Picture this: You’re with friends in Colorado, and one of the first stops you make is at a dispensary. You pick up a pre-rolled joint and — feeling pretty confident — you take a few long drags. I used to do this all the time in high school, you think. And this is legal now, what could possibly go wrong?
A few minutes later, your heart starts pounding in your chest and ears. Your limbs are cold, your mind is absolutely racing, and for lack of a better phrase: You’re freaking the **** out.
Maybe you think you’re having a heart attack. Maybe you convince yourself that you’ve been poisoned (that would be the cannabis-induced paranoia talking). Something must be wrong, you tell yourself.
If this situation sounds familiar to you, you’re far from alone. In fact, cannabis-related emergency room (ER) visits in Colorado have increased steadily since the plant was legalized for recreational purposes in 2014, according to a recent study in the Annals of Internal Medicine. And as we further destigmatize the plant — and more people start experimenting with it — experiences like this could become even more common.
So how do you avoid a cannabis-related medical emergency? Here’s everything you need to know about cannabis-related emergency room visits and what, exactly, will happen if cannabis lands you in the local ER.
Judging from the media reports, you might imagine that the nation’s emergency rooms are crammed to capacity with severely-ill cannabis users. However, many experts disagree with this assessment.
“The most important point to make is that a lot of these visits are being overemphasized. They are not very common and they’re not that big of a deal,” says Dr. Andrew Monte, an ER doctor and associate professor of emergency medicine at the University of Colorado Medical Center.
Dr. Monte has published multiple studies on cannabis use, including one titled “Acute Illness Associated With Cannabis Use, by Route of Exposure.” He estimates that at this juncture, about two to three emergency department (ED) visits can be attributed to cannabis each day. “That’s out of 300 patients a day that we see in our ED,” he says, also making the point that the vast majority of those patients are relatively easily treated.
According to Dr. Ethan Russo, a board-certified neurologist and psychopharmacology researcher who has published dozens of studies about cannabis, many of the commonly-circulated stats on cannabis should be viewed with skepticism. Why? The people doing the counting are using shoddy methodology.
“The figures we use include ‘mentions’ of cannabis,” Dr. Russo says. That means someone could come to the ER for a different reason (ex. a sprained ankle), but be counted as a cannabis-related ER visit because a urine screen shows THC. “This makes a false impression,” he explains, pointing out that THC can stay in your system for as long as a month after you use it.
Neither expert denies that cannabis-related ER visits are on the rise or that there are conditions related to using too much cannabis, but they both urge us to zoom out and look at the big picture. “Any time a drug increases with availability, we see more ED visits associated with it. And I mean any type of drug, including blood pressure medicine,” says Dr. Monte.
Many cannabis-related ER visits are caused by overconsumption — and the misleading set of symptoms that come from being overserved THC. If you’ve taken too much cannabis, you probably want to know what the worst case scenario might be. In other words, can you overdose? Unlike opioids (which cause respiratory depression) and alcohol (which shuts down breathing, heart rate, and temperature control mechanisms in the body) there’s no direct toxicity with cannabis.
So, no, you cannot overdose on cannabis in the traditional sense of the word. In fact, “You can’t really say ‘overdose’ in relation to cannabis at all,” says Dr. Perry Solomon, M.D., a board-certified anesthesiologist and cannabis expert. “You can die from an overdose of opioids, but you can’t die from an overdose of cannabis,” he continues.
While this might be small consolation if you’re on the way to the hospital with a racing heart and a head full of paranoid thoughts, at least it’s good to know that the worst case scenario isn’t quite as bad as it could be.
All that said, there certainly are side effects associated with cannabis use. Symptoms like paranoia, anxiety, increased heart rate, memory impairment, temporary psychosis, and dry mouth all make the list. When it comes to ER visits, acute psychiatric symptoms, intoxication, and cardiovascular symptoms are some of the major culprits, according to an article published in Annals of Internal Medicine.
