Addiction Medicine Made Easy | Fighting back against addiction

Hot Showers and Horror Stories: Scromiting and Cannabinoid Hyperemesis Syndrome

• Casey Grover, MD, FACEP, FASAM

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Cannabinoid Hyperemesis Syndrome (CHS), also known as "scromiting," is a debilitating condition characterized by severe nausea, vomiting, and abdominal pain that affects heavy cannabis users. Dr. Casey Grover explains this increasingly common syndrome caused by high-potency cannabis products, which paradoxically improves with hot showers and proves challenging to treat with conventional medications.

• First identified in 2009 and named "scromiting" to reflect the combined screaming and vomiting patients experience
• Cannabis potency has increased dramatically from 1% THC in the 1970s to 25-30% THC in today's products
• Patients experience cyclical episodes of diffuse abdominal pain, nausea, and vomiting lasting 24-48 hours
• Compulsive hot bathing is a hallmark symptom, with patients focusing hot water on their abdomen for relief
• Standard anti-nausea medications like Zofran don't work well; psychiatric medications like Haldol often provide better relief
• Many patients question the diagnosis because cannabis is thought to help nausea rather than cause it
• Treatment requires cannabis cessation, though symptoms may persist for months after quitting
• Multiple theories explain CHS, including nerve hypersensitivity and paradoxical stress responses from high-dose THC

To contact Dr. Grover: ammadeeasy@fastmail.com

Speaker 1:

Welcome to the Addiction Medicine Made Easy Podcast. Hey there, I'm Dr Casey Grover, an addiction medicine doctor based on California's Central Coast. For 14 years I worked in the emergency department, seeing countless patients struggling with addiction. Now I'm on the other side of the fight, helping people rebuild their lives when drugs and alcohol take control. Thanks for tuning in. Let's get started.

Speaker 1:

Today we are going to be continuing our discussion about the hazards of cannabis use. Last week, we took a look at cannabis overdose. This week, we're going to be looking at a syndrome that develops as a consequence of heavy cannabis use, and that syndrome is cannabinoid hyperemesis syndrome. Some people refer to it as scrometing syndrome. Some people refer to it as scrometing. I recorded myself giving a lecture on this topic to my colleagues at the drug and alcohol treatment program I work at, and I wanted to share this lecture with all of you. So with that, grab your barf bucket and let's get started.

Speaker 1:

Okay, we're going to discuss cannabinoid hyperemesis syndrome and I was going to give you some of the history. So this condition was first identified in 2009, and we really didn't know what it was. People had reported this syndrome of recurrent vomiting and cannabis use and compulsive bathing, and we weren't really sure what it was, and we weren't really sure what it was and I graduated medical school in 2010. And really in the first few years of my training, 2010 to 2013, we didn't know much about addiction and it was really in the mid-2010s that we started to really start tackling addiction as doctors, and particularly doctors in the emergency department and in the hospitals, doctors, and particularly doctors in the emergency department and in the hospitals. And so the lovely, lovely Dr Close, who happens to be my bride, she started working in Monterey County on trying to address addiction at the hospitals and in the emergency department and we met who you can see on the screen here, dr Ranit Lev, and Ranit is an ER doc like us, and she was working in San Diego while we were working in Monterey on trying to address addiction treatment in the emergency department. So we started by working on opioids and we started to identify more of this syndrome cannabinoid hyperemesis syndrome and she was working on treatment guidelines and trying to come up with a way to help these patients. And we were on a meeting and we were talking about it and I had just read a magazine article written by a physician just reflecting on some recent cases that he had seen and he heard a staff member say that patient isn't just vomiting, they're scrommeting, because they were screaming and vomiting at the same time. And so Ranit and Reb and myself were just brainstorming on how to help some of these patients and Ranit said scrommeting, that's genius. That's exactly what this syndrome is. And she ran with it and you can see here on the screen this is a picture of her on the news announcing her efforts in San Diego County to try to treat addiction.

