What is the treatment for cannabis hyperemesis?

Treatment for Cannabis Hyperemesis Syndrome (CHS)

Complete cannabis cessation for at least 6 months is the cornerstone of long-term management and the only truly effective approach to resolve symptoms of cannabis hyperemesis syndrome. 1

Acute Management in Emergency Setting

1. First-line interventions:

   • Topical capsaicin (0.1%) cream applied to the abdomen 1
   • Hot showers/baths - reported to provide relief in 71% of patients 1
   • IV fluid rehydration for dehydration 1

2. Pharmacologic options for acute symptom control:

   • Antipsychotics:
     • Haloperidol or droperidol (dopamine antagonists) 2
     • Olanzapine 1
   • Antiemetics:
     • Ondansetron (often less effective than antipsychotics) 1, 2
     • Promethazine (limited evidence of efficacy) 1
   • Benzodiazepines for sedation and symptom control 3

3. Medications to avoid:

   • Opioids - can worsen nausea and carry high addiction risk 1, 2

Long-term Management

1. Cannabis cessation counseling:

   • Refer to addiction specialist 1
   • Warn patients that symptom resolution typically requires complete abstinence for at least 6 months or duration equal to 3 typical vomiting cycles 1

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
   • Consider co-management with psychiatry for patients with comorbidities 1

Diagnostic Considerations

CHS should be considered in patients with:

• Cannabis use patterns: daily or near-daily use for >1 year (often >2 years) 1, 4
• Stereotypical episodic vomiting (≥3 episodes annually) 1
• Cyclic pattern resembling cyclic vomiting syndrome 1
• Relief with hot showers/baths (pathognomonic but not universal) 1

Common Pitfalls and Challenges

1. Patient denial and skepticism:

   • Many patients don't believe cannabis causes their symptoms due to its known antiemetic properties 4
   • High recidivism rates (>40% of patients) 1

2. Ineffective strategies to avoid:

   • Switching to lower THC/higher CBD formulations
   • Using edible forms instead of smoking
   • Avoiding THC concentrates
   • These approaches lack scientific validation 1

3. Diagnostic confusion:

   • Rule out other causes of vomiting: acute abdomen, bowel obstruction, pancreatitis, pregnancy, gastroparesis, cyclic vomiting syndrome 1

4. Treatment resistance:

   • Standard antiemetics often fail in CHS 3
   • Hot water bathing is consistently reported as effective across studies 5

The increasing prevalence of CHS correlates with rising cannabis use and potency, making this a growing clinical challenge 4. While various pharmacologic interventions may provide temporary symptom relief, the definitive treatment remains complete cannabis cessation 1, 2.