Episode 181: Cannabinoid Hyperemesis Syndrome Future Dr. Johnson explains the pathophysiology, assessment, and management of Cannabinoid Hyperemesis syndrome. Dr. Arreaza adds some insights on the topic. Written by Tyler Johnson, MSIV, Western University of Health Sciences, College of Osteopathic Medicine of the Pacific-Northwest. Editing and comments by Hector Arreaza, MD.
Episode 181: Cannabinoid Hyperemesis Syndrome
Future Dr. Johnson explains the pathophysiology, assessment, and management of Cannabinoid Hyperemesis syndrome. Dr. Arreaza adds some insights on the topic.
Written by Tyler Johnson, MSIV, Western University of Health Sciences, College of Osteopathic Medicine of the Pacific-Northwest. Editing and comments by Hector Arreaza, MD.
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Definition
Cannabinoid hyperemesis syndrome (CHS) is a syndrome of cyclic abdominal pain, vomiting, or nausea in older adolescents and adults who have chronic ϲаnոаbis use.
The term “marijuana” is considered racist by some people. In the 1930s, American politicians popularized the term “marijuana” in the U.S. to portray the drug as a “Mexican vice” and to have a justification to persecute Mexican immigrants.
Epidemiology
The overall prevalence of cannabinoid hyperemesis syndrome is unknown due to a lack of definitive criteria or diagnostic tests. It occurs in a population that may not disclose substance use. One study conducted in 2015 in a United States urban emergency department not named, found one-third of patients with near-daily cannabis use met criteria for having had CНЅ in the prior six months.
Why are rates of CHS increasing?
Between 2005-2014 hospitalizations cyclic vomiting syndromes increased by 60 %. concurrent cannabis use in hospitalized patients increasing from 2 to 21 percent. 7 years after the commercialization of cannabis in Canada, the Canadian health services found a 13-fold increase in cyclic vomiting syndromes
Potential correlations for the increase in CHS are increased legalization and commercialization of cannabis, higher tetrahydrocannabinol concentrations in cannabis products, and increased recognition of the syndrome.
Legal status of Cannabis in the US
Cannabis is legal in 24 states: Alaska, Arizona, California, Colorado, Connecticut, Delaware, Illinois, Maine, Maryland, Massachusetts, Michigan, Minnesota, Missouri, Montana, Nevada, New Jersey, New Mexico, New York, Ohio, Oregon, Rhode Island, Vermont, Virginia, and Washington. It is also legal in Washington, D.C. Cannabis is approved for medical use in 38 states.
Federal level:
Cannabis
is a Schedule I drug, under the Controlled Substance Act (added in 1970) in the group of Hallucinogenic or psychedelic substances.
Tetra-hydro-cannabinol
(THC, a “mind-altering substance in cannabis”) is on the same list. However, cannabidiol (CBD, derived from hemp or non-hemp plants) was removed from the Controlled Substances Act in 2018. CBD is FDA-approved (under the name of Epidiolex®) to treat rare seizure disorders.
CBD is still on the list of controlled substances in some states. I see THC as a problem.
THC increased concentration
As recreational Cannabis becomes more normalized, innovators look to find new ways to differentiate their product and increasing THC has become a common way to perform this similar to alcohol content in the beer, wine, and liquor industry.
An article by Yale School of Medicine titled “Marijuana: Rising THC Concentrations in Cannabis Can Pose Health Risks” states, “In 1995, the average THC content in cannabis seized by the Drug Enforcement Administration was about 4%. By 2017, it had risen to 17% and continues to increase. Beyond the plant, a staggering array of other cannabis products with an even higher THC content like dabs, oils, and edibles are readily available—some as high as 90%.”
Recently, cannabis-infused water started to be sold in some grocery stores.
Pathophysiology of CHS
It is not entirely understood. Some suggest multifactorial involving cannabinoid metabolism, exposure dose and tolerance modifying receptor regulation, complex pharmacodynamics at Cannabinoid receptors, and even changes in genetics and cannabinoid variation in plants.
CB1 receptors are involved in gastric secretion, sensation, motility, inflammation, and lipogenesis. The activation of CB1 and CB2 receptors has been suggested as the possible cause of CHS.
Risk Factors
CHS can occur after acute or acute on chronic use but many report daily 3-5x cannabis use cannabis use over one year and many over at least two years. Median age 24 years.
Interesting facts
Medical visits for inhaled cannabis are more likely associated with CHS while edibles are more likely for acute psychiatric reactions.
Also, CHS is a paradoxical effect since cannabis and cannabinoid receptor agonists are known antiemetics (as seen in nabilone and dronabinol (synthetic analogs of THC)) and prescribed by some physicians to combat chemotherapy effects.
Clinical Features of CHS
Cyclical pattern with abdominal pain, severe nausea, and vomiting up to 30 episodes daily. Pain is intense and even referred to as “scromiting” due to its intense nature, causing patients to scream and vomit concurrently.
Typically, it presents with 2 or more episodes over a 6-month period with no symptoms in between. It starts within 24 hours of last cannabis use (differentiating from cannabis withdrawal) and occurs at day or night.
There is a gradual symptom resolution of nausea and vomiting after several days of cannabis cessation.
Some patients had symptoms 2 days to 2 weeks after cessation.
Diagnosis of CHS
Clinical diagnosis
Rule out neurological symptoms such as migraine headaches, acute abdomen, motion sickness, and medications, such as recent antibiotics and chemotherapy.
Often the diagnosis is discovered with a thorough history reporting a decrease in symptoms with hot showers/baths.
Management of CHS
Acute
Rehydrate with Fluids
Dopamine Antagonists– Droperidol (0.625 or 1.25mg) /Haloperidol (0.05 to 0.1mg/kg with max dose of 5mg initially) favored over typical antiemetics like Zofran or Reglan.
If needed, combine with an antiemetic like metoclopramide IM or ondansetron IV and consider patients’ dehydration status likely requiring US-guided IV.
Topical capsaicin cream 0.025 – 0.1% on the abdomen.
Long term
97% resolution of symptoms completely in a systematic review of patients who stopped cannabis use.
Reinforce it may take several weeks of abstinence for symptoms to resolve and symptoms can worsen if cannabis is resumed. It is unknown if a reduction in use can prevent recurrence.
Approaches in the clinic
Educate patients on the etiology of their symptoms with complete cessation of cannabis use.
Consider referral to counseling for cannabis use disorder and abstinence support for treatment-seeking cannabis users.
Approach topics such as changing one's environment, seeking social support, and using self-help techniques to non-treatment-seeking individuals.
Consider referring patients with polysubstance use and significant comorbidities to a supervised withdrawal management setting.
Conclusion: Cannabis use is increasing with legalization and commercialization across the United States. With increased use, Cannabinoid hyperemesis syndrome incidence increases. Often it can be diagnosed with a thorough history including chronic cannabis consumption and symptomatic relief by showers. Physicians will need to develop counseling approaches to better understand CHS patients and how to approach an often-difficult topic.
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