What is the treatment for cannabis hyperemesis syndrome?

Treatment for Cannabis Hyperemesis Syndrome (CHS)

The definitive treatment for Cannabis Hyperemesis Syndrome (CHS) is complete cannabis cessation, with symptoms typically resolving completely within a short period after discontinuation. 1 For acute management, a combination of IV fluid rehydration, dopamine receptor antagonists (particularly haloperidol), hot showers/baths, and topical capsaicin cream are recommended as first-line interventions.

Diagnosis and Recognition

CHS should be identified by the following diagnostic characteristics:

• Regular cannabis use for >1 year
• Cannabis use frequency >4 times per week
• Cyclic episodes of nausea and vomiting
• Relief from hot showers/baths
• Resolution of symptoms after cannabis cessation 1

Acute Treatment Algorithm

First-Line Interventions:

1. IV fluid rehydration to correct dehydration and electrolyte abnormalities 1
2. Dopamine receptor antagonists:
   • Haloperidol 0.5-2 mg IV or PO every 4-6 hours 1
   • Haloperidol has been shown to be superior to ondansetron in randomized controlled trials, with better improvements in both pain and nausea, less use of rescue antiemetics, and shorter ED stays 2
3. Hot showers/baths - encourage patients to use this self-management technique 1
4. Topical capsaicin cream applied to the periumbilical region 1

Second-Line Options:

• Benzodiazepines (e.g., lorazepam 0.5-2 mg PO/SL/IV every 6 hours) 1
• Olanzapine (5-10 mg PO daily) 1
• Corticosteroids 1
• Serotonin receptor antagonists (less effective than dopamine antagonists) 1

Important Clinical Considerations

• Avoid opioids as they can worsen nausea and have high addiction potential 1
• Monitor patients closely for sedation and other side effects, especially when using haloperidol 1
• Be aware that higher doses of haloperidol (0.1 mg/kg) may cause acute dystonia 2
• Ondansetron and other traditional antiemetics are often ineffective for CHS 2
• The combination of haloperidol with lorazepam has shown effectiveness in adolescents with CHS 3

Long-Term Management

1. Cannabis cessation is the only definitive treatment 1, 4

   • Recommend complete abstinence for at least 3-6 months 1
   • Educate patients that symptoms will likely recur with resumed cannabis use

2. Screen for cannabis use disorder using DSM-5 criteria:

   • Mild (2-3 criteria), moderate (4-5 criteria), or severe (6+ criteria) 1
   • Consider referral to addiction treatment services

Pathophysiology and Clinical Pearls

• CHS pathophysiology remains unclear, but likely involves dysregulation of the endocannabinoid system with chronic cannabis use 5
• The paradoxical relief from hot showers/baths may be related to TRPV1 receptor activation, which is also the mechanism for capsaicin's effectiveness 5
• Male predominance (72.9%) has been observed in CHS cases 4
• CHS is becoming increasingly prevalent with higher potency cannabis products 5

Differential Diagnosis Considerations

Always rule out life-threatening conditions in the differential diagnosis:

• Acute abdomen
• Bowel obstruction
• Mesenteric ischemia
• Pancreatitis
• Myocardial infarction 1

By following this treatment algorithm and recognizing CHS early, clinicians can provide effective symptom relief while guiding patients toward the definitive treatment of cannabis cessation.