Cannabinoid Hyperemesis Syndrome Research Articles

Cannabinoid Hyperemesis Syndrome: What Do We Know?

Cannabinoid Hyperemesis Syndrome: What Do We Know?

Guidelines for Reasonable and Appropriate Care in the Emergency Department (GRACE-4): Alcohol use disorder and cannabinoid hyperemesis syndrome management in the emergency department.

The fourth Society for Academic Emergency Medicine (SAEM) Guidelines for Reasonable and Appropriate Care in the Emergency Department (GRACE-4) is on the topic of the emergency department (ED) management of nonopioid use disorders and focuses on alcohol withdrawal syndrome (AWS), alcohol use disorder (AUD), and cannabinoid hyperemesis syndrome (CHS). The SAEM GRACE-4 Writing Team, composed of emergency physicians and experts in addiction medicine and patients with lived experience, applied the Grading of Recommendations Assessment Development and Evaluation (GRADE) approach to assess the certainty of evidence and strength of recommendations regarding six priority questions for adult ED patients with AWS, AUD, and CHS. The SAEM GRACE-4 Writing Team reached the following recommendations: (1) in adult ED patients (over the age of 18) with moderate to severe AWS who are being admitted to hospital, we suggest using phenobarbital in addition to benzodiazepines compared to using benzodiazepines alone [low to very low certainty of evidence]; (2) in adult ED patients (over the age of 18) with AUD who desire alcohol cessation, we suggest a prescription for one anticraving medication [very low certainty of evidence]; (2a) in adult ED patients (over the age of 18) with AUD, we suggest naltrexone (compared to no prescription) to prevent return to heavy drinking [low certainty of evidence]; (2b) in adult ED patients (over the age of 18) with AUD and contraindications to naltrexone, we suggest acamprosate (compared to no prescription) to prevent return to heavy drinking and/or to reduce heavy drinking [low certainty of evidence]; (2c) in adult ED patients (over the age of 18) with AUD, we suggest gabapentin (compared to no prescription) for the management of AUD to reduce heavy drinking days and improve alcohol withdrawal symptoms [very low certainty of evidence]; (3a) in adult ED patients (over the age of 18) presenting to the ED with CHS we suggest the use of haloperidol or droperidol (in addition to usual care/serotonin antagonists, e.g., ondansetron) to help with symptom management [very low certainty of evidence]; and (3b) in adult ED patients (over the age of 18) presenting to the ED with CHS, we also suggest offering the use of topical capsaicin (in addition to usual care/serotonin antagonists, e.g., ondansetron) to help with symptom management [very low certainty of evidence].

Clinician perspectives on adolescent cannabis-related beliefs and behaviors following recreational cannabis legalization

BackgroundAs more states legalize cannabis, studies are needed to understand the potential impacts of recreational cannabis legalization (RCL) on adolescents from the perspective of clinicians who care for them. MethodsThis qualitative study characterized clinician perspectives on whether cannabis legalization is associated with changes in adolescents’ cannabis use beliefs, behaviors, and consequences. Semi-structured qualitative interviews were conducted with 32 clinicians in a large healthcare organization from 9/6/2022–12/21/2022. Video-recorded interviews were transcribed and analyzed using thematic analysis. ResultsThe 32 participants (56.3 % female, mean [SD] age, 45.9 [7.6] years; 65.3 % non-Hispanic White) were from Addiction Medicine (n = 13), Psychiatry/Mental Health (n = 7), Pediatrics (n = 5), and the Emergency Department (n = 7). Clinicians described post-RCL increases in adolescent cannabis use, use of non-combustible modes and high-potency products, and younger age of first use. Clinicians reported social, physical, and policy changes, including changes in social norms, appealing advertisements, marketing, and easier access. Many noted fewer perceived harms among adolescents and greater self-medication post-RCL. They described how RCL contributed to increased parental cannabis use and permissiveness around adolescent use. Finally, many described post-RCL increases in cannabis hyperemesis syndrome, and several noted increased cannabis-related psychosis and acute intoxication, and decreased court-mandated treatment. ConclusionsClinicians from diverse specialties described post-RCL increases in adolescent cannabis use and cannabis-related consequences, alongside changes in social norms, access, marketing and advertisements, and decreased perceptions of harms. Findings can inform strategies to support adolescents in the context of increased cannabis availability and acceptability post-legalization and support the development of hypotheses for broader-scale quantitative work.

