Cannabinoid Hyperemesis Syndrome: Public Health Implications and a Novel Model Treatment Guideline

For level-5 case reports (44 subjects), benzodiazepines, metoclopramide, haloperidol, ondansetron, morphine, and capsaicin were reported as effective. Effective treatments mentioned only once included fentanyl, diazepam, promethazine, methadone, nabilone, levomepromazine, piritramide, and pantoprazole. Hot showers and baths were cited in all level-4 and -5 articles as universally effective. Benzodiazepines, followed by haloperidol and capsaicin, were most frequently reported as effective for acute treatment, and TCAs for long-term treatment. As the prevalence of CHS increases, future prospective trials are greatly needed to evaluate and further define optimal pharmacologic treatment of patients with CHS.

Consent for publication

While this paper covers many of the key pathophysiological and therapeutic possibilities for cannabis use disorders presenting to acute care, limitations arising from the retrospective nature of a literature review were identified during manuscript writing. We believe more research is needed regarding both acute and long-term treatment options. Clinicians should inform patients that their symptoms are directly related to continued use of cannabis. They should further advise patients that immediate cessation of cannabis use is the only method that has been shown to completely resolve symptoms. Reassure patients that symptoms resolve with cessation of cannabinoid use and that full resolution can take anywhere from 7–10 days of abstinence.7 Educate patients that symptoms may return with re-exposure to cannabis. Provide clear documentation in the medical record to assist colleagues with confirming a diagnosis, as these patients will frequently re-present to the ED.

AGA Clinical Practice Update on Diagnosis and Management of Cannabinoid Hyperemesis Syndrome: Commentary

• A recent systematic review found poor quality of evidence beyond case reports many pharmaceuticals (20) and no randomized trials have been completed.
• An expert consensus treatment guideline is provided to assist with diagnosis and appropriate treatment of CHS.
• He says many patients don’t realize that the syndrome is connected with their use of cannabis.
• Patients suffering from CHS commonly return to the ED due to the persistence and severity of symptoms.

Often recurrent, these frequent consultations add to Sober living house the congestion of already chronically saturated emergency department(s) (ED). In order to curb this phenomenon, a specific approach for these patients is key, to enable appropriate treatment and long-term follow-up. As most patients with CHS present to the emergency department complaining of abdominal pain, patients often receive extensive evaluations with laboratory testing and imaging, along with opioid and non-opioid medications (5,15). Patients suffering from CHS commonly return to the ED due to the persistence and severity of symptoms. Early screening for cannabis use can lead to the early recognition of cannabinoid hyperemesis syndrome (emdocs) and assist the patient and clinician to avoid unnecessary ED visits, diagnostics, pharmaceuticals, and admissions (17).

• This blog aims to disrupt how medical providers and trainees can gain public access to high-quality, educational content while also engaging in a dialogue about best-practices in EM and medical education.
• Clinicians should consider other causes of abdominal pain, nausea and vomiting to avoid misdiagnosis.
• For CWS, patients should at least have three DSM-5 symptoms, within 1 week of complete cessation or reduction in cannabis use; this should occur following a heavy or prolonged use.
• With the added advantage that hydration and electrolyte substitution may reduce symptomatology 15, the next step is focusing on specifically addressing nausea and hyperemesis.

Population Health Research Capsule.

• Awareness of the syndrome, along with education regarding diagnostic criteria and treatment options, may help avoid increased costs of and potential harms from testing for other conditions while providing more targeted and definitive treatment for CHS patients.
• Meltzer says it is important for clinicians to advise those with frequent cannabinoid use or hyperemesis about the risks and subsequent disease burden.
• Interaction of CB receptors with the TRPV1 receptor explains further this phenomenon and the therapeutic effect of capsaicin cream (see below), with high doses of cannabinoids causing hypothermia and low doses of hyperthermia 9.
• One large urban academic emergency department in Colorado, where cannabis has been legalized, saw 30.7% of cannabis attributed visits related to gastrointestinal symptoms (1).
• With the only known treatment being abstinence and the high risk of relapse, it is important to rely not solely on acute care but also on long-term follow-up strategies.
• Cannabis may have a biphasic mechanism of action, where at lower or less frequent doses it has anti‐emetic effects but at higher or more chronic doses it acts as a pro-emetic.

Worse, frequent ED consultations have been shown to lead to cognitive bias from teams, which could trivialize symptoms and result in missed alternative diagnoses 45. In light of these factors, and based on the above literature review, we proceeded to review the management of chronic cannabis users presenting to our ED with hyperemesis, nausea, and/or abdominal pain. In a bid to share with other acute care units, we will now present our internal guidelines, reflecting the current level of evidence.

What is cannabinoid hyperemesis syndrome? Here’s what to know, and why experts say it’s on the rise

A systematic review of pharmacological treatments for CHS found evidence to support benzodiazepines such as lorazepam and diazepam (20). These medications work through GABA receptor agonism, thus neurotransmitter inhibition, causing sedation, anxiolysis, and muscle relaxation. To fulfill diagnostic criteria, in addition to the above conditions, in chs symptoms and signs both cases, symptoms should not be attributable to another medical condition or mental disorder and should significantly impede the performance of everyday activities 13, 22.

• Previously reserved for agitated patients, haloperidol has been used off-label for postoperative nausea and has been often used successfully to treat CHS.
• Per the Nelson Textbook of Pediatrics, cyclic vomiting syndrome is defined by having sudden onset episodes of vomiting, having at least four bouts of vomiting per hour, and often having 12 to 15 episodes of vomiting per day.
• Expert panel members engaged in an iterative process to provide evidence-based input into the draft guideline until complete consensus was achieved.
• Opioids, while often prescribed for the patient’s debilitating abdominal pain, are not appropriate for CHS, as they may, in fact, worsen nausea and vomiting.
• Her friend reports she takes numerous hot showers throughout the day and continues to smoke cannabis daily.