Rachel H. Alinsky, MD, MPH

Cannabinoid hyperemesis syndrome (CHS) is a disabling illness characterized by episodic acute vomiting and associated with chronic cannabis use.

 First described in 2004, CHS remains poorly understood and challenging to diagnose and manage. With expanding medicinal and recreational use, decreasing perception of risk,

 the bur- den of CHS on pediatric patients and clinicians will likely continue to grow.

Prevalence of CHS is uncertain but likely increasing. A 2015 study of emergency department (ED) presentations in a US state following legalization of medical cannabis found nearly double the rate of cyclic vomiting presentations and higher rates of cannabis use among these patients.

 Findings of a 2018 study estimated that 2.8 million people in the United States (approximately 1% of the population) use cannabis chronically and have symptoms consistent with CHS.

Across study findings, CHS tends to present in the late teens or the 20s.

 One research group emphasizes challenges in both diagnosis and epidemiology due to widespread use of cannabis to self-treat nausea and the relatively low rates at which patients follow up and stop using cannabis—which is required to meet current Rome IV diagnostic criteria for adults (Table 1).

Cannabis use in the United States has long been associated with racist and classist laws and law enforcement (despite liberalization

), whereas access to health care, including mental health– and substance-related care, remains disparate and unjust.

 Clinicians can help mitigate further harm and disparities through careful and thorough treatment of all patients with possible CHS.

CHS can lead to repeated presentations and admissions, with sequelae including hypovolemia, electrolyte derangements, acute kidney injury,

 esophageal injury, weight loss, and prolonged debility.

 There are multiple reports of fatalities believed to be related to CHS, including 1 from torsade de pointes due to electrolyte derangement and antiemetic-driven QT prolongation.

CHS has 3 clinical phases: prodromal, hyperemetic, and recovery.

 The prodrome comprises months of morning nausea while chronically using cannabis and is often accompanied by weight loss. The hyperemetic phase includes acute-onset nonbilious vomiting up to several times per hour, plus diffuse abdominal pain. In both phases, compulsory hot bathing for relief of symptoms is common; for example, in one systematic review, this was reported in 10 of 14 pediatric cases.

 Rome IV criteria include this feature as a “supportive remark” (Table 1

). In true CHS, the recovery phase follows cessation of cannabis use, though symptoms can persist for weeks prior to full remission.

The hyperemetic phase often prompts ED presentation, in which vomiting and abdominal pain present a diagnostic challenge. Following basic clinical and lab evaluation (including lipase), patients without diagnoses often undergo abdominopelvic CT and then, if admitted, endoscopic gastroduodenoscopy (EGD). Any testing for substances should be interpreted carefully, as false positives and negatives occur, and quantitative tests may be difficult to interpret.

 Although CHS may be considered early on, it is vital to avoid anchoring and neglect of other dangerous etiologies while also implementing supportive care. “Mimickers” of CHS that can elude CT and EGD include elevated intracranial pressure, acute intoxication, ovarian or testicular torsion, gastroesophageal dysmotility, mitochondrial disorders, and acute intermittent porphyria (see Table 1).

CHS is still considered a “functional disorder” because of the incomplete elucidation of its pathophysiology.

 However, clinicians should understand probable mechanisms to guide treatment and educate patients. These include (1) known proemetic effects of high-dose tetrahydrocannabinol, likely via dopamine signaling at the chemoreceptor trigger zone; (2) progressive cannabinoid receptor downregulation; (3) abnormal stress response due to dysregulation of the hypothalamic-pituitary axis and sympathetic nervous system; (4) upregulation of the transient receptor potential vanilloid 1 (TRPV1) receptors involved in pain, nausea, and thermoregulation; (5) delayed gastric emptying; and (6) predisposing factors, including genetic polymorphisms and untreated mood disorders.

During the hyperemetic phase, persistent vomiting drives lipolysis, releasing lipophilic THC stores and fueling a proemetic feedback loop exacerbated by starvation ketosis.

We lack high-grade evidence treatments specific to CHS, but essential management includes acute stabilization, longitudinal primary and mental health care to reduce harm of cannabis use, and serial reconsideration of diagnosis.

Treatment during the hyperemetic phase includes rehydration with bolus intravenous (IV) crystalloid fluids, IV dextrose-containing fluids (to arrest ketosis), correction of electrolyte abnormalities, and treatment of nausea (Table 2). Gastric acid suppression, nasogastric tube placement, and gastroenterology consultation should be considered to mitigate sequelae, including catastrophic esophageal rupture.

In the pediatrics literature, haloperidol and topical capsaicin cream have been reported as effective.

