WSLCB - Board Caucus
(November 26, 2024) - Cannabinoid Hyperemesis Syndrome
(CHS)

A data brief on CHS prepared by staff analyzed patterns in cannabis use not previously studied, leading to questions about further investigation of the condition from the acting board chair.

Here are some observations from the Tuesday November 26th Washington State Liquor and Cannabis Board (WSLCB) Board Caucus.

My top 4 takeaways:

• A little over a year after being established, the Research Program had become a prominent means for board member research into cannabis topics along with representing the agency in research-oriented events.
  • The Research Program at the agency was established in 2023. Once staff were hired, they began to produce both research papers on topics for agency leaders and took an active role in events with public health and prevention interests.
    • The team also organized events like the quarterly Research Roundtable which officials initially announced in September 2024 which took the place of the WSLCB Cannabinoid Science Work Group.
      • Prior to the establishment of the Research Program, the Public Health Education Liaison at WSLCB had organized private Prevention Roundtables for public health and prevention advocates to discuss issues of concern around cannabis. 
    • On August 7th, WSLCB officials led a focus group with public health and prevention representatives to gather feedback on the Research Program’s dashboard development plan. A prototype dashboard was demonstrated byWSLCB Research Analyst Nick Glodosky for the WA HCA Prevention Research Collaborative (WA HCA PRC) on September 4th in an event Cannabis Observer observed on condition of not producing recordings.
  • Research Program staff produced both Research Briefs and Data Briefs, distinguished thusly: “Research Briefs are short, non-technical summaries of scientific literature, government reports, policies, and other credible sources of information on a specific topic. Data briefs are short, non-technical summaries of literature on a specific topic paired with findings from statistical analyses.”
    • Research Program Manager Sarah Okey went over the group’s work to set up standard operating procedures (SOP) and Research Specialist Tyler Watson gave the two initial cannabis research briefs on August 20th.
    • The data brief on cannabinoid hyperemesis syndrome (CHS) was the group’s first original analysis with a potentially broader research application.

• WSLCB Research Analyst Nick Glodosky introduced and provided background information on cannabinoid hyperemesis syndrome (CHS, audio - 3m, video - WSLCB, video - TVW, data brief).
  • Glodosky explained that the research was "the result of a request made by Board Member Vollendroff" to learn more about CHS, a condition which had been “receiving increased action, and notably, was recently mentioned in the New York Times article about harms associated with frequent or heavy cannabis use.”
  • He acknowledged that some information suggested CHS was “occurring more often, although it's unclear whether this increase is due to frequent cannabis use, to increases in THC concentrations in cannabis products, or simply due to increased recognition of the syndrome by medical professionals.” There was agreement that CHS was “characterized by intense nausea, abdominal pain and cyclical vomiting following a long term period of frequent cannabis use.”
  • Glodosky claimed the condition was “difficult for medical providers to diagnose, because it's not a commonly known syndrome, and because THC is typically antiemetic, meaning that it usually reduces nausea and vomiting.” He also said the onset of CHS after initiation of cannabis use could range from “as little as six months or as long as 11 years,” and that no standard treatment had been found, “although benzodiazepines, haloperidol, and topical capsaicin can be helpful for short term symptom relief, and notably, hot showers or baths are very frequently reported to offer temporary relief from symptoms.” The only long term treatment found was to stop cannabis use, he added, but information was limited “as the disorder is somewhat uncommon.”
  • CHS had previously been mentioned in legislative hearings related to stricter cannabis regulations, at past events hosted by the Northwest Prevention Technology Transfer Center in 2020, and by WSLCB staff at the Washington Impaired Driving Advisory Council (WIDAC) on July 11th.
  • UW ADAI Research Scientist and Cannabis Education and Research Program (CERP) Director Beatriz Carlini also brought up CHS among the risks of cannabis consumption when presenting on the history of cannabinoid concentration legislation in April 2023.

