A new trend in admissions of patients with persistent severe vomiting due to long-term use of cannabis is being witnessed at the hospital’s emergency department, clinical toxicologists have noted.

These patients would have been smoking multiple joints a day for at least a few months.

The flood of vomiting cases has been observed by toxicologists as cannabis admissions to Mater Dei’s emergency department have risen since the drug was liberalised, with Malta ranking the highest in Europe for the number of presentations for synthetic cannabinoids emergencies.

The specialists from the newly set-up Malta National Poisons Centre, who also advise doctors in drug and overdose cases, said the increase was to be expected, as was the case in other countries that liberalised cannabis.

Symptoms of cannabis admissions included psychosis, loss of consciousness, seizures, and vomiting.

The ‘new’ condition has had a name for years – Cannabis-induced hyperemesis syndrome.

“But the severe and persistent vomiting is very new to us,” said Dr Jeffrey Bonnici.

Bonnici and Dr Robert Chircop – two emergency consultants at Mater Dei – are also clinical toxicologists with the poisons centre.

“We have only seen this trend over the past year and even doctors may not be aware of it,” Bonnici said about his first-hand experience with the heightened condition.

'Only treatment is to stop use'

Drawing on his global experience as president-elect of the European Association of Poison Centres and Clinical Toxicologists (EAPCCT), Mark Lawrence Zammit said Malta was only now experiencing the increase in emergency admissions due to the sustained use of both natural and synthetic cannabis.

“Nothing else explains the severe and persistent vomiting,” the toxicologists said, adding that patients often did not make the association with cannabis use.

But when asked, they admitted they had been taking the drug consistently over sustained periods.

This did not, however, necessarily happen to all long-term users, they said.

“Sometimes, hot showers can alleviate the symptoms of nausea, but the only treatment is to stop the cannabis and/or synthetic cannabis use. Otherwise, the vomiting continues,” the toxicologists said.

These patients ended up at the emergency department because the usual medication for nausea and vomiting did not help them.

They said countries where cannabis was liberalised also showed an increase in emergency attendance due to cannabis-induced vomiting.

“It may not have been diagnosed in the past. But today, with more information, it is easier to make the association, especially when no other diagnosis is suspected,” Bonnici said.

Spate of synthetic drugs and lack of enforcement

The National Poisons Centre at the Malta Life Sciences Building, which deals with exposure to toxins, also offers advice on recreational drugs, and is facing major challenges with the spate of new synthetic substances on the market, and a lack of enforcement.

“The amount of novel psychoactive substances and recreational drugs in Malta and worldwide is proving very challenging,” Zammit said, explaining that these were constantly changing.

“We need to know what is on the market, their ingredients and how to counteract this with enforcement.”

Referring to ‘MDMA gummies’ recently in circulation, and subsequently recalled, he said it was already “embarrassing” that 3,4-Methylenedioxymethamphetamine – another name for ecstasy, which is illegal – was listed on the packet.

“And then you check the product and find a new unlabelled synthetic hallucinogenic as well.”

The severe and persistent vomiting is very new to us- Dr Jeffrey Bonnici

The ‘sweets’ would still have been illegal with MDMA on the packaging, but they were being sold as though “a piece of cake”, Zammit reiterated.

'Challenges are worldwide'

While acknowledging that the situation with novel synthetic drugs was mostly “reactive”, Zammit said “new and positive tools”, such as the Poisons Centre, showed that “at least we know there is a major issue here and that we are doing something about it".

The challenges are worldwide, he continued, referring to fentanyl and other new and potent substances like nitazenes in the US.

While there have not been cases of these drugs in Malta, “we have to be careful about these trends entering Europe”, he warned.

Zammit said that while heroin was on the decline in Malta, cocaine was “king”, and the novel cannabinoids were now socially acceptable.

“We are no longer dealing with the image of the homeless heroin junky; cocaine is taken by high-functioning people at the top of society.”

Zammit called for enforcement, stressing its importance and categorically stating there was not enough of it.

He also highlighted the need for education, encouraging people to call the new 1774 helpline, and tell doctors what they have taken and their symptoms.

Zammit, who was instrumental in setting up the long-overdue Poisons Centre and who designed guidelines on this for the World Health Organisation, said it was ultimately the police’s job to actively follow the developing market of synthetic drugs.

“If illegal substances are available on the market, they need to be stopped. If the cannabis law states that you cannot smoke in public, you cannot smoke in public. It may be difficult to enforce, but it needs to be done.”

‘We live in a chemical world’

Still in its infancy, more awareness about the 1774 helpline is required and the outreach needs to be stepped up, Zammit said.

The input of Mater Dei’s two emergency consultants, who are also clinical toxicologists with the Poisons Centre, allow for 24/7 coverage of the call service to healthcare professionals. It is otherwise available to the public from 8am to 8pm.

“But we want a comprehensive 24-hour coverage,” Zammit said, adding that, so far, the service receives regular calls from emergency, but not many from the public.

The Poisons Centre is seeing the trends, admissions, calls and what is prevalent to be able to intervene accordingly, he said, noting that, as yet, most referrals come from Emergency, and mainly involve inadvertent paediatric poisonings due to exposure to household chemicals.

“We know for sure that there is lots of exposure to various toxins, including medicines and chemicals, both intentional and unintentional,” Zammit said.

When cleaning the home, few people know that if they mix bleach with acid, they get pure chlorine gas, which is toxic, dangerous and can damage the lungs if inhaled, he pointed out.

“Things happen to people and they just keep on going, without seeking medical advice,” he said, insisting household products should be stored correctly.

“While we do not want to scaremonger, we live in a chemical world and are surrounded by this.

“The truth is everything is a poison; it depends on the dose,” Zammit continued, quoting Paracelsus, the father of toxicology.

“Something that can save your life, can harm someone else. Everything has to be taken in moderation.”