Distinguishing Clinical Features of Cannabinoid Hyperemesis Syndrome and Cyclic Vomiting Syndrome: A Retrospective Cohort Study

ObjectiveTo identify clinical characteristics that distinguish cannabinoid hyperemesis syndrome (CHS) from cyclic vomiting syndrome (CVS), two conditions marked by episodes of nausea, vomiting, and abdominal pain. Study designWe performed a retrospective chart review of patients admitted to a large children’s healthcare system from 2015 through 2022. CHS and CVS patients were identified by the electronic medical record using ICD-9/10 codes. ResultsOf 201 patients screened, 125 were included. CHS patients were older than those with CVS (mean [SD] 18.06 [1.41] vs. 14.50 [2.91] years, p<0.001). There were no significant differences in gender, race, ethnicity, or hospital length of stay between groups. CHS patients were more likely to have a positive urine drug screen (86% vs. 2.9%, p<0.001), lower mean (SD) serum potassium (3.62 [0.77] vs. 3.88 [0.49], p<0.001), and higher mean (SD) serum creatinine (0.83 (0.41) vs. 0.63 (0.17), p<0.001). The average (SD) systolic blood pressure (SBP) was significantly higher in CHS patients (SBP 124.46 [10.66] vs. 118.55 [10.99], p=0.032) compared with CVS children of comparable age range. Imaging was obtained in 36% of all patients and only 2.4% had abnormalities. ConclusionsClinical features including older age, higher systolic blood pressure, positive urine drug screen, and select electrolyte findings might distinguish CHS from CVS. Abdominal imaging in both conditions is of low yield. These findings may allow for early recognition and appropriate therapy in CHS patients.

Cannabis Hyperemesis Syndrome in a Recently Abstinent Chronic User: Assessment and Intervention

BACKGROUND: Cannabis Hyperemesis Syndrome (CHS) is a condition characterized by episodic bursts of vomiting and abdominal pain linked to cannabis use. The clinical picture mimics an acute abdomen and is often misdiagnosed, especially when the patient avoids reporting their cannabis use for legal reasons.&#x0D; CASE REPORT: We report on the case of a 33-year-old man that was brought to the emergency room with a history of 3 days of non-bloody, non-projectile, and non-bilious brownish vomit, coupled with severe epigastric and left hypochondriac pain, and a slight fever. He was a daily cannabis user for several years and had stopped using a week or so before the onset of the symptoms, as he was traveling to a country with more restrictive cannabis laws. His condition deteriorated rapidly, followed by emergency room attendance, thorough diagnostic work-up, and unsuccessful interventions, including intravenous treatment with the anti-emetic Ondansetron. The patient was referred to a psychiatrist after a suspected psychogenic etiology by the medical team. The history was suggestive of CHS and also included anxious, depressed mood with ‘brain fog’. The abdominal pain was the most severe complaint. A combination of tramadol, promethazine, and mirtazapine given on an outpatient basis led to full recovery within 10 days.&#x0D; CONCLUSION: CHS can occur soon after the interruption of chronic cannabis use and overlap with withdrawal symptom. A combination of anti-histaminergic, opioid-based medication, and antidepressant mirtazapine seemed an effective treatment of CHS, which resulted in a relatively quick recovery.

Rising Inpatient Utilization and Costs of Cannabis Hyperemesis Syndrome Hospitalizations in Massachusetts After Cannabis Legalization.

