Cannabinoid Hyperemesis Syndrome

Public Health Implications and a Novel Model Treatment Guideline

Jeff Lapoint, DO; Seth Meyer, MD; Charles K. Yu, MD; Kristi L. Koenig, MD; Roneet Lev, MD; Sayone Thihalolipavan, MD, MPH; Katherine Staats, MD; Christopher A. Kahn, MD, MPH

Disclosures

Western J Emerg Med. 2018;19(2):380-386. 

In This Article

Abstract and Introduction

Abstract

Introduction: Cannabinoid hyperemesis syndrome (CHS) is an entity associated with cannabinoid overuse. CHS typically presents with cyclical vomiting, diffuse abdominal pain, and relief with hot showers. Patients often present to the emergency department (ED) repeatedly and undergo extensive evaluations including laboratory examination, advanced imaging, and in some cases unnecessary procedures. They are exposed to an array of pharmacologic interventions including opioids that not only lack evidence, but may also be harmful. This paper presents a novel treatment guideline that highlights the identification and diagnosis of CHS and summarizes treatment strategies aimed at resolution of symptoms, avoidance of unnecessary opioids, and ensuring patient safety.

Methods: The San Diego Emergency Medicine Oversight Commission in collaboration with the County of San Diego Health and Human Services Agency and San Diego Kaiser Permanente Division of Medical Toxicology created an expert consensus panel to establish a guideline to unite the ED community in the treatment of CHS.

Results: Per the consensus guideline, treatment should focus on symptom relief and education on the need for cannabis cessation. Capsaicin is a readily available topical preparation that is reasonable to use as first-line treatment. Antipsychotics including haloperidol and olanzapine have been reported to provide complete symptom relief in limited case studies. Conventional antiemetics including antihistamines, serotonin antagonists, dopamine antagonists and benzodiazepines may have limited effectiveness. Emergency physicians should avoid opioids if the diagnosis of CHS is certain and educate patients that cannabis cessation is the only intervention that will provide complete symptom relief.

Conclusion: An expert consensus treatment guideline is provided to assist with diagnosis and appropriate treatment of CHS. Clinicians and public health officials should identity and treat CHS patients with strategies that decrease exposure to opioids, minimize use of healthcare resources, and maximize patient safety.

Introduction

Cannabis is the most widely used illicit substance in the United States. In 2014, 22.2 million Americans 12 years of age and older reported current cannabis use.[1] The rapidly changing political landscape surrounding cannabis use has the potential to increase these numbers dramatically. Twenty-nine states and the District of Columbia have legalized medicinal use of cannabis.[2] In addition, as of 2017 California, seven other states and the District of Columbia have legalized recreational use of marijuana.[3] The incidence of CHS and other marijuana-related emergency department (ED) visits has increased significantly in states where marijuana has been legalized.[4] A study published in 2016 evaluating the effects of cannabis legalization on EDs in the state of Colorado found that visits for cyclic vomiting—which included CHS in this study—have doubled since legalization.[5]

Despite the syndrome's increasing prevalence, many physicians are unfamiliar with its diagnosis and treatment. CHS is marked by symptoms that can be refractory to standard antiemetics and analgesics.[6,7] Notwithstanding increasing public health concerns about a national opioid epidemic and emerging guidelines advocating non-opioid alternatives for management of painful conditions, these patients are frequently treated with opioids.[6,8,9] In light of the public health implications of a need to reduce opioid use when better alternatives exist, this paper describes the current state of knowledge about CHS and presents a novel model treatment guideline that may be useful to frontline emergency physicians and other medical providers who interface with these patients. The expert consensus process used to develop the model guideline is also described.

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