While none of these symptoms are directly life-threatening, they’re not nothing, either. Critics of legalization will argue that we’re too eager to brush the dangers of cannabis use under the rug. Even if you’re skeptical about that argument, it’s hard to know if these symptoms are no big deal or something we should all be concerned about. Here’s what top experts had to say about the negative side effects of cannabis that most commonly land people in the ER.
When it comes to plain old intoxication, there’s a lot of grey area. As Dr. Monte explains, “This group is very heterogeneous; cannabis may have contributed but they may also be drunk or used methamphetamines or another substance.” People in this group are treated on a case-by-case basis, and there’s really no way to know how much cannabis played a part in their ER visit.
In the instance of THC-induced anxiety or a panic attack, the patient’s previous experience with cannabis is a key factor. “Oftentimes, someone’s simply not used to cannabis,” says Dr. Solomon. Or maybe they’ve tried low-THC cannabis in the past, but now it’s 20 years later and the THC ratios and concentrations have increased. “If they smoke too much, they may experience an overly psychoactive effect where they’re panicking and hyperventilating,” Dr. Solomon says.
If you walk into an ER with these symptoms, your treatment would depend on the severity. “If someone is really agitated and a risk to themselves or others, we will sedate them,” says Dr. Monte. Most people in this condition have an elevated heart rate, so doctors would also do an EKG to rule out any cardiovascular complications. After that, Dr. Monte explains, they’ll observe you and if you’re improving, they’ll discharge you to a safe home with a safe friend.
As scary as this all might seem, most people who go to the ER for THC-induced anxiety and paranoia have no long-term consequences. As Dr. Russo says, the patient’s symptoms “can often be managed by talking them down, making them comfortable. And it resolves in a few hours.”
The next loose grouping of symptoms are psychiatric, culminating in something called acute toxic psychosis. While a little bit of anxiety or paranoia is common, this version is much more extreme. According to Dr. Russo, “[Excessive intoxication] starts out with anxiety, paranoia, and odd thoughts.” In most cases, that’s where it stops, too. But with toxic psychosis, “the person might become delusional, agitated, acutely paranoid. They often can’t be managed by the people around them and end up going to the hospital,” he says.
The potential volatility of people with acute toxic psychosis is worrisome for doctors. “This is the group that concerns me the most because it’s so unpredictable,” says Dr. Monte. To make things even more complicated, there’s no way to know who’s at risk or to what extent.
Often, medications end up being the answer to this problem. “Severe psychosis needs intervention. They get sedatives or antipsychotics to let things settle down,” Dr. Monte says.
Then, there’s cannabinoid hyperemesis syndrome (CHS), “a condition that leads to repeated and severe bouts of vomiting,” according to Cedars Sinai, a non-profit hospital system in southern California. Despite making a lot of headlines — including in the New York Times, which called it “A Perplexing Marijuana Side Effect Relieved By Hot Showers” — CHS is a rare condition that tends to occur in daily, long-term users of marijuana.
Dr. Monte believes this condition is both overdiagnosed and underdiagnosed. “In Colorado, we’re used to asking about cannabis use,” he says, which means a lot of people are diagnosed with CHS without considering the details of the case. As he points out, “Not all cases of vomiting plus cannabis use are CHS.”
Meanwhile, in states like South Carolina where cannabis is still illegal, it’s probably underdiagnosed because doctors aren’t asking about cannabis use and patients aren’t divulging that information either.
The good news is that this condition goes away when the person stops using cannabis. In fact, all of the side effects mentioned above are temporary, with their duration depending on the delivery method. According to Dr. Solomon, “with smoking, the symptoms will take effect immediately and last around 3 to 4 hours,” he says. But with edibles, “they can take 1.5 hours to even take effect and the effects can last 5 or 6 hours.”
Knowing this, it should come as no surprise to learn that edibles are responsible for a disproportionately large number of ER visits (and sensational media stories about incapacitated cannabis tourists). According to a study published in Annals of Internal Medicine, edibles accounted for 10.7 percent of cannabis-attributable visits between 2014 and 2016 but represented only 0.32 percent of total cannabis sales in Colorado during that same period.
This is most likely just because edibles last longer, says Dr. Monte. “With smoking, by the time you get to the ER, your symptoms might already be better.”
