The legalization of cannabis could be creating additional burdens on emergency nurses, according to the results of a recent investigation.1

An initial, qualitative study on the issue was prompted by requests from nurses to assess the effect of legalization on EDs, explains Lisa Wolf, PhD, RN, CEN, FAEN, director of the Institute for Emergency Nursing Research, a division of the Emergency Nursing Association. “This is a very preliminary look at what [legalization of cannabis] actually means to emergency nurses,” Wolf observes.

In focus groups, investigators collected information from 24 emergency nurses who provide care to patients either in states that have legalized cannabis or in states adjacent to those that have approved legalization.

“What participants talked about the most ... in terms of time, energy, emotional investment, and patient management was cannabis hyperemesis, the cyclic vomiting that comes from ingesting high levels of THC,” Wolf says. “What they described was otherwise young, reasonably healthy people who come in with intractable vomiting. The concern is that this is a repetitive presentation.”

For example, Wolf notes that when a nurse explains to patients that the cause of their vomiting is too much THC, it is not uncommon for them to reject that explanation. In fact, Wolf notes she has experienced this type of reaction herself.

“There is a disconnect between cause and effect. People are very resistant [to the message], so they keep coming back with this vomiting because [they insist] that cannabis can’t be the cause,” she shares.

Typically, such patients will insist on additional lab tests or imaging scans to determine what is really wrong with them, Wolf notes. “Managing that behavior and that disconnect was reported by study participants as the biggest change from having a larger number of people with access to cannabis,” she adds.

Study participants also reported an uptick in older patients who were presenting with stroke-like symptoms that actually turned out to be related to cannabis use, most commonly edible forms of the product.

“Our participants ... would activate all of these very high-risk protocols, not knowing that the problem is the result of an overdose of marijuana or cannabis,” Wolf reports. “People who are consuming edibles are giving [these products] to other people, and you see some things that look very serious coming into your ED.”

At the other end of the age spectrum, participants reported seeing increases in toxic ingestions of cannabis in the pediatric population. “Candies, gummies, chocolates, and brownies — kids just eat them, so a lot of [nurses] were reporting they saw some pretty serious effects in pediatric patients who had gotten into edible cannabis products,” Wolf says. “These are new [types of] presentations [such that] people needed to start asking about toxic ingestions right off the bat.” Another problem participants recounted to investigators was that many patients who presented with concerning symptoms would not disclose their cannabis use. Often, this would lead to comprehensive workups that would have been unnecessary had the clinicians been able to properly link the patients’ symptoms to their cannabis use.

“One participant told us about an older woman who was brought in with what [clinicians] thought was a stroke. Then, the woman’s daughter came running in, asking her if she told the clinicians that she had been given edibles,” Wolf relates. “People are of varying transparency on this issue.”

Investigators noted one of their most unexpected discoveries was that some EDs, particularly in early-adopter states, were filling up with cannabis tourists. “[Study participants] reported that they would get young, college-aged people ... who would show up and just kind of hang around,” Wolf shares. “The participants noted that their homeless regulars were being displaced because these younger folks were crowding them out of shelters and away from social services.”

Another problem investigators discovered was that neither healthcare providers nor patients tend to understand what types of cannabis products are available in their regions, or what the dosing or amount of THC is in many of the available products.

“This is where the public health piece of this comes in,” Wolf says. “Communities or states in which [cannabis] is now legal need to understand what the strength of it is ... and whether or how it interacts with other medicines a patient may be taking. It has got to be treated as a pharmacologically active substance.”

This study is just the first step in a longer-term investigation. Next, researchers intend to examine the issue from a more quantitative standpoint. Wolf reports that they intend to use the information they have developed so far to create a survey that can then be deployed in all 50 states to collect additional information about the effect of cannabis use on EDs and emergency nurses in particular.


  1. Wolf LA, Perhats C, Clark PR, et al. The perceived impact of legalized cannabis on nursing workload in adult and pediatric emergency department visits: A qualitative exploratory study. Public Health Nurs 2019; Aug 26. doi: 10.1111/phn.12653. [Epub ahead of print].