Discharge Instructions for Cannabinoid Hyperemesis Syndrome
Immediate Discharge Counseling
The single most critical discharge instruction is that complete and permanent cannabis cessation is the only definitive cure for cannabinoid hyperemesis syndrome, requiring at least 6 months of continuous abstinence for full symptom resolution. 1, 2, 3
Cannabis Cessation Requirements
- Stop all cannabis use immediately and permanently – this includes marijuana, THC oils, edibles, vaping products, and CBD products. 1, 3
- Symptoms will only resolve after 6+ months of complete abstinence, or a duration equal to at least 3 typical vomiting cycles for your specific pattern. 2, 4, 3
- Any resumption of cannabis use will trigger symptom recurrence. 1, 3
- Intensive cessation counseling and psychological support should be arranged before discharge, as anxiety and depression commonly accompany withdrawal. 2, 4
Expected Withdrawal Symptoms (First 1-2 Weeks)
- Cannabis withdrawal syndrome occurs in approximately 47% of regular users and begins 24-72 hours after stopping. 2, 4
- Expect irritability, anxiety, insomnia, decreased appetite, restlessness, and gastrointestinal symptoms peaking between days 2-6. 2, 4
- These withdrawal symptoms are temporary and resolve within 14 days – they are distinct from the hyperemesis episodes that occurred during active cannabis use. 4
- Pain or abdominal cramping during this period may represent withdrawal itself, not disease recurrence. 2, 4
Symptom Management at Home
For Nausea/Vomiting Episodes:
- Hot showers or baths provide temporary relief but do not treat the underlying condition. 3, 5, 6
- Over-the-counter ondansetron may be tried but often has limited effectiveness. 2, 3
- Return to the emergency department if you cannot keep down fluids for more than 12 hours – dehydration and acute kidney injury are serious complications. 7
For Withdrawal Symptoms:
- Use loperamide (Imodium) for diarrhea and gastrointestinal distress. 2, 4
- Ondansetron may help nausea during withdrawal. 2, 4
- Avoid all opioid pain medications – they worsen nausea, carry addiction risk, and do not address the underlying problem. 2, 3
Long-Term Prevention Medication
- Start amitriptyline 25 mg at bedtime tonight (if prescribed). 2, 3
- Increase by 25 mg weekly until reaching 75-100 mg nightly for long-term prevention. 2, 3
- This tricyclic antidepressant is the mainstay of preventive therapy and helps prevent symptom recurrence. 2, 3
Follow-Up Appointments Required
- Schedule with your primary care provider within 1 week for cannabis cessation support and medication management. 1
- If you were using >1.5 g/day of smoked cannabis, >20 mg/day THC oil, or >300 mg/day CBD oil, your cannabis prescriber (if applicable) must be notified of your hospitalization and diagnosis. 1, 4
- Consider referral to psychiatry or addiction medicine for severe withdrawal symptoms or if you have difficulty maintaining abstinence. 2, 4
Pregnancy Considerations (If Applicable)
- Cannabis use during pregnancy is associated with nausea and vomiting syndromes. 1
- Complete cessation is essential for both maternal health and fetal safety. 1
- Discuss all medications, including amitriptyline, with your obstetrician before taking them. 1
Red Flags – Return to Emergency Department If:
- Unable to keep down any fluids for >12 hours (risk of acute kidney injury). 7
- Severe abdominal pain that differs from your typical episodes. 2
- Blood in vomit or stool. 2
- Confusion, severe weakness, or dark urine (signs of dehydration or rhabdomyolysis). 7, 8
- Chest pain or difficulty breathing. 2
Critical Pitfalls to Avoid
- Do not resume cannabis use thinking "just once won't hurt" – any amount will restart the cycle. 1, 3
- Do not use anticholinergic medications (like Benadryl) if you experience confusion, as they worsen delirium. 2
- Do not request opioids for abdominal pain – they are contraindicated in this condition. 2, 3
- Do not delay seeking care if you cannot maintain hydration. 7
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