Cannabinoid hyperemesis syndrome
Cannabinoid hyperemesis syndrome (CHS) | |
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Capsaicin cream[2] |
Cannabinoid hyperemesis syndrome (CHS) is recurrent
Weekly cannabis use is generally required for the syndrome to occur; synthetic cannabinoids can also cause CHS.[6][5] The underlying mechanism is unclear, with several possibilities proposed.[2][5] Diagnosis is based on the symptoms, as well as the history of cannabis use (including a urine screen test if necessary).[6] The condition is typically present for some time before the diagnosis is made.[6]
The only known curative treatment for CHS is to stop using cannabis.
Another condition that presents similarly is cyclic vomiting syndrome (CVS).[3] The primary differentiation between CHS and CVS is that cessation of cannabis use only resolves CHS. CVS does not resolve with the cessation of cannabis use.[5] Another key difference is that CVS symptoms typically begin during the early morning; predominant morning symptoms are not characteristic of CHS.[9][10] Distinguishing the two can be difficult since many people with CVS use cannabis, possibly to relieve their symptoms.[5]
The syndrome was first described in 2004, and simplified diagnostic criteria were published in 2009.[11][12]
Signs and symptoms
The
Prodromal phase
The prodromal phase is characterized by mild symptoms of CHS, including nausea, anxiety and fear related to vomiting, mild abdominal discomfort, sweating, and increased thirst; symptoms can be more severe in the morning, but this is not always the case.[14] During this phase, treatment with compulsive bathing is rarely reported, and some individuals may attempt to treat their symptoms with cannabis use. This phase can last for months to years.[8][5]
Hyperemetic phase
The hyperemetic phase is characterized by the full syndromal symptoms of CHS, including persistent nausea, vomiting, abdominal pain, and retching.[8] Retching can occur up to five times per hour. Acute episodes of cannabinoid hyperemesis typically last for 24–48 hours.[3] The symptoms experienced in this phase are cyclical, and can recur unpredictably in intervals of weeks to months.[15] It is very difficult to take food or medicine by mouth during this stage, and patients may develop a fear of eating. Weight loss and dehydration due to decreased oral intake and vomiting are possible. It is during this hyperemetic phase that people with CHS are likely to present to the emergency department of the hospital for treatment.[8]
Treatment via hot water, sometimes for hours at a time, relieves symptoms for many patients, which can result in compulsive bathing or showering. People have described the hot water relief as "temperature-dependent," meaning that hotter temperatures provide greater relief.[8][3]
Recovery phase
The recovery phase begins after the patient abstains from cannabis consumption, but the time for resolution of symptoms is unclear: it has been reported to occur within two weeks,[6] or to take one to three months.[8] Lost weight can be regained due to a restoration of normal oral intake, and compulsive bathing/showering can give way to normal patterns of behavior.[8] If a person in this phase consumes cannabis again, their symptoms tend to come back.[15] Relapses are common due to reinitiation of cannabis consumption, following which many people use or increase their use of cannabis due to concerns about nausea. Increased patient education may be necessary.[3]
Complications
Two deaths were reported due to kidney failure and electrolyte disorders secondary to dehydration from persistent vomiting.[2][16]
Pathogenesis
Cannabis contains more than 400 different chemicals, of which about 60 are
Various pathogenic mechanistic theories attempting to explain symptoms have been put forward:[15]
- dose-dependentbuildup of cannabinoids and related effects of cannabinoid toxicity
- the functionality of digestive system)
- direct stimulation of cannabinoid receptors in the digestive system.
It has been hypothesized that certain people may be
Another cannabinoid called
Cannabinoid buildup theory
Diagnosis
The
Per the Rome IV criteria, all 3 of the following must be met to be diagnosed with CHS. They must be present for at least the last three months and the beginning of symptoms must be at least 6 months prior to the diagnosis being made.- Episodic vomiting that appears similar to cyclic vomiting syndrome
- Symptom onset occurs after prolonged cannabis use
- Resolution of symptoms with sustained abstinence from cannabis use[20][21]
A complete history of the person's use of cannabinoids is important in establishing the correct diagnosis.[4] CHS has often been undiagnosed, sometimes for years.[13] This may be due to reluctance on behalf of patients to fully disclose their use of cannabis to healthcare professionals, especially when another person is accompanying the patient to an appointment or emergency department visit.[13] Identifying the correct diagnosis saves money for the healthcare system and reduces morbidity associated with the condition.[3]
A
Other commonly used diagnostic tests include laboratory blood tests (
Differential Diagnoses
Prior to diagnosing and treating for a presumed CHS, more serious medical conditions need to be ruled out.