Speaker 1:

And Ranit is much more well-connected than we are. She served in the White House as an advisor on drug policy. She's written articles, she's been on the news getting the word out that there's this really bad syndrome that happens when people smoke too much cannabis, where they get this horrible syndrome of nausea and vomiting and abdominal pain called cannabinoid hyperemesis syndrome, and she popularized this term scrommeting to reflect just how miserable patients with cannabinoid hyperemesis syndrome are. So now, if you google the term scrommeting, it's a thing. So I googled the term scrommeting when I was preparing for this lecture and I'm going to read here Some people call symptoms of cannabinoid hyperemesis syndrome scrommeting.

Speaker 1:

The term combines vomiting and screaming. You may have intense pain which causes you to scream while you vomit. And here you go. This is another graphic from a recovery website scrommeting hazards of cannabis use. Here's another one from another recovery website scrommeting and symptoms of heavy marijuana use. And here is even a visual graphic of this syndrome where someone is vomiting and bathing and they're using cannabis. So this is definitely a syndrome that is well known in the recovery community and we certainly see it all the time in the emergency department.

Speaker 1:

So what is cannabinoid hyperemesis syndrome? The name itself basically says hyperemesis, meaning a lot of vomiting from cannabis, and it's a syndrome, and essentially we see two things. We see gastrointestinal symptoms, usually nausea, vomiting and abdominal pain when people use cannabis heavily. And, very interestingly, symptoms are improved with hot baths or showers, leading to compulsive bathing, and I'll actually take you through a case that we saw in our emergency department where one person was bathing compulsively in the hospital. But this is really what we see these two features.

Speaker 1:

Now why does this happen? Well, on the screen here in front of you, I have a graphic that's pointing out the potency of cannabis over the last 50 years. So cannabis in the 1970s was only 1% THC. Again, thc is the drug in cannabis that makes people high and humans like THC. So through farming technology, we've bred stronger strains of cannabis with stronger strains of cannabis to help the cannabis get stronger over time. So you can see, in 1970, the cannabis was 1% THC. By the 2000s it was about 4% THC. By 2010, it was 10% THC and as of 2022, cannabis was 18 to 20% THC and as of 2025, it's really around 25% to 30% THC. So why is this happening? As the cannabis has gotten stronger, it's behaving differently. And the best way to think about it if you were to compare it to alcohol if you smoke a joint today, it's maybe 30 times stronger than it was in 1970. That would be the equivalent, in terms of alcohol, of drinking a beer today. That has as much alcohol as 30 beers back in 1970. It's just so much stronger and so you get very different effects when you consume the same quantity of substance.

Speaker 1:

Now I wanted to see what this looked like, so I went to a cannabis dispensary in Seaside in the fall and I just wanted to see what people were buying. So here's a cannabis product. You can see that it contains 28% THC, and they are now even adding THC back into the joints to make them even stronger. So these are THC-infused joints. You can see one product is 43% THC and the other is 40% THC, so this is an incredibly strong cannabis product. Now, if you didn't know, we don't actually know the recreational dose of THC. We think it's somewhere between about two and a half and 15 milligrams. As in, if someone went to a dispensary and said I'd like to buy a single serving of cannabis, the dispensary would sell them somewhere between 2.5 and 15 milligrams of THC. Take a look at the cannabis product up in the upper right. Those four joints have 864 milligrams of THC in them. So that package of four joints has several hundred times the recreational dose of THC. So what we're just seeing is the amount of THC that's being sold is just off the charts.

Speaker 1:

Now, as doctors, we are trying to understand why this syndrome happens and what do we do about it. So this was a great scientific paper published in 2018, and it was really the best study at the time. And you can see cannabinoid hyperemesis syndrome public health implications and novel model treatment guideline. And Novel Model Treatment Guideline. And I put a red mark because, if you remember, at the beginning of the lecture, I referenced our colleague in San Diego, dr Rani Lev. There you go, that is. She was one of the authors on this paper. She was definitely really trying to help physicians across the state understand what to do with this condition and in this paper they outline what do people experience and recommend treatment protocols that we can use.

