What is the treatment for cannabinoid hyperemesis syndrome (marijuana-induced vomiting)?

Treatment for Cannabinoid Hyperemesis Syndrome (Marijuana-Induced Vomiting)

The definitive treatment for Cannabinoid Hyperemesis Syndrome (CHS) is complete cannabis cessation, which typically resolves symptoms completely within a short period. 1

Diagnosis

CHS can be identified by:

• Stereotypical episodic vomiting in patients with cannabis use for >1 year
• Cannabis use frequency >4 times per week
• Relief from hot showers/baths
• Resolution of symptoms after cannabis cessation 1

Treatment Algorithm

First-Line Interventions

1. Complete cannabis cessation (for at least 3-6 months) 1
2. Supportive care during acute episodes:
   • IV fluid rehydration
   • Dopamine receptor antagonists (e.g., haloperidol 0.5-2 mg IV or PO every 4-6 hours)
   • Hot showers/baths
   • Topical capsaicin cream (0.1%) applied to the abdomen 1

Second-Line Options

• Benzodiazepines (e.g., lorazepam 0.5-2 mg PO/SL/IV every 6 hours) 1, 2
• Olanzapine (5-10 mg PO daily)
• Corticosteroids
• Serotonin receptor antagonists (though ondansetron may provide only limited benefit) 1

Important Clinical Considerations

Effective Treatments

• Haloperidol or droperidol have shown greater efficacy than conventional antiemetics 3
• Benzodiazepines can be particularly effective by decreasing activation of Cannabinoid Type 1 Receptor (CB1) in the frontal cortex and reducing anticipatory nausea 2
• Topical capsaicin has shown positive efficacy with a low adverse-effect profile 3

Treatments to Avoid

• Conventional antiemetics often fail to provide relief 2, 3
• Avoid opioids due to risk of worsening nausea and high addiction potential 1

Emergency Department Management

• Rule out life-threatening conditions in the differential diagnosis:
  • Acute abdomen
  • Bowel obstruction
  • Mesenteric ischemia
  • Pancreatitis
  • Myocardial infarction 1

Withdrawal Management

• Provide a quiet, supportive environment with minimal stimulation
• Ensure adequate hydration
• Monitor for complications such as depression or psychosis
• Manage specific symptoms with appropriate medications:
  • Acetaminophen or NSAIDs for headaches and pain
  • Benzodiazepines for anxiety and agitation 1

Clinical Pearls

• CHS is often underrecognized by clinicians, leading to unnecessary tests, scans, and procedures 4
• The paradoxical nature of CHS (cannabis causing vomiting when it's known for antiemetic properties) often leads to patient disbelief about the diagnosis 4
• Unlike other cyclic vomiting syndromes, CHS symptoms are uniquely relieved by hot showers or topical capsaicin 4
• The prevalence of CHS is increasing with the liberalization of marijuana laws 4, 3
• The only permanent solution for CHS is complete abstinence from cannabinoids 5, 6