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For further information, see CMDT Part 38-42: Marijuana and Synthetic Cannabinoids

Key Features

  • The dried leaves and flowers of the Cannabis plant contain the psychoactive cannabinoid, delta-9-tetrahydrocannabinal (THC), which binds to endogenous cannabinoid receptors

  • Toxicity is dose dependent but varies significantly by individual, prior experience, and degree of tolerance

  • Synthetic cannabinoids ("Spice", "K2", "Black Mamba") are laboratory designed analogs of THC

  • Onset of symptoms after smoking is usually rapid (minutes) with a duration of effect of approximately 2 hours

  • Symptoms may be delayed after ingestion and can result in prolonged intoxication (up to 8 hours)

Clinical Findings

  • Mild intoxication may result in

    • Euphoria

    • Palpitations

    • Heightened sensory awareness

    • Altered time perception

    • Sedation

  • More severe intoxication may result in

    • Anxiety

    • Visual hallucinations

    • Acute paranoid psychosis

  • Physical findings include

    • Tachycardia

    • Orthostatic hypotension

    • Conjunctival injection

    • Incoordination

    • Slurred speech

    • Ataxia

  • Chronic heavy marijuana use is associated with the cannabinoid hyperemesis syndrome, which is characterized by

    • Recurrent nausea

    • Abdominal pain

    • Vomiting

  • Synthetic cannabinoids have become increasingly popular and are associated with a variety of adverse side effects including

    • Seizures

    • Kidney dysfunction

    • Serious neuropsychiatric symptoms

  • E-cigarette or vaping associated acute lung injury (EVALI) is a syndrome of diffuse lung injury associated with vaping THC adulterated with vitamin E acetate


  • Clinical history of marijuana use

  • Blood testing is available to detect presence of the psychoactive cannabinoid, delta-9-tetrahydrocannabinal (THC):

    • High levels indicate recent use

    • Low levels may persist for hours or days

  • Urine testing is available for non-psychoactive marijuana metabolites, most commonly, tetrahydrocannabinol carboxylic acid (THC-COOH): Urine test detection of THC-COOH varies from days to weeks after use, long after any psychoactive effect has passed

    • Actual detection times for THC-COOH in urine depends on marijuana dose (use), frequency of use, and individual metabolism

      • With single use, THC-COOH can typically be detected for ~3 days

      • With moderate use (4 times weekly), for ~5 days

      • With heavy (daily) use, for ~10 days

      • With long-term heavy use, for ~30 days


  • Consider activated charcoal

    • Dose: 60–100 g orally or via gastric tube, mixed in aqueous slurry, early after ingestion of large quantities

    • Do not use in comatose or convulsing patients unless the airway is protected

  • There is no specific antidote currently available

  • Treat anxiety and paranoia with simple reassurance and placement into a calming environment

  • Benzodiazepines such as lorazepam or diazepam may be used for more severe behavioral and psychomotor symptoms

  • Hypotension and sinus tachycardia should be treated with intravenous fluids

  • Topical capsaicin and haloperidol have been used with variable success for the treatment of acute vomiting in patients with cannabinoid hyperemesis syndrome

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