We described the demographics, inpatient utilization, and cost of services among patients hospitalized for putative cannabinoid hyperemesis syndrome (CHS) predating and postdating cannabis legalization in Massachusetts. As the recreational use of cannabis has been widely legalized nationally, the resulting shifts in clinical presentation, health care utilization, and estimated costs of CHS hospitalizations remain unclear in the postlegalization era. We performed a retrospective cohort study among patients admitted to a large urban hospital between 2012 and 2021, before and after the date of cannabis legalization in Massachusetts (Dec 15, 2016). We examined the demographic and clinical characteristics of patients admitted for putative CHS, the utilization of hospital services, and estimated inpatient costs pre and postlegalization. We identified a significant increase in putative CHS hospitalizations pre and post-cannabis legalization in Massachusetts (0.1% vs 0.02% of total admissions per time period, P < 0.05). Across 72 CHS hospitalizations, patient demographics were similar pre and postlegalization. Hospital resource utilization increased postlegalization, with increased length of stay (3 d vs 1 d, P < 0.005), and need for antiemetics ( P < 0.05). Multivariate linear regression confirmed that postlegalization admissions were independently associated with increased length of stay ( Β = 5.35, P < 0.05). The mean cost of hospitalization was significantly higher postlegalization ($18,714 vs $7460, P < 0.0005), even after adjusting for medical inflation ($18,714 vs $8520, P < 0.001) with intravenous fluid administration and endoscopy costs increased ( P < 0.05). On multivariate linear regression, hospitalization for putative CHS during postlegalization predicted increased costs ( Β = 10,131.25, P < 0.05). In the postlegalization era of cannabis in Massachusetts, we found increased putative CHS hospitalizations, with a concomitant increased length of hospital stay and total cost per hospitalization. As cannabis use increases, the recognition and costs of its deleterious effects are necessary to incorporate into future clinical practice strategies and health policy.

Cannabinoid hyperemesis syndrome: prevalence and management in an era of cannabis legalization.

As more states legalize cannabinoid products for recreational use and medicinal purposes, the prevalence of cannabinoid hyperemesis syndrome has become increasingly common. Yet, it remains unrecognized to many healthcare providers along with the most efficacious treatments. Cannabinoid hyperemesis syndrome most often presents with episodic vomiting secondary to chronic daily cannabis use over several months to years. Patients often complain of nausea and abdominal pain that is improved by taking hot showers or baths. Symptoms are alleviated with the cessation of cannabis use over a period of 6-12 months. Treatment for acute attacks often consists of parenteral benzodiazepines in the inpatient setting. Long-term management and prevention of further attacks are aided by tricyclic antidepressants such as amitriptyline with a dose range of 50-200 mg/d. Once a patient is in remission, amitriptyline can be tapered slowly. As cannabis becomes more widely available and accepted in the continental United States, so must education on the diagnosis of cannabinoid hyperemesis syndrome and treatment strategies.

Adverse outcomes of cannabis use in Canada, before and after legalisation of non-medical cannabis: cross-sectional analysis of the International Cannabis Policy Study

ObjectivesTo date, there is little evidence on the extent to which cannabis legalisation affects the prevalence of adverse events from cannabis at the population level. The current study examined trends...

Cannabis use in the United States and its impact on gastrointestinal health.

In recent years, the legalization and social acceptability of cannabis use have increased in the United States. Concurrently, the prevalence of cannabis use has continued to rise, and cannabis products have diversified. There are growing concerns regarding the health effects of regular and high-potency cannabis use, and new research has shed light on its potentially negative effects. Here, we review evidence of the gastrointestinal (GI) effects of cannabis and cannabinoids. Dysregulation of the endocannabinoid system might contribute to various GI disorders, including irritable bowel syndrome and cyclic vomiting syndrome, and endocannabinoids have been found to regulate visceral sensation, nausea, vomiting, and the gut microbiome. Cannabis has been shown to have antiemetic properties, and the US Food and Drug Administration has approved cannabis-based medications for treating chemotherapy-induced nausea and vomiting. Yet, chronic heavy cannabis use has been linked to recurrent episodes of severe nausea and intractable vomiting (cannabinoid hyperemesis syndrome). Given the considerable heterogeneity in the scientific literature, it is unclear if cannabinoid hyperemesis syndrome is truly a distinct entity or a subtype of cyclic vomiting that is unmasked by heavy cannabis use and the associated dysregulation of the endocannabinoid system. The changes in cannabis legalization, availability, and public risk perceptions have outpaced research in this area and there is a need for robust, prospective, large-scale studies to understand the effects of cannabis use on GI health.

