Cannabinoid Hyperemesis Syndrome (CHS)

Written by ©Antonia Teresa Amore-Broccoli, MSW. LCSW (Medical Social Worker )

with CHS medical facts paraphrased from from the Cleveland Medical Center https://my.clevelandclinic.org/health/diseases/21665-cannabis-hyperemesis-syndrome

Cannabinoid Hyperemesis syndrome (CHS), or cannabis hyperemesis syndrome, is caused by long-term cannabis (marijuana) use. People who have CHS experience repeated and severe bouts of nausea, vomiting, dehydration and stomach pain.

Cannabinoid Hyperemesis syndrome (CHS) happens when a person experiences cycles of nausea, abdominal pain and vomiting after the use of cannabis for a sustained amount of time. Temporary relief from symptoms of CHS have been reported by some people by taking hot baths and showers.

Over the last decade and more so the last 4-6 years the Emergency departments of hospitals throughout the United States have had an alarming increase of CHS patients.

“Hyperemesis” simply means severe vomiting. Compounds in the Cannabis sativa plant are called Cannabinoids which bind to cannabinoid receptors in a person's brain , spinal cord, gastrointestinal tract and other body tissues. Examples of cannabinoids include cannabidiol (CBD) and tetrahydrocannabinol (THC) .

CHS is a condition that can lead to serious health complications if a person does not receive medical treatment for it.CHS is not just a minor side effect of cannabis use.

The use of cannabis, use has increased in the mass population across all ages and diversity of people. As a result of the increased use of cannabis more and more people are seeking help for CHS. Medical researchers don't know how common CHS is but the emergency department visits are increasing throughout the world. One contributing factor is that not everyone with the CHS seeks medical help or tells their provider that they use cannabis.

One study found that 32.9% of self-reported frequent marijuana users who came to an emergency department for care met the criteria for CHS. With the widespread use, increased potency and legalization of marijuana in multiple states in the U.S., CHS may be becoming increasingly common.(site and paraphrase )

The Symptoms and Causes of CHS;

Many symptoms of CHS typically present several years after the start of chronic cannabis use. However, not all chronic and/or long term cannabis users experience CHS.

Symptoms of cannabinoid hyperemesis syndrome include: 1) Loss of appetite, 2) Persistent nausea which is often in the morning, 3) moderate to severe vomiting and retching (making the sound and movement of vomiting). This can happen up to five times an hour. 4) Intense abdominal discomfort or pain. 5) Fear of throwing up.

Hot showers and baths tend to help reduce or help the symptoms subside; but this is usually temporary. Many people with CHS tend to compulsively shower or bathe to relieve CHS symptoms and will do so often for hours throughout the day .

There are different phases of CHS syndrome that make up the specific symptoms and severity of CHS:

Prodromal phase: A person may have abdominal pain or morning nausea. People may fear throwing up but never actually vomit. This phase can last for months or years.This phase is most common in adults who have used cannabis since they were teenagers.

Hyperemetic phase: Moderate to severe symptoms which involve overwhelming, recurrent vomiting and nausea which usually lasts 24 to 48 hours. A person in this phase may start compulsively bathing and avoid certain foods or purposefully restrict your food intake. This is the characteristic phase of CHS.

Recovery phase: During recovery, a person must cease the use of cannabis completely, not even using small amounts. In the recovery phase, symptoms lessen over a few days or months. Eventually, as a person stays clean off cannabis the symptoms completely disappear.

Scromiting and CHS

Some people refer to certain symptoms of CHS as “scromiting.” This language combines “vomiting” and “screaming.” People may have such intense pain, which causes them to scream while you vomit. Similar to a woman in labor for childbirth. It can be very unpleasant and traumatic for people as many do not know that their medical symptoms are from the chronic long term use of cannabis. Also these medical symptoms can be exasperated by the distorted cognitive effects of cannabis. A person is more likely to feel more paranoid or trauma due to the intensity of being intoxicated on cannabis. The high or toxicity of cannabis can cause delusions or hallucinations of of cannabis can cause the psychological symptoms

The cause of Cannabinoid Hyperemesis Syndrome (CHS)

Medical scientists have not completely discovered the cause of CHS. It is hypothesized that CHS is due to long-term and chronic overstimulation of receptors in the person's endocannabinoid system (ECS). It is the chronic long term use of cannabis that over-stimulates the receptors causing issues with the body’s natural control of nausea and vomiting.

Risk factors for cannabinoid hyperemesis syndrome.

People who use cannabis long-term — typically for about 10 to 12 years — are at risk of developing CHS. But not every person who uses cannabis, even long-term use, develops CHS. Medical evidence has proven that CHS affects people who use cannabis at least once a week. CHS also occurs more often in adults who’ve been using cannabis since their adolescent years.

Medical Diagnosis and Tests & How is CHS Cannabinoid Hyperemesis Syndrome diagnosed?

Healthcare providers mainly diagnose CHS based on a person's symptoms through a combination of medical history and history of substance use. A medical provider will do a physical exam and may ask a person specific questions. These questions include; 1) how often is the use of cannabis (marijuana) 2) how long a person has been using cannabis, 3) when a person vomits or feels nauseated, 3) if other factors, like certain foods, lead to vomiting, 4) Whether a person has weight loss for no known reason and 5) If a person takes hot showers or baths to try to relieve symptoms.

