What is the treatment for marijuana hyperemesis syndrome?

Treatment of Cannabinoid Hyperemesis Syndrome

Complete and permanent cessation of all cannabis use is the only definitive treatment for cannabinoid hyperemesis syndrome and must be the primary therapeutic goal. 1, 2, 3

Acute Management in the Emergency Department

First-Line Acute Therapies

• Haloperidol 5 mg IV is the most effective acute antiemetic for CHS, significantly reducing hospital length of stay by nearly 50% (6.7 vs 13.9 hours, p=0.014) compared to standard antiemetics 2, 3, 4
• Add lorazepam 2 mg IV for enhanced symptom control through anxiolysis and addressing the stress-mediated component of CHS 2, 5
• Apply topical capsaicin 0.1% cream to the abdomen to activate TRPV1 receptors, which provides consistent symptomatic relief 1, 2, 3
• Hot showers or baths provide immediate temporary relief and are universally effective in all reported cases 1, 4, 5

Alternative Acute Antiemetics

• Promethazine 12.5-25 mg IV can be used as an alternative antipsychotic option 2
• Olanzapine 5-10 mg PO daily is another effective antipsychotic alternative 1, 2
• Ondansetron may be tried but typically has limited efficacy compared to its effectiveness in other conditions 1, 4

Critical Medications to Avoid

• Never use opioids as they worsen nausea, provide no benefit, and carry significant addiction risk in this population 1, 2, 3

Long-Term Preventive Management

Definitive Treatment

• Cannabis cessation counseling is essential and non-negotiable as it is the only intervention that leads to complete resolution 1, 2, 3
• Symptoms resolve after abstinence for at least 6 months or duration equal to 3 typical vomiting cycles 1

Pharmacologic Prevention

• Amitriptyline is the mainstay of long-term preventive therapy: start at 25 mg at bedtime and titrate weekly to reach the minimal effective dose of 75-100 mg 1, 2, 3
• Tricyclic antidepressants work through modulation of central nervous system pathways involved in nausea and vomiting 5

Supportive Care

• Provide psychological support as anxiety and depression are common comorbidities in this population 1
• Co-manage with psychiatry for patients with extensive psychiatric comorbidity or treatment resistance 1

Diagnostic Confirmation Before Treatment

Key Clinical Features to Identify

• Cannabis use >1 year before symptom onset with frequency >4 times weekly 1, 2
• Stereotypical episodic vomiting with ≥3 episodes annually, each lasting <1 week with acute onset 1, 2
• Pathognomonic hot water bathing behavior reported in 44-71% of cases, where patients compulsively use hot showers/baths for symptom relief 2, 3
• Absence of vomiting between episodes (though milder symptoms may persist) 6

Essential Rule-Outs

• First exclude life-threatening conditions: acute abdomen, bowel obstruction, mesenteric ischemia, pancreatitis, and myocardial infarction 1, 2, 3
• Consider other functional disorders including cyclic vomiting syndrome, gastroparesis, and rumination syndrome 2

Common Pitfalls and Caveats

• CHS is frequently underdiagnosed or misdiagnosed due to limited clinician awareness, leading to extensive unnecessary testing 3, 4, 7
• Patients paradoxically report that cannabis helps relieve their symptoms, leading to continued use and perpetuation of the syndrome 6, 2
• Many patients remain uncertain about cannabis's role and attribute symptoms to other factors like food, alcohol, or stress 2
• Standard antiemetics (ondansetron, metoclopramide) often fail in CHS, unlike their effectiveness in other conditions 4, 8
• The prevalence is increasing with cannabis legalization and dramatically higher THC concentrations in modern products 2, 3

Treatment Algorithm Summary

Acute phase: Haloperidol 5 mg IV + lorazepam 2 mg IV + topical capsaicin 0.1% + supportive IV hydration 2, 3

Subacute phase: Initiate cannabis cessation counseling immediately 1, 2

Long-term prevention: Amitriptyline 25 mg at bedtime, titrate weekly to 75-100 mg + ongoing addiction treatment support 1, 2, 3