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Cannabinoid hyperemesis syndrome

Knowlton, Mary C. DNP, RN, CNE

doi: 10.1097/01.NURSE.0000577992.82047.67
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Abstract: Cannabinoid hyperemesis syndrome (CHS) is characterized by severe cyclical nausea, vomiting, and abdominal pain relieved by compulsive hot water bathing in the setting of chronic cannabinoid use. This article reviews the characteristics, proposed pathophysiology, treatment modalities, and role of nurses caring for patients with CHS.

This poorly understood disorder is characterized by severe cyclical nausea, vomiting, and abdominal pain in chronic cannabis users. Learn to recognize and manage the signs and symptoms and teach patients how to prevent a recurrence.

Mary C. Knowlton is an associate professor at Western Carolina University in Cullowhee, N.C.

The author has disclosed no financial relationships related to this article.

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THE LANDSCAPE IS CHANGING in the US. Cannabis, a drug that was once illegal, can now be used lawfully for recreational purposes in 10 states and Washington DC.1 With 192 million users globally, it was the most commonly used drug in 2016, according to the United Nations Office on Drugs and Crime.2

As changes in legislation increase accessibility, the potential for chronic habitual cannabis use increases. Although cannabis has antiemetic properties, some individuals who use cannabis chronically experience a paradoxical hyperemesis syndrome.3,4 This article reviews the characteristics, pathophysiology, and management of CHS as well as the role of nurses in caring for the affected patients.

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Background

First reported in 2004, CHS is characterized by cyclical vomiting in which individuals who use cannabis find relief by compulsively bathing in hot water.3 In the past 20 years, crossbreeding and genetic modification of marijuana crops have produced higher levels of delta-9-tetrahydrocannabinol (THC), the active ingredient.5 The increased incidence of CHS may be related to increases in both the accessibility and potency of the cannabis currently available on the market.6

It is difficult to quantify the number of chronic cannabis users impacted by CHS, but patients presenting with cyclical vomiting doubled after marijuana was legalized in Colorado. In an attempt to identify the prevalence among regular users of cannabis (more than 20 days per month), a survey of 2,127 individuals found that 32.9% of 155 regular users had experienced symptoms.7 Extrapolating this to the general population, there are potentially 2.75 million individuals who may experience CHS annually.

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Pathophysiology

The pathophysiology of CHS is not clearly understood, but research is underway. Many theories have been proposed to explain its occurrence. For example, THC is highly lipophilic. This could result in accumulation of THC in fat and eventually serum with chronic cannabis use.8-10

Cannabinoids primarily act through the type 1 cannabinoid receptor (CB1) and the type 2 cannabinoid receptor (CB2). These receptors are located in both the central nervous system and the gastrointestinal (GI) tract. CB1 receptors in the GI tract help regulate inflammation, gastric acid secretion, and intestinal motility. On the other hand, CB1 receptors located in the central nervous system also produce a feeling of euphoria.6,8 CB2 receptors are located in the periphery and are involved in regulating the immune system.8

One theory posits that dysregulation in either the hypothalamic-pituitary-adrenal (HPA) axis or the endocannabinoid system produces CHS, as these systems interact with the sympathetic nervous system.6,8,11,12 According to this theory, prolonged, high levels of cannabinoids may activate the CB1 receptors in the HPA axis.6 Another theory suggests that cannabinoids directly activate CB1 receptors in the GI tract.11

Additionally, the involvement of a genetic polymorphism has been speculated, which may explain why only a small minority of individuals develop CHS.6,10 More research is needed to better understand its pathophysiology.

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Presentation and diagnosis

CHS is similar to cyclic vomiting syndrome, but it occurs only in individuals involved with long-term cannabis use.11 A systematic review of 211 case study reports on CHS patients under age 50 identified the following major diagnostic characteristics:11

  • severe, cyclical patterns of nausea and vomiting over a period of months
  • use of cannabis at least weekly
  • abdominal pain
  • resolution of signs and symptoms after cannabis cessation
  • symptom relief with compulsive hot baths or showers
  • regular cannabis use for over a year
  • male.

In this study, the median age in which individuals started using cannabis was 16, with CHS developing at a median age of 24.11

Other signs and symptoms have been reported with less consistency. These include autonomic signs such as flushing and diaphoresis and a weight loss of 5 to 10 kg (11 to 22 lb).9 Additionally, case reports describe complications from nausea and vomiting, such as dehydration, fluid and electrolyte imbalances, orthostatic hypotension, GI injury, and acute renal failure.6,11

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Three phases

CHS has three phases: prodromal, hyperemetic, and recovery.8

  • The prodromal phase consists of early morning nausea, fear of vomiting, anorexia, and abdominal pain that lasts for days.8 Many patients increase the use of cannabis during this phase in the mistaken belief that this will ease their nausea and other symptoms.6
  • The hyperemetic phase is characterized by cyclical bouts of uncontrollable nausea and vomiting, as well as increased abdominal pain intensity and a compulsion to bathe in hot water to relieve symptoms.6,8 This pattern of cyclical vomiting can repeat every few weeks or months.3
  • In the recovery phase, symptoms resolve. This phase, which occurs when the patient abstains from cannabis, is characterized by a return to normal eating and bathing, as well as the absence of nausea, vomiting, and abdominal pain. Even with abstention, CHS symptoms may take 7 to 10 days to abate.13 Reintroducing cannabis typically results in immediate symptom recurrence.6

As many providers are unfamiliar with CHS, its diagnosis is often delayed.13 In an analysis of 17 patients in three different medical centers over a 5-year period, the patients had approximately 17.9 ED visits and incurred $76,290 on average in diagnostic testing expenses and ED charges.14