Speaker 1:

So when people experience this syndrome, what do they feel? They usually have diffuse abdominal pain, meaning the whole abdomen hurts. We see it much more commonly, believe it or not, when cannabis is smoked. At the time that this paper was published, we did not really see it with edibles I don't know if that's still true and people might be asymptomatic, meaning they have no symptoms for days or even weeks, and then they'll get a random flare-up of nausea, vomiting and abdominal pain, and these flares usually last 24 to 48 hours. But there are definitely cases where people are not able to keep things down and have symptoms for over a week. And again, there's this very interesting feature where people will bathe compulsively for hours at a time. Usually it's a hot bath or shower with the stomach under the hot surface of the water or with the shower head the hot surface of the water or with the shower head actually focused on the abdomen. We see it in the emergency department, right, people come in, they're in pain, they're vomiting, they can't keep down fluids. That's why we have emergency departments.

Speaker 1:

What's very unfortunate about this syndrome is our normal nausea meds. These are called anti-emetics. Our normal nausea medicines don't really work. So if any of you have been treated with ondansetron, also known as Zofran, or given it to a client, it doesn't really work and this is one of the things that makes it very frustrating for us as doctors to treat and very frustrating for patients, because we really don't have a lot of medications that work, believe it or not. We have found that strong psychiatric medication seems to help. If any of you have worked with mental health patients.

Speaker 1:

We use haloperidol, also known as Haldol, to sedate people when they're psychotic and hallucinating and agitated, believe it or not, haloperidol works for cannabinoid hyperemesis syndrome. You might also recognize the name olanzapine, also known as Zyprexa, as something that we use for when someone's got mania from bipolar or psychosis from schizophrenia. We sedate them with it and that's what we end up using for patients with cannabinoid hyperemesis syndrome. They tend to be very dehydrated from all the vomiting, so we give them IV fluids and their body just needs time. It's really frustrating for patients and providers alike, and I show you a picture here that I found on Google of a frustrated physician. This is how emergency department staff feel about cannabinoid hyperemesis syndrome. It's very difficult to treat. Patients are completely miserable. It's very, very frustrating. Now let's say somebody comes into the emergency department and they're miserable, they're vomiting, they're screaming out in pain and we actually get them better and send them home.

Speaker 1:

How do we treat this? Well, as you can imagine, if the cannabis is causing it, the treatment is to stop using cannabis, and what's frustrating is that symptoms actually can persist for months after patients stop using cannabis. So here's how this looks Somebody stops using cannabis. They maybe don't use cannabis for four to six weeks and they don't feel better. They have more recurrent episodes. So they're like, hey, the doctor was wrong and they go back to using cannabis Again. Fairly frustrating to treat, both short-term and long-term, just because patients really need to be cannabis-free for a long time and a lot of them, because of, maybe, cannabis use disorder, they can't stop, or they just feel like the doctors were wrong and it wasn't the cannabis, so they go back to it and then the cycle restarts.

Speaker 1:

We do have some medications for cannabinoid hyperemesis syndrome that can be helpful. There is an antidepressant called amitriptyline. It's in the class of antidepressants known as tricyclic antidepressants. We use it a lot in chronic pain. It changes the way that the nerves function that's actually how it helps with depression so it can sometimes reset the nerves around pain or migraines. So we often try it and there is some evidence that amitriptyline helps the nerve changes related to heavy cannabis use go back to normal sooner.

Speaker 1:

People often have a lot of acid in the stomach when they are having these episodes of nausea and vomiting, so I use acid-reducing medications. You might know omeprazole. That's over-the-counter. My personal preference is pantoprazole, which is very similar. It just works a little bit better. It's a prescription that one's called Protonix, and then if someone's on cannabis and trying to stop, there's really not good literature on how to treat cannabis withdrawal. There are some small studies that show that gabapentin can be helpful to treat cannabis withdrawal, so I often use that.

