What is Cannabinoid Hyperemesis Syndrome?
Abdominal cramps, nausea, and vomiting may be signs of various health conditions. It requires careful examination of the patient’s history to pinpoint the cause and develop the right treatment plan. These symptoms can be due to infections, neurological disorders, or even certain chemicals. One less-known cause that first made it to medical research in 2004 is a syndrome linked to long-term use of cannabis, intriguingly, this condition seems to be eased by hot showers or baths. This condition has been named ‘cannabinoid hyperemesis syndrome’ (CHS).
With the rise in cannabis use across all ages, particularly among teenagers and for medical purposes such as preventing vomiting induced by cancer treatments, stimulating appetite in people with severe weight loss, and mitigating pain (as in peripheral neuropathies), and muscle spasms (as in multiple sclerosis), it’s key to understand the risk factors and symptoms of CHS. This understanding is not only vital for emergency situations but also for everyday health care.
What Causes Cannabinoid Hyperemesis Syndrome?
Vomiting is not as simple of a process as it may seem; it involves various parts of the body working together. This process starts when something distressing is perceived – this could be anything from a bad smell to a scary thought. That stimulus alerts a particular section of the brain, leading to stimulation of a nerve called the vagus nerve.
Following this, certain processes start causing increased saliva production, the closing up of the windpipe to prevent food or liquid from entering the lungs, the opening of stomach sphincters, and the reverse movement of small intestine contents back to the stomach. Lastly, a combined action of stomach and abdominal muscles pushes the vomit out of the mouth.
The gut has several receptors, including those for cannabinoids and histamine, that can directly influence the process of vomiting when stimulated. Besides stimulation from the nervous system, these receptors can also be influenced by different chemicals.
Cannabis is known to have effects on different nerve and hormone pathways, thus it has the unique capability to either cause or stop vomiting. For instance, cannabinoid receptors in the brain and the parasympathetic nervous system, which help control the body’s stress response, can be affected by cannabis. This allows cannabis to influence a wide range of bodily processes.
Risk Factors and Frequency for Cannabinoid Hyperemesis Syndrome
Cannabis hyperemesis syndrome is a condition that can be hard to diagnose for several reasons. Sometimes, patients may not want to reveal certain information, such as illegal drug use, which can make diagnosis complex for doctors. Also, this condition can be confused with others such as cyclical vomiting syndrome or “abdominal migraine”. Sometimes people use cannabis to treat this syndrome, which adds more confusion.
For sure, one key factor in diagnosing cannabis hyperemesis syndrome is a history of cannabis use. Interestingly, cannabis is the most commonly used regulated substance in the world. It’s estimated that between 3% and 5% of the global population has used cannabis at least once, with most of these uses being non-prescription.
- Age plays a role in cannabis smoking, and the average age of first use differs by country.
- About half of people in the United States first try marijuana when they’re around 20 years old.
- In the U.S., males and females start using marijuana at about the same age during their teenage years.
- The ethnicity of cannabis users has evolved over time. In the 20th century, the majority of cannabis users were Hispanic, but in the 21st century, the majority are non-Hispanic whites.
Signs and Symptoms of Cannabinoid Hyperemesis Syndrome
Cannabis Hyperemesis Syndrome, often referred to as CHS, is diagnosed using a set of specific criteria known as the Rome IV criteria:
- The symptoms must have been present for at least three months, and the onset of symptoms should have occurred at least six months prior to diagnosis.
- The patient exhibits regular episodes of vomiting that are similar in onset, duration, and frequency to cyclic vomiting syndrome.
- The symptoms present after prolonged, excessive use of cannabis.
- A sustained cessation of cannabis use contributes to a relief in vomiting.
- The condition may be associated with an unusual bathing behavior, such as taking prolonged hot baths or showers.
However, it’s important to note that these criteria might not provide all the necessary details such as the specific amount of cannabis use or the exact number of vomiting or bathing episodes. An essential point in these criteria is the resemblance of the condition to cyclic vomiting syndrome. Cyclic vomiting syndrome, by definition, includes sudden onset episodes of vomiting with at least four bouts per hour and typically 12 to 15 episodes per day. These episodes are spaced apart by weeks or months, and the person returns to a normal state in between episodes.
