What is the management of Cannabis Hyperemesis Syndrome?

Management of Cannabis Hyperemesis Syndrome

The definitive treatment for Cannabis Hyperemesis Syndrome (CHS) is complete and permanent cessation of all cannabis use—this is the only intervention that leads to long-term resolution and prevents recurrent episodes. 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, 3
• Suspect CHS in patients with regular cannabis use (>4 times weekly for >1 year) presenting with cyclic vomiting episodes (≥3 annually) 2, 3
• Ask specifically about hot shower/bath use for symptom relief—this occurs in 44-71% of CHS patients and is a key diagnostic clue 1, 2, 3

Acute Pharmacologic Management

Prioritize haloperidol or droperidol as first-line agents—these butyrophenones reduce hospital length of stay by nearly 50% (6.7 vs 13.9 hours, p=0.014) compared to conventional antiemetics 3, 4, 5

Additional acute therapies include:

• Topical capsaicin 0.1% cream applied to the abdomen—activates TRPV1 receptors and provides consistent symptom relief 1, 2, 3
• Benzodiazepines—address the stress-mediated component through sedating and anxiolytic effects 1, 3, 5
• Promethazine or olanzapine as alternative antipsychotics 1, 2
• Ondansetron may be tried but has limited efficacy compared to its use in other conditions 1, 2
• Aggressive intravenous fluid resuscitation is essential to prevent dehydration-related complications and rhabdomyolysis 6

Critical Medications to Avoid

Do not use opioids—they worsen nausea, fail to address the underlying pathophysiology, and carry high addiction risk 1, 2, 3, 6, 4

Laboratory Monitoring

• Check creatine kinase (CK) levels in patients with severe or prolonged vomiting, particularly those with acute kidney injury, as rhabdomyolysis can occur 6
• Assess renal function as acute kidney injury can develop from both hyperemesis and rhabdomyolysis 6

Long-Term Management and Prevention

Cannabis Cessation Counseling

Cannabis cessation counseling is mandatory and non-negotiable—it is the only definitive cure for CHS 1, 2, 6

• Symptoms resolve after abstinence for at least 6 months or duration equal to 3 typical vomiting cycles 1, 2
• Combining evidence-based psychosocial interventions with pharmacology may be necessary for successful long-term management 1

Prophylactic Pharmacotherapy

Start amitriptyline as the mainstay of preventive therapy: 1, 2, 7

• Begin at 25 mg at bedtime
• Titrate weekly by 25 mg increments
• Target minimal effective dose of 75-100 mg at bedtime
• Once in remission, amitriptyline can be tapered slowly 7
• Monitor closely for efficacy and adverse effects 1

Psychiatric Co-Management

• Consider psychiatry referral for patients with extensive psychiatric comorbidities or treatment resistance 2
• Address anxiety and depression, which are common comorbidities 2

Diagnostic Criteria

CHS diagnosis requires all three components: 1, 2

1. Clinical features: Stereotypical episodic vomiting resembling cyclic vomiting syndrome with acute onset, ≥3 episodes annually
2. Cannabis use patterns: Duration >1 year before symptom onset, frequency >4 times weekly on average
3. Cannabis cessation: Resolution of symptoms after abstinence for ≥6 months or duration equal to 3 typical vomiting cycles

Common Pitfalls

• CHS is frequently underdiagnosed or misdiagnosed due to limited clinician awareness, leading to extensive unnecessary testing 3, 5, 8
• Many patients remain uncertain about the role of cannabis use and attribute symptoms to food or other causes despite recurrent episodes 1
• Recidivism rates are high—over 40% of patients may stop treatment over time but continue cannabis use 1
• Strategies lacking scientific validation include switching to lower THC/higher CBD formulations, using edible forms, or avoiding THC concentrates 1

Perioperative Considerations

For patients with CHS undergoing surgery: 3

• Provide enhanced prophylactic multimodal antiemetic therapy perioperatively due to increased risk for post-anesthesia intractable vomiting
• Anticipate higher anesthetic and postoperative analgesic requirements in chronic cannabis users
• Consider processed depth of anesthesia EEG monitoring (BIS) for heavy cannabis users
• Use multimodal non-opioid analgesia strategies postoperatively