Speaker 1:

Some people really cannot give up cannabis. Cannabis use disorder used to be fairly uncommon. I was always taught growing up that cannabis wasn't addictive. That may or may not have been true, but what I can tell you is, in 2025, cannabis use disorder is a legitimate diagnosis and there are people who cannot stop using cannabis, despite consequences. If someone absolutely says I cannot stop using cannabis, despite consequences, if someone absolutely says I cannot stop using cannabis, then you could recommend that they switch to edibles, as there's maybe some evidence that cannabinoid hyperemesis syndrome is less common with edibles as compared to when cannabis is smoked, and I'm not sure why that happens. Maybe that's because people were using less when they were using edibles. The edible industry has really followed the rest of the cannabis industry in that there are very high potency products out there, so hard to know. Okay, so I've talked to you about how doctors and healthcare providers feel about cannabinoid hyperemesis syndrome. What do patients think about cannabinoid hyperemesis syndrome? And I love this scientific paper. It's one of my favorites. Pardon the expletive, but this is the actual title of the paper in the National Library of Medicine. I still partly think this is bullshit.

Speaker 1:

A quantitative analysis of cannabinoid hyperemesis syndrome perceptions among people with chronic cannabis use and cyclic vomiting. They literally sat down with people and interviewed them once they were diagnosed with cannabinoid hyperemesis syndrome to see what they thought. Here's what they found. A lot of the people who were diagnosed with this syndrome were very convinced that it was not the cannabis, because symptoms came on randomly. In other words, they couldn't correlate any particular cannabis behavior with symptoms. So they thought, well, shoot, it must not be the cannabis, because I can't come up with a link.

Speaker 1:

Most of the people in the study related an experience that someone came to them and said you know, hey, it's the cannabis, you got to stop. But no one really explained it to them. So they questioned the diagnosis. And then the last two points I thought were very profound. People told them that the cannabis was the cause of their symptoms, but no one actually told them how to stop. So a lot of them weren't really sure what to do. What if I can't sleep? Do I wean myself off of it? Do I need to go get counseling? So that's one thing, is that we can do. Better is, when someone has this is to tell them yeah, let's actually get you some help on how to stop cannabis. And then the other thing is no one asked the people who used cannabis what they were using cannabis for. Were they anxious? Were they having insomnia? Was it pain, so that they could actually address the issue that was making them use cannabis. So I think in my mind you know, if somebody has this and I ask them why they're using cannabis and they say, well, hey, I'm using Indica to sleep, my response would be well, shoot, let's put you on a non-addictive sleeping med and see if we can get you off the cannabis. So we really have to set patients up to succeed when it comes to quitting cannabis.

Speaker 1:

So the next question is why do we have this syndrome, cannabinoid hyperemesis syndrome? What's the cause? What's the reason? Well, the answer is we don't really know and there's a couple of theories. One theory is that cannabis is active in the brain and nervous system and heavy cannabis use changes how the nerves function and it creates some hypersensitivity in the nerves in the gut. Hard to know if that's what's going on. This hypothesis here makes a little bit more sense to me. So nausea and vomiting is a stress response in the body. Like we see it, when someone's in really bad pain, they might vomit, or when people exercise really hard, they might vomit. In other words, nausea and vomiting is one of the ways that the body responds when it's under stress. Interestingly, low-dose cannabis acts like a downer. It lowers the stress response and that can explain why cannabis has often been used to help people with nausea and vomiting, like if they have AIDS or if they have cancer, and that's actually another reason why a lot of patients who have this syndrome don't believe it is.

