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


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

In This Article

Treatment of CHS

Per the expert consensus guideline, once the diagnosis of CHS has been made and there is a low suspicion for other acute diagnoses, 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 employ as first line treatment.[18,20] While this recommendation is made based on very limited data including a few small case series, capsaicin is inexpensive, has a low risk side-effect profile, makes mechanistic sense, and is well tolerated.[20,22] Conversely, there are no data demonstrating efficacy of opioids for CHS. Capsaicin 0.075% can be applied to the abdomen or the backs of the arms. If the patients can identify regions of their bodies where hot water provides symptom relief, those areas should be prioritized for capsaicin application. Patients should be advised that capsaicin may be uncomfortable initially, but then should rapidly mimic the relief that they receive with hot showers. Additionally patients must be counseled to avoid application near the face, eyes, genitourinary region, and other areas of sensitive skin, not to apply capsaicin to broken skin, and not to use occlusive dressings over the applied capsaicin. Patients can be discharged home with capsaicin, advising application three or four times a day as needed. If capsaicin is not readily available, but there is a shower available in the ED, patients can be advised to shower with hot water to provide relief. Educate patients to use caution to avoid thermal injury, as there are reports of patients spending as long as four hours at a time in hot showers.[11]

Other possible therapeutic interventions include administration of antipsychotics such as haloperidol 5 mg IV/IM or olanzapine 5 mg IV/IM or ODT, which have been described to provide complete symptom relief in case reports.[23,24] Conventional antiemetics, including antihistamines (diphenhydramine 25–50 mg IV), serotonin antagonists (ondansetron 4–8 mg IV), dopamine antagonists (metoclopramide 10 mg IV), and benzodiazepines can be used, though reports of effectiveness are mixed.[7,9] Provide intravenous fluids and electrolyte replacement as indicated. Avoid opioids if the diagnosis of CHS is certain.

Clinicians should inform patients that their symptoms are directly related to continued use of cannabis. They should further advise patients that immediate cessation of cannabis use is the only method that has been shown to completely resolve symptoms. Reassure patients that symptoms resolve with cessation of cannabinoid use and that full resolution can take anywhere from 7–10 days of abstinence.[7] Educate patients that symptoms may return with re-exposure to cannabis. Provide clear documentation in the medical record to assist colleagues with confirming a diagnosis, as these patients will frequently re-present to the ED.