Gastric Adenocarcinoma Masquerading as Cannabis Hyperemesis Syndrome

Gastric Adenocarcinoma Masquerading as Cannabis Hyperemesis Syndrome

Persisting and repetitive vomiting in adolescence: a consequence of cannabinoid use

ABSTRACT Background Persisting and uncontrollable vomiting in adolescence can indicate several disorders, from self-limiting diseases to life-threatening conditions. Case Report Herein, we present the case of an adolescent boy with two previous hospitalizations for persistent vomiting with abdominal pain who showed no improvement after ondansetron and omeprazole treatment. Both episodes were characterized by emesis, abdominal discomfort/pain with normal physical examination, and normal radiography and blood analysis. The patient reported relief following a hot water bath. During the second episode, a urinary drug test was performed, which was positive for cannabinoids. Subsequently, he confessed to frequent cannabinoid use during the past two years. Discussion Cannabinoid hyperemesis syndrome is characterized by cycles of severe persistent nausea and recurrent vomiting associated with abdominal pain in the setting of chronic cannabis use. Physicians should be aware of and fully consider this differential diagnosis due to the rise in cannabis use worldwide.

The Impact of Gastroparesis on Medical Therapy for Gastroesophageal Reflux Disease (GERD)

Symptoms suspicious for gastroesophageal reflux disease (GERD) represent frequent indications for medical presentation, as do symptoms potentially compatible with delayed gastric emptying. In this clinical setting, care must be taken to characterize patient symptoms accurately, and also appropriately evaluate for pathophysiologic processes including visceral hypersensitivity, rumination syndrome, supragastric belching, cannabinoid hyperemesis, and cyclic vomiting syndrome. While proton pump inhibitors (PPI) are the foundation of medical management of GERD, delayed gastric emptying is a downstream factor that can promote gastroesophageal reflux and warrants tailored clinical management. Specifically, patients with refractory symptoms in the setting of GERD and delayed gastric emptying may benefit from personalized adjunct medical therapy with prokinetics.

Cannabinoid hyperemesis syndrome presenting with ventricular bigeminy

The is a case of a 28-year-old male presenting to an emergency department (ED) via emergency medical services (EMS) with a chief complaint of “gastritis.” He was noted to have bigeminy on the pre-arrival EMS electrocardiogram. He was ultimately diagnosed with cannabinoid hyperemesis syndrome (CHS). CHS is becoming an exceedingly common emergency department presentation due to the poorly regulated but widespread availability of cannabis products. The authors discuss a case of CHS and ventricular bigeminy.

Cannabis use and cyclical vomiting syndrome: An open debate

IntroductionCyclical vomiting syndrome (CVS) carries a significant financial burden on the U.S. healthcare system due to the recurrent emergency department visits and inpatient hospitalizations. We aimed to update the literature on the predictors of hospital utilization and readmission among individuals admitted with CVS. MethodsThis is a retrospective nationwide study of patients hospitalized with a primary diagnosis of CVS. Using weighted data from the National Inpatient Sample (NIS) and the National Readmission Database (NRD), we conducted a multivariate regression analysis to assess predictors of length of stay (LOS), and 30-day readmission. ResultsPrimary admissions for CVS totaled 35,055 in the NIS, and 31,240 in the NRD. 2012 patients (6.4%) were readmitted within 30 days. On multivariate regression, cannabis use was associated with reduced LOS (adjusted Mean Difference (aMD) = −0.53 days, 95% CI: −0.68 to −0.38), and 30-day readmissions (adjusted Hazard Ratio (aHR) = 0.63, 95% CI: 0.54–0.73). DiscussionCannabis use among CVS admissions was associated with reduced LOS and 30-day readmissions; these results could be in fact driven by Cannabis Hyperemesis Syndrome (CHS)-related hospitalizations and the effect of cannabis cessation on decreased symptomatology. ICD-10 coding for CHS should be transitioned to specific codes to improve the differentiation between CVS and CHS-related hospitalizations.

S4063 Sometimes it's Not Cannabis Hyperemesis Syndrome: A Case of Duodenal Adenocarcinoma in a 48-Year-Old Female

S4063 Sometimes it's Not Cannabis Hyperemesis Syndrome: A Case of Duodenal Adenocarcinoma in a 48-Year-Old Female

