First Opinion is STAT’s platform for interesting, illuminating, and provocative articles about the life sciences writ large, written by biotech insiders, health care workers, researchers, and others.
To encourage robust, good-faith discussion about issues raised in First Opinion essays, STAT publishes selected Letters to the Editor received in response to them. You can submit a Letter to the Editor here, or find the submission form at the end of any First Opinion essay.
The story
“ER docs are too quick to assume cannabis users are experiencing this rare side effect,” by Jordan Tishler
The response
Association of Cannabinoid Specialists’ president Jordan Tishler argues that cannabinoid hyperemesis syndrome, or CHS, is being “dangerously” over-diagnosed in Massachusetts emergency rooms. Unfortunately, his conclusion is based on anecdotal reports and his own informal polling of his colleagues — not any hard data or statistics.
I’m a practicing gastroenterologist and a CHS researcher, and our group’s epidemiological work shows the opposite. Following our analysis of Massachusetts emergency rooms between 2012 and 2021 (more than 15 million visits), we found cases of CHS skyrocketed by more than 1,350%. In our study, published in the American Journal of Gastroenterology on June 13, we were careful to only count CHS diagnoses after ruling out other causes of nausea and vomiting that might have otherwise confounded the diagnosis.
Concerningly, the increase in CHS cases was largest in younger adults between 18 and 34, a population often the most vulnerable to marketing and at the highest risk of developing substance addiction. Furthermore, the rising concentrations and potency of tetrahydrocannabinol — the active ingredient THC in cannabis — parallels the increased risk of emergency room visits for CHS.
Our work supports Tishler’s assertion that CHS has led to rising costs that have overburdened an already straining health care system, with my own hospital spending 150% more on CHS-related hospitalizations following cannabis legalization.
However, we found that these costs are due to our health care team performing X-rays, CT scans, and endoscopies, among other studies, to rule out alternative conditions, before reaching a CHS diagnosis. Other health care systems have cited similar trends in the high costs attributed to diagnosing CHS.
Our state and health care system need to do a better job of diagnosing and supporting people with cannabis-related diseases. We need a national billing code for CHS to better understand its prevalence. Medical systems need to train clinicians in how to sensitively ask questions about cannabis use, and learn how to engage people in a nonjudgmental way. In Massachusetts, we need money set aside from the record-breaking $1.64 billion in gross cannabis sales last year ($272 million in Massachusetts tax revenue in 2024) to fund research to better understand both good and bad effects of wide public consumption of cannabis.
As cannabis use accelerates, we need to sensitively address how to better recognize and treat CHS — a condition that we’ve shown to be rising in prevalence. Denying or ignoring that CHS cases are increasing is not the solution.
— Sushrut Jangi, M.D., gastroenterologist at Tufts Medical Center and assistant professor at Tufts University School of Medicine.
The response
A specialist in London, Ontario, strongly suggested that my morning nausea and throwing up was CHS. Even though I told him that my symptoms were only in the morning and once I purged I felt better, he stopped listening to me. I’d never had to have a hot bath to relieve my nausea. I still smoke marijuana to this day, and whatever had been happening in the mornings stopped. This doctor made me feel defensive because I could tell he’d made up his mind. Very frustrating experience for me.
— Linda Hay
The response
As a recently retired emergency department physician, I find that this article does indeed raise a valid point about anchoring. There are many patients whose appearance, frequent visits, history of drug or alcohol abuse, or something else trigger an anchoring response among us. We as ED providers must be very careful about recognizing and overcoming our biases.
However, extensively working every patient up who uses marijuana and presents with nausea and vomiting raises other critical issues. SMA syndrome is very, very rare — cannabis hyperemesis syndrome is not. Should abdominal CTs be ordered on each and every patient suspected of having hyperemesis cannabis? This would lead to unnecessary radiation, excessive cost, incidental findings which in turn could provoke anxiety and cause unnecessary work up. The vast majority of such cases do not require CT scans.
Furthermore, CT scans, especially in younger patients, increase lifetime risk of cancer. If a small nodule, which is often found on CT, is noted, then further work-up with periodic CTs may be indicated, even though the risk of that nodule developing the cancer is very small. I have witnessed colleagues who, at some point in their ED career, missed a rare condition and then subsequently in every similar case ordered extensive, unnecessary labs and CTs. In conclusion, neither anchoring nor looking for “zebras” (medical jargon for rare conditions) in each and every case is a good medical practice.
— Rick Tietz
The story
“PhRMA CEO: ‘Most-favored nation’ policy isn’t the way to lower drug prices,” by Stephen J. Ubl
The response
Big Pharma is doing what it does best: defending its profits by misrepresenting the facts. PhRMA CEO Stephen J. Ubl’s arguments in his recent op-ed against President Trump’s most-favored nation (MFN) executive order distorts the reality of the United States’ sky-high drug prices. Here’s the truth: Trump’s MFN executive order takes a critical first step in tackling high drug prices by tying American drug prices to the lowest price in other comparable countries. The Trump administration rightly points out that the United States represents less than 5% of the world’s population but funds around three-quarters of global pharmaceutical profits.
And that’s no accident. Big Pharma charges Americans over three times more than other wealthy countries for the same drugs and is not doing anything to comply with the Trump administration’s EO — despite the fact that 78% of American voters support its efforts to lower American drug prices in line with those abroad. Instead, drug manufacturers have focused on exporting their influence abroad to raise prices in Europe — a tactic to avoid dropping drug prices for Americans.
The facts are clear: Big Pharma prioritizes its profits ahead of Americans’ interests. The industry has deployed an arsenal of direct-to-consumer advertisements and anti-competitive tactics to hide the truth from its role in skyrocketing drug prices, while spreading fears that innovation will slow if prices decrease. We know this is simply untrue, as a recent assessment of the 10 largest pharmaceutical companies found that they spent $36 billion more on advertising drugs than on R&D in one year.
What’s more, Big Pharma routinely exploits the U.S. patent system to block cheaper, generic alternatives from entering the market. Thankfully, lawmakers have introduced legislation to encourage more generic competitors to enter the market.
The American people recognize Big Pharma’s playbook and are supportive of President Trump’s efforts to give Americans a better deal. A recent national survey found that 85% of American voters support broader “America First” pharmaceutical reforms.
The Trump administration and lawmakers have taken crucial first steps, but they need to follow through on these commonsense reforms to ensure that Big Pharma stops its profiteering off American patients.
— J.D. Hayworth, spokesperson for the Pharmaceutical Reform Alliance and representative for Arizona in the U.S. House of Representatives from 1995-2007
The story
“The U.S. must invest in mRNA vaccines against pandemic influenza viruses now,” by Steve Osofsky
The response
Steve Osofsky notes that Operation Warp Speed saved lives not only in the United States, but around the world. Living in Canada, I benefitted from prompt access to Covid vaccines made by Moderna and Pfizer. The willful ignorance of the current administration similarly puts at risk not just the lives of citizens and residents of the United States, but the peoples of the world. There is no doubt that Canada and many other countries have been freeloading on military preparedness. But the decision to cancel contracts with Moderna by the wealthiest country in the world reveals a set of values that lack a moral foundation.
— John G. Hollins, Ph.D.
