesis, we know that this boils down to receptors in the brain and receptors in the gut. Therefore, it’s a gut-brain interaction issue,” says study author Michael M. Shalaby, MD, assistant professor of clinical emergency medicine at the University of Pennsylvania Perelman School of Medicine. “There may be certain receptors that are more abundant in women, which may account for this occurring more frequently in women. And there may be something similar going on for the Caucasian component.”
According to a survey of more than 1,000 people who reported experiencing CHS symptoms, 85% reported at least one emergency department visit and 44% had at least one hospitalization.
Almost all the respondents reported daily cannabis use. More than 40% said they used cannabis more than five times a day.
Long-term use was common, too. Some 44% reported using the drug regularly for more than five years. For many others, marijuana use dated back a decade or longer.
Getting to a diagnosis
Despite the new diagnostic code, experts believe CHS is often missed.
“There is no specific test for this syndrome, so it’s not always well-documented or easily coded,” says Joshua Ring, MD, associate medical director of education in the emergency department of Duke Regional Hospital in Durham, North Carolina. “If I were to search for it to see how many people showed up to the ER with cannabinoid hyperemesis syndrome, there probably would be a gross underestimation of the actual problem.
“There are a lot of reasons why someone might have vomiting, and we don’t always want to attribute it to one particular thing,” he adds.
CHS’s symptoms can be confused with other ailments, including cyclic vomiting syndrome (a similar ailment not caused by cannabis) and gastroparesis (when the stomach muscles can’t move food through the intestines properly, triggering pain and vomiting). The disorder also mimics stomach flu and food poisoning.
One clue to the presence of CHS is when a patient reports getting relief by taking hot showers, a common phenomenon.
It doesn’t help that “sometimes we don’t really know the extent of someone’s marijuana use,” Ring says. “Oftentimes people are reluctant to share [information about] their drug use, something that they might feel like they are being judged on. It’s hard to make that diagnosis without having all the information available.”
Still it’s important to probe.
“I try to make sure that I’m not asking in a judgmental way,” says Shalaby. “I will bring it up at the very end: ‘By the way, just out of curiosity, do you happen to use cannabis products?’”
Yet some patients simply can’t accept that their marijuana use is behind their puzzling symptoms, especially those who have consumed cannabis for a long period with no ill effects. It’s not clear why the problem may emerge after years — or decades — of chronic use, though it could be the greater potency of cannabis products.
To break through the denial, McGann sometimes shares popular articles on the syndrome.
“People might not believe the New England Journal of Medicine, but they might believe High Times,” a publication that espouses cannabinoid use, he says.
There’s another factor behind the disbelief: Cannabis has legitimate medicinal purposes, specifically for easing pain and nausea.
“It’s confusing because we also use cannabis to help people who have had cancer treatments and [are being treated for] other medical conditions,” Clem says.
That fact underscores a common conundrum.
“If people are having symptoms like nausea, they’ll use marijuana products and they feel better temporarily, but then they start vomiting, and it becomes a vicious cycle,” Ring says.
Addressing CHS symptoms
Although there are no specific medications for quelling the symptoms of CHS, there are treatments that have been shown to be effective.
“The strongest treatments are the dopamine antagonists, aka antipsychotics [haloperidol, droperidol, and olanzapine], because they have a very strong antiemetic component,” says Shalaby. “They act very strongly on the vagal complex in the central nervous system and help with vomiting.”
Benzodiazepines are also helpful for managing retching as well as the general restlessness that comes with CHS, he says, adding, “They really help patients feel calmer.”
Although anti-nausea medications such as ondansetron and metoclopramide are often called on for treating CHS, data suggest that antipsychotics perform better, Shalaby says.
“Then we use any sort of analgesic but with an attempt to avoid opioids,” he says. “CHS is a chronic issue, and most patients present to the emergency department more than once in their lifetime. Recognizing that 80% of opioid addictions start with prescription opioids, we try not to use that. And opioids actually promote vomiting by inhibiting gastric motility.”
One underused antidote is capsaicin cream rubbed on the belly.
“It’s one of the only treatments that we have that directly targets what’s going on with cannabinoid hyperemesis syndrome by targeting the specific receptors,” says Shalaby. “It’s not novel, but people forget about it. Some hospitals don’t even stock it.”
Targeting the problem early
Though emergency department physicians are skilled at treating CHS patients’ immediate needs, ideally they would like to target the problem before it results in another trip to the ED.
“We’re well versed at assessing where patients are and giving them resources that they can use,” says McGann. “I’ve had patients that, once I told them that this is what’s going on and it’s caused by marijuana, said, ‘I’m done. I’ll never touch it again.’ But as with many addictions, we have patients who really struggle to stop. Those are patients that we can offer referrals to addiction clinics and addiction medicine specialists.”
Clem tries to really listen to patients to understand what might be behind their cannabis use, such as mental health struggles, admittedly a tall order in a busy emergency department.
“It’s really hard to sit down and talk with them, to be able to reach them and give them hope that there are other ways than cannabis to deal with whatever it is,” she says. “Unless they are willing to look for other ways to treat whatever reason for them using cannabis, they probably won’t get the help they need.”
Clem will emphasize to patients, particularly adolescents, the toll the drug is taking on users.
“We know that it affects the frontal lobe development in people who are young, which is sad,” she says. “I try to stress that to my teens: ‘This is not the time to be doing that, because your brain isn’t fully formed.’ I want people to really think about why they’re using it and if there is something that is safer and better.”
Above all, Clem wants patients to know that they should feel welcome in the ED.
“Don’t be afraid to come to the emergency department if you’re having this problem,” she says. “We really do want to help you. And then be open to what we suggest, so that this doesn’t become a recurrent problem for you.”