Speaker 1:

Cannabis is known to help with nausea and vomiting. What's interesting is that as the cannabis potency has increased and people are using higher doses of cannabis, the intoxicating effects of high-dose THC have a paradoxical stimulating effect. It's almost like an upper, and we see this when people consume a lot of THC. They sometimes get really paranoid, and so the thought is that high-dose THC actually is a stress response on the body which brings out the nausea and vomiting and get this. This is really interesting. When we are under stress, the body needs to mobilize as much energy as possible to be able to do our fight or flight response right. If a lion jumps through my window and I have to basically run for my life or fight back, I need every bit of energy I can so my muscles can function, and so when the body is stressed, it starts breaking down fat tissue for energy, and you may know that THC deposits in our fat tissue. So when we start to get in this stress response, the body breaks down fatty tissue that's called lipolysis and it actually releases some of the stored THC in the fatty tissue, which brings the levels of THC in the body up and actually worsens the stress response and leads to more nausea and vomiting. I thought that was pretty interesting. And vomiting, I thought that was pretty interesting. So still trying to work out the details.

Speaker 1:

There's one other hypothesis as to why this happens, which is that as cannabis has gotten stronger, there's now a withdrawal syndrome. So traditionally, when cannabis was weak, we didn't really think of cannabis withdrawal. But take a look, this is a graphic from the Cleveland Clinic, which is a very respected hospital system in America. And here you go Marijuana withdrawal. The most common symptoms include decreased appetite, nausea and vomiting and abdominal pain. So there's probably a component of some cannabis withdrawal that underlies this cannabinoid hyperemesis syndrome. People will say that sometimes smoking cannabis makes them feel better while they're experiencing the syndrome symptoms. It's a little bit all over the place, but what we do know is that it's very clearly present. We see quite a bit of it and, again, my hypothesis is that there's probably some cannabis withdrawal that factors into this syndrome as well. So let's go through a clinical case and we can actually talk through what this looks like when people come into the emergency department and then actually a symptoms resolve.

Speaker 1:

So we had a 28-year-old female who was presenting to our emergency department in Monterey over about 18 months with multiple episodes of abdominal pain, nausea and vomiting. And the way this works as a doctor in the ER or in the hospital is you assume the worst case scenario right? Is it appendicitis? Is it a kidney stone? Is it the gallbladder? Is it stomach flu? So every time this patient would come in we had to evaluate what is this. So we did CAT scans, we did ultrasounds, we did blood work, urine testing, we did all sorts of tests and they would all come back that they couldn't find anything. And so she provided a history of heavy cannabis use, recurrent nausea, vomiting and abdominal pain and compulsive bathing and all her tests came back negative. So we were able to tell her this is cannabinoid hyperemesis syndrome and the patient was just absolutely not. You guys are totally wrong. Cannabis is fine, cannabis is great, I'm going to keep using.

Speaker 1:

And she just kept coming back to the hospital with flares of these symptoms. A lot of times it's hard to treat the symptoms. Like I mentioned, a lot of our usual medications don't work that well. So on one occasion we admitted her to the observation unit and she wanted to bathe because that was soothing to her and she showered for so long that she actually used up all of the hot water in one area of the hospital, which was very disruptive to care elsewhere in the hospital, of the hospital, which was very disruptive to care elsewhere in the hospital. And we actually had to put a policy for the ER that she wasn't allowed to bathe if she was at the hospital because she used up the hot water and other patients needed it and obviously she wasn't happy, which I totally get. And I've sometimes wondered why patients come to the ER because they can bathe at home and they're much more comfortable there. And what I can tell is they seem to just overwhelm the ability to have hot water soothe them and they get too dehydrated. So they come in. But I've had a number of patients over the years that are just like doc, I understand you guys are trying, but I'm just going to go home and get in the shower and I'll feel better and I have to respect that. We're just wanting to feel better. So just to give you a sense of how bad people feel when they have this syndrome.

Speaker 1:

This particular patient came back to the emergency department again. I actually took care of her and we started an IV and we gave her some fluids and we started some medicine and she said I need to take a shower. And I said I'm really sorry, we can't. You showered so much last time that you used up water in another area of the hospital and the hospital told us no. And she was completely miserable, still very nauseated, and she said well, I have to bathe. I feel horrible and poor thing. She started bargaining with me like, well, what circumstances could a patient bathe under? And I was saying well, you know, if a patient is contaminated with pesticide, we have to bathe them. And she was asking me can you lie? Can you tell the charge nurse that I was contaminated with pesticides? And I just was like no, no, I can't lie. And I felt horrible because she was completely miserable and she ended up actually leaving that day to go home and bathe.

