Cannabinoid Hyperemesis Syndrome

●

CHS is a syndrome of cyclic vomiting, nausea, and abdominal pain often refractory to available antiemetics

and analgesics in patients who chronically use cannabis.

o

Hallmark symptom of CHS is compulsive hot bathing as it results in symptom relief.

●

Cannabis cessation is the only current definitive treatment of CHS.

o

Treatment is unknown, but regimens include capsaicin, dopamine antagonists, and benzodiazepines.

o

Opioids should be avoided as they may exacerbate nausea and vomiting.

Capsaicin

Dopamine Antagonists

Benzodiazepines

Mechanism of

Action

Stimulates transient receptor

potential vanilloid-1 (TRPV1),

a G-protein coupled

receptor on peripheral

tissue; TRPV1 interacts with

the endocannabinoid

system resulting in symptom

relief

Antagonizes dopamine

receptor upregulation in

chronic cannabis use; targets

D2 receptors in the

gastrointestinal tract and

chemoreceptor trigger zone

Stimulation of inhibitory

neurotransmitter GABA to

reduce nausea/vomiting

anticipation; dereases

activation of cananbnioid

type receptor 1 (CB1) in

frontal cortex

Dose

2-3 inch strip

Haloperidol: 1-5 mg

Droperidol: 0.625-2.5 mg

Clonazepam: 0.5 mg

Administration

Topical application to

abdomen or back of arms

IV, PO

IV, PO, ODT

Recommended

Dosage Form

Cream: 0.05%, 0.075%, 0.1%

IV

IV, ODT

Adverse Effects

Author,

Year

Design

(Sample Size)

Intervention &

Comparison

Outcomes

Capsaicin

Kum et al.,

2021

Retrospective, cohort

(n=201)

Topical capsaicin

Adult & pediatric patients

● Greater proportion of patients who received capsaicin

achieved primary efficacy outcome

(55 vs 21%, p<0.001, OR 1.44 [95% CI 0.586-0.820])

● Reduction in time to discharge following capsaicin

admin (3.72 vs 6.11 hr, p=0.001)

Yusuf et al.,

2021

Retrospective,

observational

(n=55)

Topical capsaicin vs no

capsaicin

● Capsaicin administration within first two rounds of

medication treatment had significantly shorter length

of stay (4.83 vs 7.09 h, p=0.01)

● No difference in 24 h bounceback or admission rate

between groups (0.11 vs 0.10, p=0.43; 0.19 vs 0.05,

p=0.07)

Dean et al.,

2020

Double-blind,

randomized, placebo-

controlled

(n=30)

Topical capsaicin 0.1% vs

placebo

Capsaicin administration was associated with

significant reduction in nausea/vomiting at 30

●

Capsaicin and dopamine antagonists appear as potential treatment options for CHS symptom management;

however the only true treatment is cannabis cessation.

Lapoint J, et al. West J Emerg Med. 2018:19(2):380-86.

Sorensen CJ, et al. J Med Toxicol. 2017;13:71-87.

Kum, et al. Am J Emerg Med. 2021;49:343-51.

Yusuf, et al. Am J Emerg Med. 2021;43:142-8.

Dean, et al. Acad Emerg Med. 2020;27(11):1166-72.

Wagner S, et al. Clin Toxciol (Phila). 2020;58(6):471-5.

Graham, et al. Pediatrics. 2017;140(6):e20163795.

Dezieck L, et al. Clin Toxicol (Phila). 2017;55(8):908-13.

Ruberto A, et al. Ann Emerg Med. 2021;77(6):613-9.

• Lee, et al. Clin Toxicol (Phila). 2019;57(9):773-7.
• Witsil JC, et al. Am J Ther. 2017;24(1):e64-7.
• Inayat F, et al. BMJ Case Rep. 2017;bcr2016218239.
• Hickey JL, et al. Am J Emerg Med. 2013;31(6):1003.e5-6.
• Kheifets M, et al. IMAJ. 2019;21:404-7.