There are specific factors that should be taken into account when diagnosing this condition. These include: demographics and associated risk factors like age, gender, medical and surgical history; details about the vomiting like its onset, frequency and progression; any other related symptoms such as headaches; usage of hot showers or baths; length of intervals without vomiting; use and effectiveness of prior treatments; history of drug use and periods of abstinence; ability to follow up with a primary care provider; and other health conditions particularly mental health disorders like anxiety, depression, and panic disorder, as well as migraines.
Proper diagnosis based on these factors can help avoid unnecessary medical tests, referrals, and can guide correct medical advice for patients.
Testing for Cannabinoid Hyperemesis Syndrome
Aside from risk factors related to age or other conditions such as heart disease or diabetes, doctors will usually perform several tests when you visit the emergency department. These can help to check your body’s fluid and mineral balance, and whether you might be dehydrated. This is done by a test called a metabolic panel.
A complete blood count is another common test that checks the number and types of cells in your blood. Your doctor might ask about your recent travels and combine these answers with your blood tests to check if you have any infections. A urinalysis, or a urine test, can check for urinary tract infections and also measure substances in your urine called ketones, which can tell your doctor about your nutrition status and how your body is breaking down food.
An electrocardiogram (EKG) is a test that measures the electrical activity of your heart. Your doctor might order an EKG if you’re on certain medications or if they’re considering giving you medications that can affect your heart’s rhythm. In particular, they’ll look at a measure called the QTc interval, which is part of your heart’s electrical cycle.
If you’re a woman, you may also be asked to take a pregnancy test to make sure you’re not pregnant, or to check if the pregnancy is occurring outside of the womb, which is known as an ectopic pregnancy.
Finally, your doctor might order imaging tests such as X-rays or scans. These help to check if there are any concerns related to surgery. However, this decision is totally up to the doctor who will base it on your specific symptoms and medical history.
Treatment Options for Cannabinoid Hyperemesis Syndrome
Treating Cannabinoid Hyperemesis Syndrome (CHS), a condition often caused by long-term, heavy use of marijuana and characterized by episodes of nausea and vomiting, can be challenging, as the illness tends not to respond well to traditional medicines for reducing nausea (antiemetics). Often, drugs such as ondansetron and metoclopramide used in emergency situations and by primary care doctors are not effective.
In recent years, various treatment options have been suggested based on case studies, including short-term use of benzodiazepines, which are medications typically prescribed for treating conditions like anxiety. Additionally, tricyclic antidepressants might help for long-term control, and even antiepileptic drugs such as levetiracetam and antipsychotic drugs like haloperidol might be beneficial, though these findings are based on limited studies.
Research has also examined medications that can block the effects of chemicals in the brain called dopamine and serotonin, which play a role in causing nausea and vomiting. Dopamine antagonists, which block the effects of dopamine, can help prevent vomiting. Some examples include metoclopramide, prochlorperazine, promethazine, and haloperidol.
Serotonin antagonists, like ondansetron, dolasetron, and granisetron, are drugs that counter the effects of serotonin (a chemical that helps transmit signals in the brain) in the gastrointestinal tract to help manage nausea. Likewise, tricyclic antidepressants also block serotonin and can help limit nausea. However, these need to be used carefully because of their potential side effects, such as liver damage and abnormal heart rhythms. Anticholinergic medications, which help control the speed of transmissions of nerve signals, might also help control vomiting by affecting the brain, though they might not significantly affect abdominal pain often experienced by patients with CHS.
Opioids, while often prescribed for severe abdominal pain, are not ideal for CHS as they could worsen nausea and vomiting.
Interest has been shown in heat therapy as a potential treatment, because many CHS patients report that hot baths or showers relieve their symptoms. However, the degree to which heat therapy reduces or completely gets rid of symptoms is uncertain.
Capsaicin, a compound found in chili peppers, has been proposed as a pain reliever. Capsaicin can activate pain receptors that are also activated by high temperatures and acidic conditions. Topical capsaicin and exposure to hot water might help reduce pain by affecting this system.
