What is the management and treatment for Cannabis Hyperemesis Syndrome (CHS)?

Cannabis Hyperemesis Syndrome: Management and Treatment

The definitive treatment for cannabis hyperemesis syndrome is complete and permanent cessation of cannabis use—this is the only intervention that leads to long-term resolution of symptoms. 1, 2

Diagnostic Criteria to Confirm Before Treatment

You must establish three key elements before diagnosing CHS 1, 2:

• Clinical features: Stereotypical episodic vomiting occurring ≥3 times annually, resembling cyclic vomiting syndrome 1, 2
• Cannabis use patterns: Duration >1 year before symptom onset, with frequency >4 times weekly 1, 2
• Cannabis cessation test: Resolution of symptoms after abstinence for at least 6 months OR duration equal to 3 typical vomiting cycles 1, 2

Hot water bathing behavior (compulsive hot showers/baths) occurs in 71-92% of CHS patients and is a strong diagnostic clue, though not pathognomonic. 1, 2

Acute Management in the Emergency Department

First Priority: Rule Out Life-Threatening Conditions

Before attributing symptoms to CHS, exclude acute abdomen, bowel obstruction, mesenteric ischemia, pancreatitis, and myocardial infarction 1, 3. This is a critical pitfall—CHS is frequently misdiagnosed due to limited clinician awareness, leading to extensive unnecessary testing 3.

Acute Pharmacological Management

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

Additional acute therapies with evidence 1, 2, 3:

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

Critical Medication to Avoid

Never use opioids—they worsen nausea, do not address the underlying pathophysiology, and carry high addiction risk. 1, 2, 3, 4

Supportive Care

Aggressive intravenous fluid resuscitation is essential to prevent dehydration-related complications and rhabdomyolysis 4. Check creatine kinase (CK) levels and renal function in patients with severe or prolonged vomiting episodes, particularly those with acute kidney injury 4.

Long-Term Management Algorithm

Step 1: Cannabis Cessation Counseling (Essential)

Counsel patients that they must cease cannabis use for a minimum of 3 months to achieve symptom relief and confirm the diagnosis. 5 This specific timeframe is critical—shorter periods may lead to false reassurance and continued suffering 5.

Emphasize that 1, 2:

• Switching to lower THC/higher CBD formulations is NOT validated
• Using edible forms instead of smoking does NOT prevent CHS 3
• Avoiding THC concentrates alone is NOT sufficient

Step 2: Tricyclic Antidepressant Prophylaxis

Start amitriptyline as the mainstay of preventive therapy 1, 2, 3:

• Begin at 25 mg at bedtime 1, 2
• Titrate weekly by 25 mg increments 1, 2
• Target minimal effective dose: 75-100 mg at bedtime 1, 2
• Monitor closely for efficacy and adverse effects 1

Step 3: Ongoing Monitoring

Recidivism is high—many patients remain uncertain about the role of cannabis despite recurrent episodes 1. Psychological support is beneficial as anxiety and depression are common comorbidities 2. Consider co-management with psychiatry for patients with extensive psychiatric comorbidity or treatment resistance 2.

Special Perioperative Considerations

Patients with CHS require enhanced prophylactic antiemetic therapy perioperatively due to increased risk for post-anesthesia intractable vomiting. 3 Cannabis users may require higher doses of anesthetic agents and higher postoperative analgesic requirements 3. Consider processed depth of anesthesia EEG monitoring (BIS) for heavy cannabis users 3. Use multimodal non-opioid analgesia strategies postoperatively 3.

Common Pitfalls to Avoid

• Do not accept partial cannabis reduction—only complete cessation resolves symptoms 1, 2
• Do not stop evaluation at 1-2 weeks of abstinence—minimum 3 months is required for diagnostic confirmation 5
• Do not use conventional antiemetic dosing—CHS requires multimodal therapy different from standard PONV protocols 3
• Do not overlook rhabdomyolysis risk—check CK levels in severe cases 4