What is the best course of action for a patient with chronic abdominal pain, weight loss, and back pain, who also uses cannabis daily?

Immediate Priority: Rule Out Cannabis Hyperemesis Syndrome and Expedite GI Workup

This patient's presentation is highly concerning for Cannabis Hyperemesis Syndrome (CHS) given daily cannabis use since end of [DATE], progressive epigastric pain, weight loss, and variable bowel symptoms—cannabis cessation for at least one week is the most critical immediate intervention, with urgent GI evaluation to exclude malignancy or other serious pathology. 1, 2

Immediate Actions for Abdominal Pain and Weight Loss

Cannabis Cessation Protocol

• Mandate complete cannabis cessation for a minimum of 1 week to assess for CHS, as symptoms typically resolve within 1-2 weeks of abstinence 3, 1, 4
• CHS is diagnosed when prolonged (>1 year) and heavy cannabis use (>4 times weekly, often daily) precedes symptom onset, and this patient meets these criteria with daily use throughout the day 3
• The American Gastroenterological Association requires 6 months or at least 3 typical cycle lengths of cannabis abstinence to definitively rule out CHS 3
• Monitor for cannabis withdrawal symptoms (irritability, anxiety, insomnia, abdominal pain) which peak in the first week and last 1-2 weeks 3, 4

Acute Symptom Management

• Avoid opioids entirely as they worsen nausea and carry high addiction risk in cannabis users 1, 2
• Consider topical capsaicin 0.1% cream applied to the epigastric region for pain relief, which activates TRPV1 receptors and provides consistent benefit in CHS 1, 2
• If severe nausea/vomiting develops, use haloperidol or droperidol (butyrophenones) as first-line antiemetics, which reduce hospital length of stay by nearly 50% in CHS patients 1, 2
• Continue nutritional supplement drinks (Boost) as tolerated for caloric support 1

Urgent Diagnostic Workup

• Do not delay the scheduled gastroenterology consultation and abdominal ultrasound—these must proceed urgently given progressive weight loss and concerning symptoms 1
• The mildly elevated ALT (45) and CRP (9) warrant hepatobiliary imaging to exclude gallbladder disease, hepatic pathology, or pancreatic issues 1
• One-time esophagogastroduodenoscopy (EGD) is appropriate to exclude obstructive lesions, malignancy, peptic ulcer disease, or esophageal stricture causing the "blockage sensation" 3
• If symptoms do not improve within 3-5 days or worsen, proceed immediately to emergency department for expedited imaging (CT abdomen/pelvis) and possible endoscopy to rule out malignancy, bowel obstruction, or other life-threatening pathology 1, 2

Critical Diagnostic Considerations

Distinguishing CHS from Other Pathology

• CHS typically presents with cyclic episodes of nausea/vomiting, not constant progressive symptoms 3, 1, 2
• This patient's progressive, non-cyclic symptoms with continuous weight loss raise concern for structural GI pathology (malignancy, stricture, motility disorder) rather than pure CHS 3
• The "blockage sensation" after eating suggests possible mechanical obstruction or severe gastroparesis requiring urgent evaluation 3
• Rule out life-threatening conditions first (bowel obstruction, mesenteric ischemia, pancreatitis, malignancy) before attributing symptoms solely to cannabis 2

Cannabis and IBD Considerations

• The Canadian Association of Gastroenterology recommends against using cannabis for abdominal pain in Crohn's disease, as it does not induce symptomatic remission and is associated with 5-fold increased risk of requiring surgery 1, 5
• While cannabis may subjectively improve pain symptoms, it is associated with worse disease prognosis in IBD patients 5

Management of Severe Back Pain

Immediate Pain Control

• Trial NSAIDs (ibuprofen 600-800mg TID or naproxen 500mg BID) immediately, as Tylenol has been ineffective and NSAIDs are not contraindicated in cannabis users 3, 1
• Cannabis users may require higher analgesic doses due to tolerance, so standard NSAID dosing may need optimization 3, 1
• Continue heating pad use as adjunctive therapy 3

Red Flag Monitoring

• The normal back X-ray is reassuring, but the severe, progressive pain extending to right mid-back warrants close monitoring for neurological symptoms 3
• Immediately seek emergency care if any of the following develop: urinary retention/incontinence, saddle anesthesia, progressive leg weakness, or bilateral leg numbness 3
• The extension to right mid-back raises concern for referred visceral pain from abdominal pathology (pancreas, kidney, gallbladder)—this reinforces urgency of abdominal imaging 1

Cannabis Withdrawal Management

Expected Withdrawal Timeline

• Symptoms occur 24-72 hours after cessation, peak in the first week, and last 1-2 weeks 3, 4
• This patient consuming cannabis daily throughout the day is at high risk for withdrawal symptoms 3

Symptomatic Treatment

• Gabapentin can be considered for withdrawal-related anxiety, restlessness, and pain 3
• Benzodiazepines (short-term, limited duration) may help with severe anxiety or insomnia during withdrawal 2, 4
• Do not use nabilone or nabiximols for substitution unless severe Cannabis Withdrawal Syndrome (CWS) develops requiring psychiatric referral 3

Criteria for Specialist Referral

• Refer to addiction medicine or psychiatry if: severe withdrawal symptoms develop, patient fails brief motivational intervention, significant comorbid mental health disorders emerge, or depression/psychosis develops during withdrawal 4

Follow-Up and Monitoring Plan

Short-Term (Next 3-7 Days)

• Phone follow-up as scheduled to assess response to cannabis cessation and symptom trajectory 1
• If GI symptoms improve significantly with cannabis cessation, this supports CHS diagnosis 3, 1
• If symptoms persist or worsen despite cannabis cessation, this mandates urgent GI evaluation for alternative pathology 1, 2

Medium-Term (1-6 Months)

• If CHS is confirmed by symptom resolution with cessation, long-term cannabis abstinence is the only definitive treatment 3, 1, 2, 6
• Consider tricyclic antidepressants (amitriptyline 25mg at bedtime, titrate to 75-100mg) for long-term symptom management if cyclic symptoms persist 3, 1, 2
• Brief psychosocial support using motivational interviewing principles is first-line treatment for cannabis use disorder 4

Critical Pitfalls to Avoid

• Do not attribute all symptoms to cannabis without excluding serious GI pathology—progressive weight loss and constant symptoms are atypical for CHS alone 3, 2
• Do not use opioids for pain management in this cannabis-using patient with GI symptoms 1, 2
• Do not delay GI workup waiting for cannabis cessation trial—both should proceed simultaneously given red flag symptoms 1
• Do not use dexamphetamine for cannabis use disorder—this is explicitly contraindicated 4
• Do not recommend cannabis continuation for pain management, as evidence shows harm in GI conditions and no benefit for inducing remission 1, 5