What is the treatment for cannabis-induced cyclic vomiting syndrome?

Treatment of Cannabis-Induced Cyclic Vomiting Syndrome (CHS)

The most effective treatment for cannabis-induced cyclic vomiting syndrome is complete cannabis cessation for at least 6 months, which is the only truly effective approach to resolve symptoms. 1, 2

Diagnosis Confirmation

Before initiating treatment, confirm the diagnosis of CHS using these criteria:

• Stereotypical episodic vomiting (≥3 episodes annually)
• Cannabis use for >1 year before symptom onset
• Cannabis use frequency >4 times per week
• Resolution of symptoms after cannabis cessation 1

Treatment Algorithm

Acute Management

1. First-line interventions:

   • Topical capsaicin (0.1%) cream applied to the abdomen 1, 2
   • Hot showers/baths (utilized by 92.3% of patients for symptom relief) 2, 3
   • IV fluid rehydration for dehydration 2

2. Pharmacologic options:

   • Haloperidol or droperidol (butyrophenones) which have shown better efficacy than traditional antiemetics 2
   • Benzodiazepines (short-term use only) 1
   • Promethazine 1
   • Olanzapine 1
   • Ondansetron 1

3. Medications to avoid:

   • Opioids (worsen nausea and carry addiction risk) 1, 2
   • Traditional antiemetics are often ineffective 4

Long-term Management

1. Cannabis cessation (definitive treatment):

   • Complete abstinence from cannabis use 1, 2, 3
   • Symptoms typically begin improving within days to weeks after stopping cannabis 2
   • Refer to addiction specialist for cessation support 2

2. Pharmacologic adjuncts:

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

3. Supportive care:

   • Co-management with psychiatrist/psychologist for patients with psychiatric comorbidities 1, 2
   • Address anxiety and depression, which are common associated conditions 1

Important Clinical Considerations

• Diagnostic pitfall: CHS is frequently misdiagnosed, leading to unnecessary testing and delayed treatment 4. Patients often present multiple times before receiving the correct diagnosis.

• Patient education challenges: Many patients remain skeptical about cannabis as the cause of their symptoms and may attribute them to food, alcohol, stress, or other gastrointestinal disorders 1, 5. Clear education about the syndrome is essential.

• Compulsive hot water bathing: While not pathognomonic (also seen in cyclic vomiting syndrome), this behavior is reported in 71-92.3% of CHS patients and can be a helpful diagnostic clue 1, 3

• Recidivism risk: Despite education about CHS, recurrence rates are high due to continued cannabis use 1. Emphasize that symptom resolution requires complete abstinence, not just reduction in use.

• Monitoring: Follow patients closely during cannabis cessation to confirm symptom improvement and provide support for abstinence 2

The evidence for CHS treatment is limited to case series and small clinical trials, but the consistent finding across all sources is that cannabis cessation is the cornerstone of effective management 1, 2, 3. While symptomatic treatments may provide temporary relief, they do not address the underlying cause of the syndrome.