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Management

Currently, no standardized treatment guidelines or evidence-based protocols have been developed for CHS, as all recommendations are based on case studies.5 The only definitive treatment for CHS has been abstinence from cannabis use. In a systematic review, symptoms resolved in over 96% of patients who stopped using cannabis.11

Immersion into a hot bath or shower relieves symptoms in minutes, with increased relief corresponding to higher water temperatures.3,9 Some patients have reported spending more than half of their day bathing, even waking from sleep to shower.3,6 The effectiveness of bathing is poorly understood. As CB1 receptors are located near the thermoregulatory center in the hypothalamus, however, it has been hypothesized that they play a role in intestinal vasodilation and body temperature regulation.6,12

Symptomatic treatment has been attempted, but patients respond poorly to many common antiemetic therapies, such as promethazine, metoclopramide, and ondansetron, as well as to nontypical agents, such as benzodiazepines and olanzapine.8

Haloperidol has reportedly provided some relief in select patients.6,15 Opioid medications have also been used in an attempt to manage abdominal pain, but they should be avoided because they may trigger rebound abdominal pain, decreased bowel motility, or opioid dependence issues.5,11 Other treatments may include proton pump inhibitors for gastritis and fluid resuscitation to correct fluid and electrolyte imbalances.6,11

When administered as a cream, capsaicin, the active ingredient in chili peppers, creates a sensation of warmth and activates transient receptor potential vanilloid 1 (TRPV1). TRPV1 is found in the peripheral nervous system and may be involved in the endocannabinoid system.11,16 Many believe capsaicin creams work similarly to hot baths and showers.13,15 Application of topical capsaicin cream to the abdomen or arms has been shown to reduce symptoms within 45 minutes.6 An expert consensus panel of ED providers in San Diego, Calif., created guidelines that include the use of capsaicin cream for first-line symptomatic treatment.13

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Nursing considerations

Nurses play a major role in caring for patients with CHS, as they excel in building a rapport with patients and fostering a milieu that promotes the disclosure of sensitive information such as recreational drug use. Considering the varying legal status of cannabis from state to state, discussions related to cannabis use can be delicate. These can be made more complex in patients who are minors, as their parents or guardians may be present.

Nurses should obtain a detailed patient health history that outlines the age a patient began using cannabis and the amount used weekly, as well as information on his or her strategies to treat CHS symptoms, such as hot showers and baths.11 Due to repeated patient requests to shower or bathe, the strain on nursing staff can be profound. Understanding patients' compulsive need to bathe is key in educating nurses as they encounter patients with CHS in a caring and compassionate fashion.

Once CHS is diagnosed, patient education is essential. Individuals who use cannabis need to understand that cannabis is the causative factor and that cessation is required for sustained symptom relief. Motivational interviewing is a patient-centered approach to counseling used to help patients change problem behaviors, such as substance use.17 It may also be a useful tool for nurses, as they help patients identify intrinsic motivators and make the behavioral changes necessary to resolve CHS. Additionally, nurses should provide patients and families with access to substance abuse specialists in the ED and to information and community-based resources for continued treatment for CHS.6,18

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Rare but serious

CHS is a rare but potentially serious disorder that is often unrecognized by healthcare professionals. Nurses can help by eliciting a complete history of recreational drug use from patients presenting with CHS symptoms and providing cannabis cessation education to help them avoid CHS in the future.

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REFERENCES

1. Leins C. States where recreational marijuana is legal. US News & World Report. 2019. http://www.usnews.com/news/best-states/slideshows/where-is-pot-legal?onepage.
2. United Nations Office on Drugs and Crime. World Drug Report 2018. http://www.un-ilibrary.org/drugs-crime-and-terrorism/world-drug-report-2018_d29e3f27-en.
3. Allen JH, de Moore GM, Heddle R, Twartz JC. Cannabinoid hyperemesis: cyclical hyperemesis in association with chronic cannabis abuse. Gut. 2004;53(11):1566–1570.
4. Kim HS, Anderson JD, Saghafi O, Heard KJ, Monte AA. Cyclic vomiting presentations following marijuana liberalization in Colorado. Acad Emerg Med. 2015;22(6):694–699.
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13. Lapoint J, Meyer S, Yu CK, et al Cannabinoid hyperemesis syndrome: public health implications and a novel model treatment guideline. West J Emerg Med. 2018;19(2):380–386.
14. Zimmer DI, McCauley R, Konanki V, et al Emergency department and radiological cost of delayed diagnosis of cannabinoid hyperemesis. J Addict. 2019;2019:1307345.
15. Waterson Duncan R, Maguire M. Capsaicin topical in emergency department treatment of cannabinoid hyperemesis syndrome. Am J Emerg Med. 2017;35(12):1977–1978.
16. Richards JR, Gordon BK, Danielson AR, Moulin AK. Pharmacologic treatment of cannabinoid hyperemesis syndrome: a systematic review. Pharmacotherapy. 2017;37(6):725–734.
17. Ingersoll K. Motivational interviewing for substance use disorders. UpToDate. 2019. http://www.uptodate.com.
18. Pélissier F, Claudet I, Gandia-Mailly P, Benyamina A, Franchitto N. Cannabis hyperemesis syndrome in the emergency department: how can a specialized addiction team be useful? A pilot study. J Emerg Med. 2016;51(5):544–551.
Keywords:

cannabinoid hyperemesis syndrome; cannabis; capsaicin cream; CHS

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