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Hashish (Cannabis) Intoxication - Toxicology Department Management
Hashish is a concentrated cannabis resin containing high levels of delta-9-tetrahydrocannabinol (THC). Management in the toxicology/emergency department is primarily supportive - there is no specific antidote.
1. Clinical Presentation (Recognize Before Treating)
CNS/Behavioral signs (within 20-30 min of smoking; up to 1-2 hrs after oral ingestion):
- Euphoria, anxiety, panic, paranoia
- Impaired motor coordination and judgment
- Sensation of slowed time
- Social withdrawal
- In severe cases: hallucinations, acute psychosis
Autonomic/Physical signs (within 2 hours):
- Conjunctival injection (red eyes)
- Tachycardia
- Dry mouth
- Increased appetite
- Possible hypertension
Duration: Smoked/vaped effects last 2-3 hours; oral/edible ingestion can persist 6-10 hours due to slower absorption and hepatic conversion to 11-OH-THC (more potent).
2. Initial Assessment
- Secure IV access; monitor vitals (BP, HR, SpO2, temperature, ECG)
- Blood glucose (hypoglycemia can mimic intoxication)
- Urine/serum toxicology screen - rule out polysubstance use (alcohol, opioids, stimulants, synthetic cannabinoids)
- Note: Standard urine screens detect THC-COOH (metabolite) but do not detect synthetic cannabinoids (K2/Spice) - these require specific testing
3. Non-Pharmacological Measures (First-Line)
These should be tried before any medication:
- Calm, quiet environment - place in a low-stimulation room, dim lights
- Reassurance and "talk-down" - speak in a calm, non-judgmental tone; orientate the patient to time and place
- Observation - most mild-moderate intoxications resolve with supportive care within 4-8 hours
- Hydration - oral or IV fluids if dehydrated
- Monitoring - continuous cardiac monitoring for tachycardia; watch for arrhythmias
4. Pharmacological Treatment (with Doses)
A. Anxiety / Panic / Agitation - Benzodiazepines (First Choice)
Use when reassurance fails or anxiety is severe:
| Drug | Route | Dose | Notes |
|---|---|---|---|
| Lorazepam (Ativan) | IV / IM / PO | 2-4 mg IM/IV; repeat q 15-30 min if needed | First-line; monitor for respiratory depression, sedation |
| Diazepam | IV / PO | 5-10 mg IV slowly; PO 5-10 mg | Longer duration; useful if effect needed >24h |
| Midazolam | IM / IV | 2.5-5 mg IM | Fast onset; useful for severe agitation |
Monitor vitals after every dose. Avoid benzodiazepines in concurrent alcohol intoxication (risk of respiratory depression) or TBI.
B. Acute Psychosis / Paranoid Delusions - Antipsychotics
Reserve for cannabis-induced psychosis or when benzodiazepines are insufficient:
| Drug | Route | Dose | Notes |
|---|---|---|---|
| Haloperidol | IM / IV | 5 mg IM q 20-30 min until stabilized | Fast-acting; watch for EPS (extrapyramidal symptoms); add diphenhydramine 25-50 mg IM to prevent dystonia |
| Olanzapine | IM | 5-10 mg IM | Lower EPS risk; do NOT combine IM olanzapine + IM lorazepam (risk of hypotension/respiratory depression) |
| Risperidone | PO | 2 mg PO | Useful for paranoid features; onset 1-2 hours; PO only |
| Quetiapine | PO | 25-50 mg PO | Useful for mild-moderate agitation + sedation |
If psychotic symptoms persist beyond a few days, evaluate for underlying primary psychotic disorder (schizophrenia, bipolar disorder).
C. Cannabinoid Hyperemesis Syndrome (CHS)
Cyclical severe vomiting in chronic heavy users (may resist standard antiemetics):
| Drug | Route | Dose | Notes |
|---|---|---|---|
| Haloperidol | IM | 5 mg IM | Often effective when antiemetics fail |
| Topical Capsaicin | Topical | Apply to abdomen | Symptomatic relief; mechanism unclear |
| IV Fluids | IV | Normal saline - titrate to hydration status | Replace fluids and electrolytes |
D. Tachycardia / Cardiovascular Monitoring
- Mild tachycardia (HR < 120 bpm): observe, reassure - usually resolves spontaneously
- Persistent significant tachycardia: benzodiazepines (anxiolysis lowers sympathetic drive)
- Arrhythmias: treat per ACLS protocols; cardiology consult if needed
E. Gastric Decontamination
- Generally not indicated for smoked hashish
- Consider activated charcoal (1 g/kg PO, max 50 g) if oral ingestion (edibles) was within 1-2 hours and airway is protected
- Gastric lavage: rarely needed; only for massive ingestion < 1 hour with intact airway
5. Synthetic Cannabinoids (K2, Spice) - More Severe Toxidrome
If presentation is atypical (marked hypertension, seizures, hyperthermia, hyperkalemia, severe agitation beyond typical cannabis), suspect synthetic cannabinoids:
- Benzodiazepines remain first-line for agitation and seizures
- Temperature control (cooling measures for hyperthermia)
- IV fluids for rhabdomyolysis risk
- Airway protection may be required
- Poison Control consultation
6. Disposition
| Severity | Disposition |
|---|---|
| Mild intoxication, resolving | Observe 4-8 hours, discharge with caution advice |
| Moderate with significant anxiety or psychosis | Admit to toxicology/observation ward |
| Persistent psychosis > 24-48 hours | Psychiatric evaluation + admission |
| Polysubstance ingestion / synthetic cannabinoids | ICU or monitored bed |
Key Points Summary
- No antidote exists for cannabis/hashish intoxication
- Supportive care + calm environment is the mainstay - most patients recover within 4-8 hours
- Benzodiazepines (lorazepam 2-4 mg IM/IV) for anxiety, panic, agitation
- Antipsychotics (haloperidol 5 mg IM or olanzapine 5-10 mg IM) for acute psychosis - never combine IM olanzapine with IM lorazepam
- Always screen for polysubstance use and synthetic cannabinoids (which are far more dangerous)
- Refer to substance abuse counseling before discharge
Sources: Kaplan & Sadock's Comprehensive Textbook of Psychiatry; Medscape - Cannabinoid Poisoning Treatment (updated Jan 2024); Medscape - Cannabis-Related Disorders Medications; StatPearls - Cannabis Use Disorder (2025); AAFP - Drug Abuse, Intoxication and Withdrawal.
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