 Among pediatric patients in 2 systematic reviews published in 2021, benzodiazepines were reportedly effective in certain patients; one review noted that ondansetron was reportedly effective in only 2 of 5 pediatric patients who received it.

 Medications reported as frequently ineffective in these reviews include metoclopramide, promethazine, and opioids.

Adult research reflects similar patterns. In a recent randomized controlled trial (RCT) of 33 adults, haloperidol (0.05 mg/kg or 0.1 mg/ kg IV), which blocks proemetic dopaminergic stimulation at the chemoreceptor trigger zone, was found superior at both doses to ondansetron (8 mg IV) in the primary outcome: the average of changes in abdominal pain and nausea scores at 2 hours. Three of the patients who received the higher dose of haloperidol had specific adverse effects (AEs): 2 dystonic reactions and 1 akathisia.

Topical capsaicin cream (0.025%- 0.1%) applied to the abdomen has been reported to be effective for treating CHS in adults, via activation of TRPV1 receptors (downregulated in CHS), leading to decreased substance P signaling in the brain stem.

 TRPV1 receptors are also activated by temperatures over 43 °C, explaining relief from hot- water bathing and abdominal hot packs.

 Oral aprepitant, often used for chemotherapy-induced nausea, was reportedly effective in 1 adult case report of CHS, via inhibition of neuromedin K tachykinin receptor– binding by substance P.

Haloperidol and topical capsaicin have pathophysiologic bases and evidence for use in CHS. They are likely more effective than 5-HT3 antagonists (eg, ondansetron), though evidence amounts to systematic reviews of cases and 1 small RCT. Benzodiazepines have been reported effective in some cases but can pose a risk of dependence.

Adolescents with CHS and cannabis use disorder (CUD) benefit from a combination of pharmacologic treatment, behavioral interventions, and family support.

By Rome IV criteria, the diagnosis of CHS is confirmed only when symptoms resolve upon ceasing use. Clinicians should help patients toward this goal following physiologic stabilization. To approach substance use disorders, the American Academy of Pediatrics recommends the Screening, Brief Intervention, and Referral to Therapy tool.

 Evidence-based, validated screening tools for adolescents include Screening to Brief Intervention; the Brief Screener for Tobacco, Alcohol, and Other Drugs; and the Alcohol, Smoking, and Substance Involvement Screening Test. These help quantify the degree of substance use to build insight and direct referrals.

Brief intervention can include motivational interviewing toward reducing harm and/or use. This may include providing information about potential cognitive, psychiatric, and physical harms of cannabis use, plus clear patient-centric recommendations. Many adolescents use cannabis to manage anxiety, depression, and/or prior trauma, in which case it is crucial to offer safer options, including psychotherapy and pharmacotherapy with well-studied efficacy and AEs.

All patients should be referred to practical primary care, with an appointment scheduled and provider handoff given, if feasible. Adolescents with multiple ED presentations for CHS, high-risk substance use (eg, injection use, combination of sedatives), and/or cooccurring mental health disorders may benefit from referral to specialty care.

 The American Society of Addiction Medicine criteria can guide appropriate level of care, whereas the Substance Abuse and Mental Health Services Administration provider locator can identify local resources. This area requires prompt policy attention, because just 26% of US addiction treatment facilities offer services for adolescents.

Psychosocial treatment modalities, including cognitive-behavioral therapy, motivational enhancement therapy, contingency management, and family-based interventions, have been associated with reduced frequency of cannabis use and dependence severity.

 The Community Reinforcement and Family Training method aims to improve family members’ understanding of addiction and, by creating a supportive environment, can help motivate adolescents to seek care.

There are limited data for long- term pharmacotherapy for CUD. In 1 RCT of 116 patients (including 20 younger than age 18 years), N-acetylcysteine 1200 mg twice daily was associated with an odds ratio of 2.4 for abstinence over 8 weeks, whereas a subsequent RCT of 302 patients over 12 weeks showed no difference between groups, though subgroup analysis suggested benefit among younger patients.

 Although patients receive treatment for CUD, they should continue receiving any medication that is safely and effectively treating CHS-related nausea, with the mutual expectation that nausea should decrease over days to weeks. Any patient stopping or reducing use should be monitored and treated for cannabis withdrawal symptoms, including insomnia, anxiety, irritability, and depression (Table 2).

Cannabis is the third most commonly used substance among adolescents in the United States.

 Potency and societal acceptance are rising, with use increasing further during the COVID-19 pandemic.