Nausea and vomiting of pregnancy and prenatal cannabis use in a Michigan sample

Nausea and vomiting of pregnancy, also referred to as morning sickness, affects more than 70% of all pregnancies. Symptoms range from mild to severe and, in some cases, can be debilitating, resulting in a reduced quality of life. Moreover, prenatal cannabis use prevalence has doubled in the United States, and cannabis potency, measured by the concentration of delta-9-tetrahydrocannabiniol, has increased from 10% in 2009 to 14% in 2019. State-level recreational legalization of cannabis may contribute to the liberalization of its use and reduced risk perception. Furthermore, the relatively recent discovery of cannabinoid hyperemesis syndrome may contribute to the mischaracterization of morning sickness in individuals who use cannabis during pregnancy. Although cannabis has well-documented antiemetic properties, there is insufficient research on the topic. Therefore, it is essential to establish a tangible understanding of the association between nausea and vomiting of pregnancy and prenatal cannabis use. This study aimed to estimate the degree to which nausea and vomiting of pregnancy might be associated with prenatal cannabis use in a sample of pregnant people in Michigan, a state where recreational cannabis use became legal in December 2018. This was a prospective study of participants from the Michigan Archive for Research on Child Health, a population-based pregnancy cohort that was recruited using a probability-based sampling approach. Participants were recruited from 22 prenatal clinics located throughout Michigan's lower peninsula. Cross-sectional analyses were performed for data available between October 2017 and January 2022. Among this sample of Michigan pregnant people, 14% (95% confidence interval, 11%-16%) reported cannabis use. Participants who experienced increasing morning sickness severity had higher odds of using cannabis (adjust odds ratio, 1.2; 95% confidence interval, 1.1-1.2). When the sample was restricted to first-trimester morning sickness and cannabis use, the results remained statistically robust. When the direction of the association was reversed, an increase in morning sickness severity was detected among participants who used cannabis during pregnancy (ßadjusted, 0.2; 95% confidence interval, 0.1-0.2). Lastly, the association between prepregnancy cannabis use and first-trimester morning sickness was investigated. Study findings suggest an increase in morning sickness severity among people who used cannabis in the 3 months before pregnancy compared with those who did not use cannabis (ßadjusted, 0.1; 95% confidence interval, 0.003-0.200). Study findings indicated a link between nausea and vomiting of pregnancy and prenatal cannabis use. Moreover, this study revealed that using cannabis in the 3 months before pregnancy is associated with first-trimester morning sickness severity. The strengths of our study contribute to the scant epidemiologic evidence in this area of research. More fine-grained, time-specific data on nausea and vomiting of pregnancy and prenatal cannabis use are necessary to draw inferences about cause-effect relationships. Our study might provide a basis to discourage cannabis use during pregnancy until more evidence is collected.

Cannabis Use Patterns and Whole-Blood Cannabinoid Profiles of Emergency Department Patients With Suspected Cannabinoid Hyperemesis Syndrome.

The objectives of this study were to characterize the detailed cannabis use patterns (eg, frequency, mode, and product) and determine the differences in the whole-blood cannabinoid profiles during symptomatic versus asymptomatic periods of participants with suspected cannabinoid hyperemesis syndrome recruited from the emergency department (ED) during a symptomatic episode. This is a prospective observational cohort study of participants with symptomatic cyclic vomiting onset after chronic cannabis use. Standardized assessments were conducted to evaluate for lifetime and recent cannabis use, cannabis use disorder, and cannabis withdrawal symptoms. Quantitative whole-blood cannabinoid testing was performed at 2 times, first when symptomatic (ie, baseline) and at least 2 weeks after the ED visit when asymptomatic. The differences in cannabinoid concentrations were compared between symptomatic and asymptomatic testing. The study was conducted from September 2021 to August2022. There was a difference observed between delta-9-tetrahydrocannabinol metabolites, but not the parent compound during symptomatic episodes and asymptomatic periods. Most participants (84%) reported using cannabis > once per day (median 3 times per day on weekdays, 4 times per day on weekends). Hazardous cannabis use was universal among participants; the mean cannabis withdrawal discomfort score was 13, indicating clinically significant rates of cannabis withdrawal symptoms with cessation of use. Most participants (79%) previously tried to stop cannabis use, but a few (13%) of them had sought treatment. Patients presenting to the ED with cannabinoid hyperemesis syndrome have high cannabis use disorder scores. Further studies are needed to better understand the influence of THC metabolism and concentrations on symptomatic cyclic vomiting.

