What is the treatment for Cannabinoid Hyperemesis Syndrome (CHS)?

From the Guidelines

The primary treatment for Cannabinoid Hyperemesis Syndrome (CHS) is complete cessation of cannabis use for at least 6 months, or at least equal to the total duration of 3 typical vomiting cycles in that patient, as this is the only definitive way to resolve symptoms long-term. During acute episodes, supportive care includes intravenous fluids for dehydration, antiemetics such as ondansetron, promethazine, or metoclopramide, and hot showers or baths which many patients report provide temporary relief 1. Topical capsaicin cream (0.1%) applied to the abdomen can also help reduce nausea and vomiting through TRPV1 receptor activation, similar to how hot water provides relief 1. Benzodiazepines like lorazepam may help with associated anxiety and can reduce nausea, while haloperidol has shown effectiveness in some cases 1. Pain management with non-opioid analgesics is recommended as opioids may worsen nausea. For long-term management, counseling to achieve marijuana cessation and tricyclic antidepressants, such as amitriptyline, are the mainstay of therapy, with the minimal effective dose being 75–100 mg at bedtime, starting at 25 mg and titrating the dose with increments each week to reach minimal effective dose 1.

Some key points to consider in the treatment of CHS include:

• Avoiding opioids due to worsening of nausea and high risk of addiction 1
• Using topical capsaicin cream with close monitoring of efficacy and adverse effects 1
• Considering co-management with a psychologist or psychiatrist for patients with extensive psychiatric comorbidity or lack of response to standard therapies 1
• Recognizing that anxiety and depression are common associated conditions in CHS patients 1

It is essential to note that CHS occurs because chronic cannabis use disrupts the endocannabinoid system, particularly in the digestive tract and brain's vomiting centers, and that THC initially has antiemetic properties, but with chronic use, paradoxically causes vomiting through receptor downregulation and altered gut motility 1. Recovery typically takes several months of complete cannabis abstinence, with symptoms often worsening initially before improving.

From the Research

Treatment Options for Cannabinoid Hyperemesis Syndrome (CHS)

• The primary treatment for CHS is cannabis cessation, as it is the only intervention that provides complete symptom relief 2, 3, 4, 5.
• Symptom relief can be achieved through various pharmacological and non-pharmacological therapies, including:
  • Topical capsaicin cream as a first-line treatment 2, 4, 5.
  • Antipsychotics such as haloperidol and olanzapine, which have been reported to provide complete symptom relief in limited case studies 2, 3, 5.
  • Dopamine antagonists like droperidol, which has been shown to reduce the length of hospital stay and the total number of antiemetic dosages administered 6.
  • Conventional antiemetics, including antihistamines, serotonin antagonists, and benzodiazepines, although their effectiveness may be limited 2, 3, 4.
• Non-pharmacological therapies include:
  • Hot showers or baths, which can provide symptom relief 2, 3, 4, 5.
  • Supportive care with intravenous fluids 4.
• Opioids and benzodiazepines should be avoided as first-line therapy for CHS, as they may be harmful and lack evidence for effectiveness 2, 3.

Key Considerations for Clinicians

• Clinicians should be able to recognize the common presentation of CHS and assist with treatment in the emergency department 3.
• Directed questions about cannabis use and the effect of hydrothermotherapy on CHS symptoms can frequently confirm the diagnosis, enabling appropriate pharmacotherapy and referral to addiction treatment 5.
• Clinicians should educate patients that cannabis cessation is the only intervention that will provide complete symptom relief 2, 3, 4, 5.