• Glodosky analyzed Washington-specific data from the International Cannabis Policy Study (ICPS) to better understand CHS and shared conclusions from his novel analysis.
  • Board members learned more about ICPS Washington-specific cannabis data during a presentation in November 2022.
  • Glodosky explained that, to “examine risk factors associated with CHS,” he “used a binary logistic regression analysis, which looks at different factors to predict the likelihood of a specific outcome.” Based on the ICPS survey responses from 1,109 cannabis consumers in Washington state, there were “6% or 67 past-year cannabis users reported experiencing CHS in the past year,” on par with “rough estimates of U.S. prevalence rates at about 5%” (audio - 5m, video - WSLCB, video - TVW).
    • Looking at potential risk factors for CHS, Glodosky “found that males were more likely to report past year CHS than females, where 81% of those who reported past-year CHS were male.” Moreover, the results indicated “younger individuals were more likely to report CHS than older individuals, where the age group that was the most commonly reported past year CHS were those 21 to 25 and the mean age overall was 34,” he said. Glodosky concluded that findings suggesting “that young people, particularly young males, are at higher risk for CHS is consistent with past research,” however individuals “who reported using cannabis for only medical purposes were more likely to report CHS than those who used for either only [recreational] purposes or for both medical and non-medical purposes.” He deemed this a “novel finding and somewhat surprising, although prior research has shown that medical cannabis users may be using for more serious health conditions relative to those who use for non-medical only, or for both non-medical and medical reasons.” Specific medical conditions might also be higher CHS risk factors.
    • Glodosky “also found that those who reported using any amount of illegal cannabis were more likely to report experiencing CHS than those who use cannabis from only legal sources, where 76% of those who experienced CHS reported that they had used at least some cannabis from an illegal source.” He further speculated responses may show “legal cannabis is safer to use given that it's regulated and there's required testing for things like contaminants.”
    • Lastly, he’d investigated “individual effects of different types of cannabis products,” and found that “out of the nine product categories used by ICPS, the only ones that predicted increased likelihood of reporting CHS were more frequent use of vape oils and liquids, concentrates, and edibles.” This determination had been “consistent with other literature suggesting that manufactured cannabis products, and often those that have higher THC concentrations, may have higher risk relative to more traditional forms of cannabis, like flower.” Additionally, Glodosky pointed out there’d also been “a strong association between frequent use of concentrates and cannabis use disorder.”
  • Glodosky was prepared to draw some conclusions after his analysis of ICPS data for Washington (audio - 2m, video - WSLCB, video - TVW):
    • “CHS prevalence in Washington is similar to nationwide estimates.”
    • “Cannabis use frequency is commonly identified in the literature as a risk factor for CHS,” primarily “when it was the only predictor in the model.” However, “it was no longer significant” once more “variables were added to the model,” Goldosky said. This meant one’s sex and “use from illegal sources may play a more important role, or may co-occur with cannabis use frequency.”
    • Besides “some risk factors that are consistent with prior research…we also identified other more novel potential risk factors, including the use of cannabis from illegal sources, medical compared to non-medical use, and the use of certain types of cannabis products.”
    • However, the results “should be interpreted with caution as…they are based on self-report information, not medical diagnoses, and rates of CHS were low” in the ICPS sample.
    • “More research on the topic is needed."

• Acting Chair Jim Vollendroff asked about collaboration on the topic with regulators from other states, and whether he’d conducted outreach to interested parties in preparing the data brief.
  • Vollendroff wondered about the reception of his CHS findings by other state officials within the Cannabis Regulators Association (CANNRA), to which Glodosky replied that no one had reached out (audio - <1m, video - WSLCB, video - TVW).
    • During his presentation, Glodosky mentioned that he “recently presented these findings at the CANNRA medical cannabis subcommittee meeting” and was “seeing if there are other states interested in collaborating to see if these findings hold when broadening the sample or comparing between states.”
    • When Vollendroff asked whether there were “any other states that were interested in further collaboration or conversation around CHS,” Glodosky responded that “nobody's reached out yet.”
    • CANNRA’s annual member meeting was scheduled from December 2nd to 4th in San Diego.
  • Vollendroff was also curious if Glodosky had spoken with interested parties in Washington to inform his CHS research to “hear locally what we might be seeing in hospital emergency rooms or from others locally who are front line clinicians” (audio - 2m, video - WSLCB, video - TVW).
    • Glodosky replied that he had not; “I did reach out …to the Washington Poison…Center, but they don't specifically track cannabinoid hyperemesis syndrome.”
    • Vollendroff subsequently suggested that the WSLCB organize a panel discussion on the topic, hoping to hear “from individuals in our state who…either have been impacted themselves, clinicians or emergency room physicians, and maybe others that we can identify.” He argued that WSLCB could host “a panel of some kind to come and talk to us from a perspective of a clinician, family, policymaker, perhaps, or whatever makeup of the panel, I think would be super interesting.” Glodosky agreed, calling the work “very helpful.”

Information Set