What is the treatment for cannabis hyperemesis syndrome (CHS)?

Treatment for Cannabis Hyperemesis Syndrome (CHS)

The definitive treatment for cannabinoid hyperemesis syndrome is complete cannabis cessation for at least 6 months, which is the cornerstone of long-term management and the only truly effective approach to resolve symptoms. 1, 2

Diagnosis and Clinical Features

CHS should be suspected in patients presenting with:

• Stereotypical episodic vomiting (≥3 episodes annually)
• Cyclic pattern resembling cyclic vomiting syndrome
• Relief with hot showers/baths (reported in 71% of patients)
• Cannabis use patterns:
  • Duration >1 year before symptom onset
  • Frequency >4 times per week
  • Often daily use (reported in 68% of cases)
  • Multiple times per day (median 3 times daily) 1, 2

Acute Management

1. First-line interventions:

   • Topical capsaicin (0.1%) cream applied to abdomen (activates transient receptor potential vanilloid type 1 receptors)
   • Hot showers/baths (encourage as temporary relief measure)
   • IV fluid rehydration for dehydration 1, 2

2. Pharmacologic options:

   • Haloperidol or olanzapine (most effective antiemetics for CHS)
   • Benzodiazepines (e.g., lorazepam) for short-term symptom control
   • Promethazine or ondansetron (though often less effective than antipsychotics) 2, 3

3. Medications to avoid:

   • Opioids (worsen nausea and carry high addiction risk) 1, 2

Long-term Management

1. Cannabis cessation:

   • Refer to addiction specialist
   • Provide counseling and support for cannabis discontinuation
   • Warn patients that symptoms typically require complete abstinence for at least 6 months or duration equal to 3 typical vomiting cycles 2

2. Pharmacologic therapy:

   • Tricyclic antidepressants (TCAs), particularly amitriptyline
     • Start at 25 mg at bedtime
     • Titrate weekly to reach minimal effective dose of 75-100 mg 1, 2, 3

3. Psychiatric co-management:

   • For patients with comorbidities
   • Address underlying mental health conditions that may contribute to cannabis use 2

Clinical Challenges and Pitfalls

• Patient denial: Many patients find it difficult to accept that cannabis is causing their symptoms, as cannabis is often perceived as an antiemetic 4
• High recidivism rates: >40% of patients relapse to cannabis use 2
• Unproven strategies: Switching to lower THC/higher CBD formulations, using edible forms instead of smoking, or avoiding THC concentrates lack scientific validation 2
• Delayed diagnosis: CHS remains under-recognized despite being first described over 15 years ago, leading to medical wandering, repeated hospitalizations, and unnecessary invasive procedures 5, 4, 6

Differential Diagnosis

Before confirming CHS diagnosis, rule out:

• Acute abdomen
• Bowel obstruction
• Mesenteric ischemia
• Pancreatitis
• Myocardial infarction
• Rumination syndrome
• Gastroparesis
• Cyclic vomiting syndrome unrelated to cannabis
• Pregnancy
• Migraine
• Functional chronic nausea and vomiting syndrome 1, 2

Remember that the paradoxical nature of CHS (cannabis causing vomiting despite its antiemetic properties) often leads to diagnostic confusion and treatment delays. Early recognition and prompt referral to addiction specialists are crucial for effective management.