Treatment
Many traditional medications for nausea and vomiting are ineffective.
Symptomatic relief is noted with exposure to hot water (greater than 41°C, 106°F), which is mediated by
The use of
Epidemiology
The exact proportion of the population affected by this syndrome is difficult to conclude because there has not always been a specific criteria for diagnosis, there are no diagnostic tests to confirm it, and cannabis use may not be reported truthfully.[21] A 2015 study that surveyed patients from an urban emergency department found that 32.9% of people who reported cannabis use of at least 20 days per month met criteria for CHS.[28] Using this data, the authors estimated that roughly 2.75 million Americans suffer from CHS.[28] However, the author and other experts on the subject acknowledge that there are limitations to this estimation and the prevalence of this disease can not be concluded at this time.[21][28]
In the United States, an analysis of data from the
The number of people affected was unclear as of 2015.[30] CHS has been reported more frequently in people that use cannabis daily (47.9% of people with CHS) and greater than daily (23.7% of people with CHS), compared to once weekly users (19.4% of people with CHS) and less frequent users (2.4% of people with CHS).[4] A significant increase in the incidence of CHS (and other cannabis-related visits to the emergency department) has been noted in U.S. states that have legalized cannabis, with the incidence of cyclic vomiting prominently doubling in the US state of Colorado after legalization.[25] As the use of cannabis continues to be legalized at the state level, the prevalence of CHS is expected to increase in the US.[4]
As of 2017[update] a French pharmacovigilance program for drug users had received reports of 29 cases of CHS. At the time there were 113 case described in the international medical literature. CHS incidence is likely to have been substantially under-reported.[31] A retrospective application of the 2016 Rome IV criteria to cases recorded in prior literature suggested that the number of people with CHS had been over-estimated.[29]
History
Cannabinoid hyperemesis was first reported in the
The name "cannabinoid hyperemesis syndrome" was also coined at this time. The report focused on nine patients who were chronic cannabis users who presented with cyclical vomiting illness. One woman in the study reported that warm baths provided the only relief from the nausea, severe vomiting, and stomach pain, and reportedly burned herself in a hot water bath three times trying to get relief.[33]
Society and culture
CHS is not very well known.[34] An emergency department physician in 2018 commented that the condition wasn't on their "radar" in the five years prior, though the condition was being diagnosed more often now.[35] Many people are surprised by the notion that cannabis can induce symptoms of nausea and vomiting, given the fact that cannabis is used to prevent nausea and vomiting.[35]
The
References
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- ^ https://www.jem-journal.com/article/S0736-4679(12)01472-2/abstract
- ^ Brodwin E (15 February 2019). "A mysterious syndrome in which marijuana users get violently ill is starting to worry researchers". Business Insider. Archived from the original on 14 May 2019. Retrieved 26 March 2019.
- ^ Rabin R (9 April 2018). "Marjuana linked to 'unbearable' sickness across US as use grows following legalisation". The Independent. Archived from the original on 10 May 2018. Retrieved 10 May 2018.
- ^ a b Bartolone P. "'I've screamed out for death': Heavy, long-term pot use linked to rare, extreme nausea". USA TODAY. Archived from the original on 10 May 2018. Retrieved 10 May 2018.
- IFLScience. 13 July 2021. Archivedfrom the original on 25 January 2022. Retrieved 25 January 2022.
- Snopes.com. 2017. Archivedfrom the original on 25 January 2022. Retrieved 25 January 2022.
Further reading
- Deceuninck E, Jacques D (September 2019). "Cannabinoid hyperemesis syndrome: a review of the literature". Psychiatr Danub (Review). 31 (Suppl 3): 390–394. PMID 31488758.
- Khattar N, Routsolias JC (2018). "Emergency Department Treatment of Cannabinoid Hyperemesis Syndrome: A Review". Am J Ther (Review). 25 (3): e357–e361. S2CID 9800385.
- Leu N, Routsolias JC (May 2021). "Cannabinoid Hyperemesis Syndrome: A Review of the Presentation and Treatment". J Emerg Nurs (Review). 47 (3): 483–486. S2CID 232218693.
- Sanders L, M.D (16 November 2022). "It Was Her Third Visit to the E.R. What Was Causing Her Abdominal Pain?". The New York Times. ISSN 0362-4331. Retrieved 25 November 2022.