Speaker 1:

She was so uncomfortable and our medications weren't helping and also, as a part of what she was going through, she was really really anxious during these episodes and she couldn't be left alone and she would ask her nurse to stay with her and talk to her and you know the nurses have three other patients and it just it was. It was a really difficult scenario for everyone. She was very uncomfortable and very anxious. We were trying to attend to her but we had limitations on her ability to bathe and staff's time to be with her and it was just. It was really hard for about 18 months when she would come in and one day we just noticed that she hadn't been seeing us for a while and so I was working in the ER about 18 months later and she was visiting another patient who was sick and she recognized me and said hey, dr Grover, can I talk to you? And I said sure, and she walked out into the hallway, into a quiet area with me and she said I just really want to thank you. I finally realized it was the cannabis and I got some help and I quit and all my symptoms went away and I wanted to thank you and the ER staff for taking care of me so many times. And I didn't actually ask her how she had gotten treatment, but I know she had gotten into therapy to work on her anxiety and she was able to get back to work and find some purpose and it ended up having actually a good ending after all. But good heavens, she was miserable for those 18 months.

Speaker 1:

So you might be asking why the term scrommeting? You probably get it. People are really uncomfortable. There's actually a little bit more to the story. So, having taken care of dozens and dozens of patients with this syndrome, what actually I observe is they have really intense nausea and pain, more than vomiting. In other words, people feel I'm really nauseated. Maybe if I would vomit I would feel better, but they can't get anything out. Usually they're sitting bolt upright and they're sweaty and they're holding a vomit bucket and they're just putting it close to their face, hoping the vomit will come out, and nothing's coming up. And sometimes patients will put their fingers down their throat that they just want to feel better. They're completely miserable and the best way I can say it is it's this anguished yell, scream, groan, moan, just hoping that if they yell loud enough, the vomit will come out. And it's really unfortunate. You'll walk into the emergency department and you hear this very particular noise and you're like oh, room seven has cannabinoid hyperemesis syndrome. It's this deep guttural just hoping, hoping that vomit will come out. And yeah, people would tell me that cannabis wasn't addictive and I would tell them come work a shift with me. In the emergency department I see patients with cannabinoid hyperemesis syndrome. They are completely miserable and their addiction to cannabis is strong enough that, despite this, they will not stop. Okay, so let's put it all together.

Speaker 1:

Cannabinoid hyperemesis syndrome involves recurrent abdominal pain, nausea and vomiting, as I mentioned, more pain and nausea and it comes from recurrent cannabis use. We only make the diagnosis after we've ruled out other and more serious causes. People will bathe compulsively to try to relieve their symptoms. The treatment is we stop cannabis and we have to help them stop cannabis. So they may have withdrawal. We have to manage that. They likely need to get into some counseling, get into groups, because we want to address the issues that were leading them to cannabis in the first place. And then we want to try to address things like insomnia, anxiety and pain that lead to cannabis use. And then there are some medications specifically for cannabinoid hyperemesis syndrome that will allow people to feel better faster and then, truly, people really are committed that, hey, cannabis works for me. I think it's a medicine. No, I don't think cannabis is the problem. People are often reluctant to believe that cannabis is the cause.

Speaker 1:

Before we wrap up, a huge thank you to the Montage Health Foundation for backing my mission to create fun, engaging education on addiction, and a shout out to the nonprofit Central Coast Overdose Prevention for teaming up with me on this podcast. Our partnership helps me get the word out about how to treat addiction and prevent overdoses To those healthcare providers out there treating patients with addiction. You're doing life-saving work and thank you for what you do For everyone else tuning in. Thank you for taking the time to learn. Everyone else tuning in. Thank you for taking the time to learn about addiction. It's a fight we cannot win without awareness and action. There's still so much we can do to improve how addiction is treated. Together we can make it happen. Thanks for listening and remember treating addiction saves lives.