If you’ve read up on the possible side effects of cannabis use, it’s normal to want to prevent them by only taking small doses. Unfortunately, a “small amount” of cannabis means something different for each individual. It’s very difficult to predict how someone will react to cannabis. Why?
“No one knows,” says Dr. Solomon. “It has nothing to do with sex, age, weight, height, or any of the other parameters you might expert.”
This is what makes it so hard for physicians to give their patients direction, and why there are so many mishaps that land people in the ER.
“When I speak to healthcare professionals they want to know how many milligrams to suggest because they’re dealing with that type of medicine,” says Dr. Solomon. “But it’s just not like that.”
Dr. Russo has done a lot of investigating on the interpersonal variation in cannabis tolerance. He explains that, “It depends on things we can’t readily measure right now, like underlying endocannabinoid tone.”
Endocannabinoid tone is an abstract concept (for now, at least) that refers to the overall status of your endocannabinoid system, including the density of cannabinoid receptors and the enzymes involved in producing and metabolizing them.
Despite the confusion surrounding cannabis dosing, there are ways to greatly lower your risk of a negative reaction.
First, follow the rule “start low and go slow.” According to Dr. Solomon, that’s a lot easier to do with vaping or smoking flower than an edible.
“Take a hit and wait. You’ll know very quickly how you’re feeling. If that’s what you’re looking for, you’re done,” he says.
It’s worth mentioning that virtually all the negative side effects of cannabis use can be attributed to tetrahydrocannabinol (or THC), which is well-known as the main intoxicating compound in the cannabis plant. When you’re trying out cannabis, the THC content is what you’ll want to look out for. Dr. Solomon recommends starting with a dose as low as 2 or 3 miligrams and then slowly increasing until you get the effects you want.
Choosing products that have been lab-tested is also key. “Consistency in these products is a huge issue,” says Dr. Monte, referring to an article by the The Denver Post where they tested products that were supposed to contain 180 mg of THC but found that they actually had anywhere from 100 mg to 0 mg. “Just because someone thinks they got a specific dose, doesn’t mean they actually did,” he says.
In addition to being mindful of the delivery method, testing procedures, and THC level, it’s also important to be aware of the CBD content in the product. Using CBD and THC together appears to decrease adverse events.
For example, with Marinol, a drug composed of pure THC, psychosis has been seen with oral doses as low as 10 or 15 mg a day. But according to Dr. Russo, a study on the drug Sativex — which contains 48 mg of THC per dose, along with an equal amount of CBD — reported only 4 incidents of psychosis out of 250 total exposures.
If you’re new to cannabis, experts recommend starting with a full-plant extract or flower — which contain an array of cannabinoids and terpenes that increases the therapeutic window and decreases undesirable side effects — instead of dabs, shatter, or other delivery methods that involve highly concentrated, isolated compounds.
If you’ve gotten this far, you’re now an expert in the side effects of cannabis use and (hopefully) how to avoid them. But if you do find yourself in a situation where you’ve smoked, vaped, or otherwise consumed too much THC — what should you do?
According to Dr. Solomon, “CBD sometimes does modify the psychoactive effect of THC.” So if you have a CBD oil around, you can give that a try. Other than that, anything that helps you relax or calm down is worth a try. “Put on some relaxing music, talk to someone, and hang out in a quiet, dark room,” he says.
If those tips fail to manage your symptoms, don’t hesitate to go to the ER, even if you suspect it’ll lead to an embarrassing story later. “It’s not your job to figure out if you’re having an emergency. That’s my job as an ED physician,” says Dr. Monte.
As cannabis sheds its “Reefer Madness”-era reputation, we’re all learning more about how we’ve been misled about the risks of using it. Yes, there are side effects; but they’re pretty easily avoidable and all in all, cannabis is a much safer drug than alcohol, opioids, or nicotine — which kill 88,000, 17,000, and 480,000 Americans every year, respectively.
But that doesn’t mean taking too much is funny or completely harmless. As Dr. Russo explains, “It’s very scary, it can end up being expensive, and [in some states] it can get you in trouble with the law.”