What Pediatricians Need to Know About Cannabinoid Hyperemesis

In a recent PediaCast CME episode, guest host Alicia McVity, FNP talks with Leah Middelberg, MD, and Alek Adkins, MD, about the rise of cannabinoid hyperemesis cases in emergency rooms, and how Ohio’s recent legalization of marijuana may have an impact on this number.

Cannabinoid hyperemesis syndrome (CHS) is a condition caused by chronic cannabis use that leads to cycles of nausea and vomiting. Compounds in Cannabis sativa plants, including tetrahydrocannabinol (THC) and cannabidiol (CBD), bind to cannabinoid receptors in your brain, gastrointestinal tract and other body tissues and are the primary factors in this syndrome.

According to Dr. Adkins, some reports estimate up to 16% to 30% of cannabis users may have experienced CHS, and that this syndrome has been recognized since the early 2000s.

With the recent legalization of marijuana in states such as Ohio and the switch to higher THC concentrations and CBD ratios in products, there are more instances of cannabis hyperemesis cases in emergency departments, according to Dr. Alek Adkins. Although most adults are forthcoming about their cannabis use, diagnosing CHS can be difficult in adolescent patients who may be more nervous about providing their history.

Because CHS is considered an exclusion diagnosis, meaning it can only be diagnosed by ruling out other complications, a urine drug screen may be helpful in pinpointing this syndrome.

What Causes CHS?

According to Dr. Adkins, the exact cause of CHS is still unknown. However, the most common theory suggests a dysregulation of cannabinoid receptors in the brain and gut caused by long-term overstimulation from cannabis.

Cannabinoid receptors play an important role in helping control nausea, body temperature and inflammatory responses throughout the body. The cannabinoid receptors in the transient receptor potential protein (TRPV1) help balance different parts of the nervous system. But with long-term stimulation and cannabis use, the balance becomes disrupted, causing cycles of vomiting.

The Stages of CHS

CHS has three stages. Stage 1, known as the prodromal phase, can last anywhere from a few weeks to months at a time. Patients may suffer from mild nausea or discomfort. Symptoms are usually worse in the morning, and some people will self-treat by increasing their cannabis use – unintentionally worsening symptoms.

The hyperemetic phase, the second phase, is the most characteristic phase of CHS. Patients suffer from overwhelming, recurrent vomiting and nausea cycles as much as 4-5 times per hour with around 12-15 cycles per day. Dr. Middelberg says this stage can last up to a week. Most patients in this phase will restrict their food intake and take warm baths or showers to prevent nausea. There is a risk for electrolyte changes, dehydration, abnormal EKGs and low blood sugar as a result of such frequent vomiting. This is when most patients present in the emergency room.

The final phase, or the recovery phase, happens when the patient stops using cannabis and is characterized by a slow return to normal nutritional intake and weight. During this phase, symptoms can lessen over a few days or months before they completely disappear.

Treatment for CHS

The only known treatment for CHS is to stop cannabis use completely. Researchers are currently studying several treatment options to manage the hyperemetic phase of CHS, but there have yet to be any approved by the U.S. Food and Drug Administration (FDA). Most people with CHS who stop using cannabis will feel relief from symptoms within 10 days.

The best way to prevent CHS is to minimize the use of cannabis or avoid it altogether. Dr. Adkins emphasizes the importance of recognizing and being aware of CHS symptoms as the legalization of recreational marijuana use spreads throughout the United States.

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