How is cannabis emesis syndrome managed?

Management of Cannabis Hyperemesis Syndrome (CHS)

The definitive treatment for cannabis hyperemesis syndrome is complete cessation of cannabis use, which is the only intervention that leads to long-term resolution of symptoms. 1

Acute Management

For patients presenting with acute symptoms, the following interventions may provide relief:

• Topical capsaicin (0.1%) applied to the abdomen can provide symptom relief by activating transient receptor potential vanilloid type 1 receptors 1
• Benzodiazepines have shown efficacy in case series and may work by decreasing activation of Cannabinoid Type 1 Receptor in the frontal cortex 2, 3
• Antipsychotics such as haloperidol, promethazine, and olanzapine can be effective for acute symptom management 1, 3
• Ondansetron may be tried but often has limited efficacy compared to conventional antiemetic use in other conditions 1
• Hot showers or baths (hydrothermotherapy) provide temporary symptomatic relief for 71% of patients and can be a diagnostic clue 1, 4
• Avoid opioids as they may worsen nausea and carry addiction risk 1

Emergency Department Approach

In the emergency department setting:

• Rule out life-threatening conditions first (acute abdomen, bowel obstruction, mesenteric ischemia, pancreatitis, myocardial infarction) 1, 5
• Consider CHS in patients with:
  • Regular cannabis use (especially >4 times weekly for >1 year) 1
  • Cyclic vomiting episodes (≥3 episodes annually) 1
  • Relief with hot showers/baths 6, 4
  • Prior negative workups for other causes 1, 5

Long-term Management

For long-term management:

• Cannabis cessation counseling is essential and the only definitive treatment 1, 6
• Tricyclic antidepressants (particularly amitriptyline) are the mainstay of therapy:
  • Start at 25 mg at bedtime 1
  • Titrate weekly to reach minimal effective dose of 75-100 mg 1
• Psychological support may be beneficial as anxiety and depression are common comorbidities 1
• Co-management with psychiatry for patients with extensive psychiatric comorbidity or treatment resistance 1

Common Pitfalls

• Misdiagnosis is common as patients may not disclose cannabis use or clinicians may not specifically ask about it 6, 3
• Patient denial about the relationship between cannabis and symptoms is frequent; many attribute symptoms to other factors like food, alcohol, or stress 1
• Recidivism is high, with many patients returning to cannabis use despite symptom resolution with abstinence 1
• Ineffective treatments that lack scientific validation include switching to lower THC/higher CBD formulations, using edible forms, or avoiding THC concentrates 1
• Unnecessary testing is often performed when CHS is not recognized early 3, 5

Diagnostic Criteria

CHS should be diagnosed based on:

1. Clinical features: Stereotypical episodic vomiting (≥3 episodes annually) 1
2. Cannabis use patterns: >1 year of use before symptom onset, frequency >4 times weekly 1
3. Cannabis cessation: Resolution of symptoms after abstinence for at least 6 months or duration equal to 3 typical vomiting cycles 1

With appropriate diagnosis and management focusing on cannabis cessation as the primary intervention, patients can achieve complete resolution of this debilitating syndrome.