Unexpected cause of recurrent diabetic ketoacidosis in type 1 diabetes: a case report

BackgroundGastrointestinal (GI) symptoms are commonly observed in patients with diabetic ketoacidosis (DKA), which usually resolves completely with therapy. However, GI symptoms can persist after DKA resolves, which can pose diagnostic and management challenges for physicians, especially when dealing with an exceptional diagnosis such as cannabinoid hyperemesis syndrome (CHS).Case presentationIn this case report, we present a patient with type 1 diabetes who had been treated for DKA 6 times in the past year and was eventually diagnosed with CHS.ConclusionIn conclusion, this case demonstrates that a presumptive and incorrect diagnosis can mislead physicians, especially when dealing with challenging diagnoses. Therefore, patients with type 1 diabetes with unusual presentations, such as unexpectedly high pH and bicarbonate levels, with hyperglycemic ketosis should be screened for illicit drug use, especially cannabis.

Cannabinoid hyperemesis syndrome: Clinical trajectories and patterns of use three months following a visit to the emergency department.

Cannabinoid hyperemesis syndrome (CHS) is a clinical condition of cyclic vomiting, nausea, and abdominal pain associated with chronic cannabis use. Despite increased recognition of CHS, there are limited details on cannabis use practices and symptoms over time. Understanding what happens in the period surrounding the emergency department (ED) visit, including any changes in symptoms and cannabis use practices following the visit, can help inform the development of patient-centered interventions around cannabis use disorder for patients with CHS. A prospective observational cohort (n = 39) of patients with suspected CHS recruited from the ED at the time of a symptomatic cyclic vomiting episode was followed for 3 months. Disease progression, cannabis use practices, and health care utilization were monitored. Participants reported high rates of persistent CHS symptoms (abdominal pain, nausea, or cyclic vomiting) in the 2-week period immediately following an ED visit with a median duration of 7 days. Cannabis use frequency and quantity were reduced immediately after the ED visit, but most participants returned to pre-ED visit cannabis use patterns within a few days. Recurrent ED visits for cyclic vomiting were reported by 25% of participants who completed follow-up during the 3-month follow-up period. Participants continued to have ongoing symptoms after the ED visit, but most managed symptoms on their own and did not return to the ED. Longitudinal studies beyond 3 months are needed to better understand the clinical course of patients with suspected CHS.

Youth cannabis use in Canada post-legalization: service providers’ perceptions, practices, and recommendations

BackgroundIn 2018, Canada legalized recreational cannabis use with the purpose of protecting youth and restricting access. However, concerns have been raised that this objective has not been met as rates of cannabis use among youth aged 16–24 have not declined. Youth cannabis use is associated with various adverse effects including psychosis, anxiety, depression, suicidality, respiratory distress, cannabinoid hyperemesis syndrome, and intoxications. Service providers play a crucial role in addressing youth cannabis use. This study aimed to understand Ontario service providers’ perceptions, practices, and recommendations on youth cannabis use.MethodsThis mixed method study included a survey and two focus groups. The survey was distributed to mental health service providers serving youth aged 16–24 across Ontario who were given the option to participate in a focus group. The survey included closed and open-ended questions regarding perceptions, practices, and recommendations, while the focus groups explored these categories in greater depth. Descriptive statistics were used to analyze close-ended questions and interpretative content analysis was applied for open-ended questions. Focus group data were analyzed using thematic analysis.ResultsThe survey was completed by 160 service providers and 12 participated in two focus groups. Regarding perceptions, 60% of survey participants agreed with legalization, 26% had a strong understanding of medical versus recreational cannabis, 84% believed that cannabis has physical and mental health risks, and 49% perceived stigmatization. Less than half of the survey participants reported screening or assessing cannabis use, 16% stated they are highly familiar with treating cannabis use, and 67% reported that they rarely work with families. Subthemes identified in the focus groups under perceptions included normalization and stigmatization, harms for youth, and stigma, racism, and discrimination. Subthemes under practice included cannabis not being the primary focus, challenges with screening, assessment, and intervention, and referral to specialized services. Both the survey and focus group participants recommended increasing public education, enhancing service provider training, improving regulation and policies, reducing stigma and minimization, improving service access, and providing more culturally responsive services.ConclusionYouth cannabis use in Canada remains a significant public health concern, necessitating a more comprehensive plan to protect Ontario youth and reduce associated harms.