However, not everyone is forthcoming and honest about their cannabis use. There may be fear of stigma or discrimination despite new laws around recreational use. When people do not disclose their cannabis use or medical providers are not asking these specific above questions people are often misdiagnosed CHS as other GI conditions, like cyclic vomiting syndrome. cyclic vomiting syndrome (CVS).

Medical Providers typically use the following criteria to diagnose CHS:

Severe cyclic vomiting episodes, 2) Abdominal pain, 3) Long-term, frequent marijuana use (more than one year) 4) Symptoms stop with sustained abstinence from marijuana use, 5) Compulsive bathing in hot water. Medical Providers usually recommend certain tests to rule out other causes of nausea and vomiting, like: Blood tests, Urinalysis and/or Imaging tests, like a CT scan or MRI.

Management and Treatment for Cannabinoid Hyperemesis Treatment?

The only known treatment to permanently get rid of CHS is to cease the use of cannabis completely. A person may have symptoms and side effects of CHS for a few weeks after quitting cannabis. These symptoms can be compounded by or be combined with the detox and withdrawal symptoms of cannabis. Over time, CHS symptoms will disappear.

If a person has a cannabis use disorder and needs help quitting, professional treatment is available. Talk to a healthcare provider or therapist who specializes in addiction and/or an addiction counselor. Some people may need intensive addiction medication treatment either inpatient or outpatient. For immediate ongoing daily and free support people can attend marijuan anonymous or other self recovery programs. See tab on resources for a comprehensive list.

Currently there are currently no therapies approved by the U.S. Food and Drug Administration (FDA) for CHS, however, medical researchers are currently studying several treatment options to manage the hyperemetic phase of CHS.

A person may need to go to the hospital for severe CHS. Medical healthcare providers may give a person : IV fluids and electrolytes if and when a person becomes dehydrated from vomiting, 2) Antiemetics, though these often aren’t effective at relieving vomiting in CHS and 3) Other alternative therapies for symptom relief, like capsaicin cream to relieve pain.

How can people stop Cannabinoid Hyperemesis Syndrome?

The only known and reliable cure for CHS is to stop using cannabis. Hot showers and baths may relieve the nausea for a while, but it will not cure CHS. The risk of taking too many hot baths can increase dehydration due to sweating.

You may use home treatments to relieve CHS symptoms immediately after quitting cannabis. These remedies may help you feel better while you transition to the recovery phase. Your healthcare provider may recommend:Antihistamines, like diphenhydramine (Benadryl®), 2) Capsaicin cream to relieve pain, 2) Pain relievers (analgesics)ike ibuprofen (Advil®, Motrin®) or acetaminophen (Tylenol®), 3) Prescription medications, including benzodiazepines (like lorazepam),antipsychotic medications (like haloperidol) or Tricyclic antidepressants or another.

Some providers and specifically psychiatrists may recommend the use of the anti-convideulatant prescription drug Gabapentin. Gabapentian in the field of addiction medicine in the practice of treating cannabis use disorder has been temporarily helpful during the acute detox phases of cannabis use disorder assisting with the physical cravings, insomnia and mood stabilizers assisting people in the first 3-18 months of sobriety A study in published in 2011 suggest Gabapentian has a significant effect in decreasing the use or desired use of cannabis over the course of treatment study relative to a placebo. *(https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3358737/).

Furthermore, most people with CHS who stop using cannabis have relief from the acute physical symptoms within 10 days and many do not need medical interventions. It may take people a few months to feel fully recovered from the CHS physical symptoms of loss of appetite, nausea, vomiting and weight loss.

Prevention: How can a person prevent Cannabinoid Hyperemesis Syndrome?

The only proven way to prevent cannabis hyperemesis syndrome is to avoid cannabis (marijuana).

Quitting marijuana use can be hard. If you need help quitting, speak to a healthcare provider or connect with your local addiction treatment services.

You can also call the Substance Abuse and Mental Health Services Administration (SAMHSA) National Helpline at 1.800.662.4357. It’s a free, confidential service that’s open 24/7, 365 days a year. They provide treatment referrals and information in English and Spanish.

Outlook / Prognosis

What are the possible complications of cannabinoid hyperemesis syndrome?

There are several possible complications of CHS, including:

Electrolyte imbalance.
Malnutrition.
Weight loss.
Tooth decay.
Choking, pneumonitis and/or aspiration pneumonia.
Injury to your esophagus, like Boerhaave’s syndrome or Mallory Weiss tear.
Scald burns from using very hot water to try to manage symptoms.

When should a person go to the emergency department for cannabinoid hyperemesis syndrome?

CHS can increase your risk for severe dehydration. Call 911 or go to your nearest emergency room if you have any dehydration symptoms, including:Dehydration Symptoms, Dark or very little pee.Delirium (sudden confusion).

Dizziness.
Fatigue or unexplained sleepiness.
Quickened heart rate.
Rapid breathing.
Syncope (fainting).

Cannabinoid hyperemesis syndrome (CHS) is a very unpleasant — and potentially dangerous — complication of long-term cannabis use. Because of this possible complication, it’s important to use caution with cannabis, including all cannabis products. If you think you have CHS or cannabis use disorder, talk to a healthcare provider. They’re available to help.

Glossary;

cannabinoids include cannabidiol (CBD) and tetrahydrocannabinol (THC) . https://www.webmd.com/pain-management/cbd-thc-difference

cyclic vomiting syndrome. cyclic vomiting syndrome (CVS).

Dehydration Symptoms Dehydration.

Delirium Delirium (sudden confusion)