What is the treatment for hyperemesis (excessive vomiting) resulting from cannabinoid use?

Treatment of Cannabinoid Hyperemesis Syndrome

The definitive treatment for cannabinoid hyperemesis syndrome is complete cannabis cessation, which is the only intervention that leads to long-term resolution of symptoms. 1, 2

Acute Management in the Emergency Department

Initial Assessment

• Rule out life-threatening conditions first: acute abdomen, bowel obstruction, mesenteric ischemia, pancreatitis, and myocardial infarction before attributing symptoms to CHS 1, 2
• Suspect CHS in patients with regular cannabis use (>4 times weekly for >1 year) presenting with stereotypical episodic vomiting (≥3 episodes annually) 2
• Look for the diagnostic clue of hot water bathing behavior—patients compulsively use hot showers or baths for symptom relief 2, 3

First-Line Acute Pharmacotherapy

Prioritize haloperidol or droperidol as first-line agents, as butyrophenones reduce hospital length of stay by nearly 50% (6.7 vs 13.9 hours, p=0.014) compared to standard antiemetics 3

Additional acute treatment options include:

• Topical capsaicin 0.1% cream applied to the abdomen—activates TRPV1 receptors and provides consistent symptom relief 1, 2, 4
• Benzodiazepines for their sedating and anxiolytic effects, which address the stress-mediated component of CHS 1, 3, 5
• Promethazine or olanzapine as alternative antipsychotics 1, 2
• Ondansetron may be tried but often has limited efficacy compared to its use in other conditions 1, 2

Critical Treatment Pitfalls

• Avoid opioids—they worsen nausea, carry high addiction risk, and do not address the underlying pathophysiology 1, 2, 6
• Patients receiving capsaicin require 67% fewer additional medications before discharge and have significantly reduced opioid requirements (166.5 vs 69 mg OME) 4

Supportive Care

• Provide aggressive intravenous fluid resuscitation to prevent dehydration-related complications and rhabdomyolysis 6
• Check renal function and creatine kinase levels in patients with severe or prolonged vomiting episodes, particularly those with acute kidney injury 6
• Allow hot showers or baths for temporary symptomatic relief during the acute phase 2

Long-Term Management

Cannabis Cessation Counseling

Cannabis cessation is essential and the only definitive cure—resolution of symptoms requires abstinence for at least 6 months or duration equal to 3 typical vomiting cycles 1, 2

Preventive Pharmacotherapy

Tricyclic antidepressants (amitriptyline) are the mainstay of long-term therapy:

• Start at 25 mg at bedtime 1, 2
• Titrate weekly by 25 mg increments 1
• Target minimal effective dose of 75-100 mg at bedtime 1, 2, 3

Additional Long-Term Strategies

• Provide psychological support, as anxiety and depression are common comorbidities 2
• Consider co-management with psychiatry for patients with extensive psychiatric comorbidity or treatment resistance 2
• Topical capsaicin 0.1% cream can be continued with close monitoring of efficacy and adverse effects 1

Common Clinical Pitfalls

CHS is frequently underdiagnosed or misdiagnosed due to limited clinician awareness, leading to extensive unnecessary testing 3. The paradox that patients report cannabis helps relieve their symptoms while it actually causes them contributes to diagnostic confusion and poor treatment adherence 1. Despite recurrent episodes and a CHS diagnosis, many patients remain uncertain about the role of cannabis use and attribute their symptoms to food or other factors 1.

Recidivism rates are high—even after diagnosis and counseling, many patients continue cannabis use, though >40% of patients can eventually stop all treatments for CHS over time 1.