In 2018, a review of twenty cases revealed that topical capsaicin cream significantly alleviated pain and vomiting in CHS patients. However, these findings haven’t yet fully confirmed capsaicin as a definitive treatment for CHS because of variances in diagnostic criteria and the novelty of this diagnosis. Yet, given its simple application, easy access, and limited side effects except for localized warmth, stinging, and itching, capsaicin might serve as a helpful addition to treatment plans aimed at controlling nausea and pain in suspected CHS patients.
What else can Cannabinoid Hyperemesis Syndrome be?
When dealing with symptoms like abdominal pain, nausea, and vomiting, it’s crucial to consider other potential medical conditions before concluding that a patient has CHS, or Cannabinoid Hyperemesis Syndrome. These conditions might be influenced by the patient’s age and other risk factors, and some may require immediate medical attention or even surgery. Some possible conditions that might first come to mind include:
- Gastritis
- Gastrointestinal reflux disease (GERD)
- Peptic ulcer disease (PUD)
- Appendicitis
- Diverticulitis
- Sigmoid volvulus
- Biliary colic
- Pancreatitis
- Nephrolithiasis
- Urinary tract infection
For women who are of childbearing age, other possible conditions include:
- Ectopic pregnancy
- Ovarian torsion
Elderly patients, especially those with hypertension, may experience symptoms like vague abdominal pain, nausea, and vomiting due to heart-related conditions such as aortic disease or unusual coronary artery syndromes.
It’s also important to keep in mind that numerous toxicities, infections, and non-penetrating injuries can produce similar symptoms. Certain neurological conditions like a stroke in the brain area controlling nausea might result in these symptoms too, sometimes worsened by abdominal pain from forceful vomiting. Lastly, psychological factors can also cause vomiting syndromes and various other symptoms, which should be carefully evaluated by the doctor.
What to expect with Cannabinoid Hyperemesis Syndrome
The outlook for recovery is generally positive as long as the diagnosis is made early and the patient decides to stop using cannabinoid products. Cannabinoids are chemical compounds found in cannabis, often referred to as marijuana. The difficulty or complications associated with this disease often relate to the inability to manage symptoms because of ongoing use of cannabinoids, leading to frequent hospital visits.
Possible Complications When Diagnosed with Cannabinoid Hyperemesis Syndrome
The Cannabinoid Hyperemesis Syndrome, or CHS, can have multiple complications. With frequent vomiting, there’s always a risk for an upset in the body’s electrolyte and fluid balance. If anti-nausea medicines don’t work, patients may become dehydrated and not get enough nutrients. Constant, uncontrollable vomiting could also lead to patients accidentally breathing in vomit, which can cause lung inflammation or aspiration pneumonia. Furthermore, forceful vomiting may also cause damage to the esophagus, a condition known as Boerhaave’s syndrome.
Possible Complications:
- Disturbance in body’s electrolyte and fluid balance
- Dehydration
- Nutritional deficiencies
- Aspiration (breathing in vomit), leading to lung inflammation or aspiration pneumonia
- Injury to the esophagus (Boerhaave’s syndrome)
Preventing Cannabinoid Hyperemesis Syndrome
In simpler terms, the best way to combat any illness isn’t just to deal with its symptoms, but to eliminate the cause of the illness. For a condition known as cannabis hyperemesis syndrome, the primary treatment is to stop using cannabis. This is not an easy task and often requires a strong commitment from the patient, a supportive and understanding family doctor, and appropriate counseling and resources for dealing with drug misuse.
Cannabis, also known as marijuana, is the most commonly used illegal drug in the United States. It’s the third most common reason why people seek treatment, following alcohol and opioids. Many people find it hard to stop using cannabis, even after multiple attempts. According to a research study from 2018, only about half of the individuals treated in an outpatient setting were able to stay away from cannabis for two weeks or more. From this group, about 71% started using the drug again within six months, and most of them went back to their previous levels of use. Only about eight percent of individuals who tried to quit using cannabis on their own were able to stay away from the drug for six months.
There are programs designed to help people with addictions, such as Alcoholics Anonymous and Narcotics Anonymous, which facilitate a twelve-step recovery process. There’s also a similar program called Marijuana Anonymous. Some research has been done on this program’s success in helping people to reduce and eventually quit their use of cannabis. One specific study involving a small group of 36 teenagers found a positive relationship between attending meetings as part of the twelve-step facilitation program and the number of days they stayed away from the drug over a three-month period.