 CHS is one serious consequence. Presentation to care during the prodromal or hyperemetic phases of CHS can prompt a variety of short- and long-term outcomes, from repeated ED visits with catastrophic sequelae to successful symptom control and patient-centric connection with long-term care. When pediatricians are aware, CHS symptoms can be the canary in the coal mine, leading patients to multidisciplinary support, insight, motivation, and long-term recovery.

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Articles

Here is what pediatric health care providers need to know about this often debilitating disorder.

Diagnosis and treatment of cannabinoid hyperemesis syndrome

Although the home should be a safe place, many families do not realize the potential danger hidden in their medicine cabinets. Every day in the United States, 670 adolescents initiate prescription opioid misuse.

 According to the 2019 National Survey on Drug Use and Health, 16% of adolescents aged 12 to 17 years report past year prescription opioid use, and 2.3% report misuse.

 Early opioid use has been associated with development of risky health behaviors, mental health disorders, use of other substances such as heroin, and future diagnosis of substance use disorder.

 Unintentional or intentional overdose is also of concern: From 1999 to 2016, annual pediatric mortality from opioid poisonings increased 268%.

Opioids pose a unique challenge because they are prescribed to treat pain, which varies from patient to patient, and may be prescribed in larger amounts than necessary post acute injury. Furthermore, families may not dispose of unused medications because of uncertainty about appropriate methods or desire to use prescriptions to treat future pain.

 The home environment has been shown to influence adolescent morbidity and mortality: Parent opioid use and family opioid prescriptions are respectively associated with adolescent opioid misuse and risk of overdose.

 Half of adolescents report obtaining these medications from family members, and more than 20% of adults prescribed opioids report giving medications to others, suggesting appropriate management of both adolescent and family prescriptions is crucial.

In addition to the particularly concerning consequences of opioid misuse, many nonopioid medications commonly found in medicine cabinets may also pose harm to children and adolescents through acute ingestion. In 2019, the US Poison Control Centers received 177,068 calls regarding medication or toxin exposure in 13- to 19-year-olds.

 Implicated medications include nonopioid analgesics, antidepressants, antihistamines, stimulants, cardiovascular medications, and hypoglycemics. Compared with younger children, adolescents are more likely to have intentional exposures and experience adverse outcomes, including death, from ingestion of opioids or other medications.

Despite the clear potential risks of prescription substances, few families report receiving relevant guidance from health care providers about proper medication management and storage, and many families therefore lack knowledge to practice safe medication storage at home.

 Research has shown that parental risk perception affects safe medication management, and there appears to be a common misconception that medications in the home do not pose a significant risk to adolescents.

 Fortunately, studies have shown that anticipatory guidance on the hazards of prescription opioid misuse and appropriate medication management improves parental behaviors regarding safe storage.

 Pediatricians can therefore have an important role in preventing adverse consequences of acute or chronic medication misuse.

Clear guidance from providers and families is particularly important for adolescents, who may be curious about or experiment with medication misuse. Parents can reduce risk by directly communicating expectations about substance use to their adolescents, including providing positive encouragement regarding abstinence, setting clear expectations, and defining reasonable consequences of violating trust. The Partnership to End Addiction has information on talking to children about medication misuse and parent strategies to prevent substance use.

 Families with controlled medications at home should take additional precautions. This includes locking up these medicines, counting pills, and educating adolescents about potential consequences of misuse. Families of adolescents with mental health concerns, particularly self-injurious behavior or suicidal ideation, may be advised to lock all medications out of sight.

Anticipatory guidance is also necessary when adolescents are prescribed medications. Safe medication management begins at the time of initial prescription with provider explanation of dosing, adverse effects, and duration of use. Providers should consider screening adolescents for substance use when prescribing controlled medications and emphasize the importance of never sharing medications: 16% to 29% of adolescents and young adults prescribed stimulants report being asked to divert their medication.

For adolescents with medical conditions requiring long-term medication use, families and providers should discuss a plan for developmentally appropriate transition from supervised medication use to adolescent independent use. This process should begin when the adolescent remembers to take the medication as prescribed, is able to name the medication and appropriate dose, and has shown independence in other areas (ie, completes homework without prompting).

 Caregivers should continue intermittent monitoring of medication administration with weekly pill dispensers or pill counting and remain vigilant for changes in adolescents’ functioning concerning possible signs of inappropriate use (poor grades or new conflicts at home).

Safe medication management also includes safe storage and disposal. The American Academy of Pediatrics, American College of Preventive Medicine, and the US Food and Drug Administration (FDA) recommend that families lock controlled medications out of sight, provide developmentally appropriate parental monitoring, and discard unused medications.

Lastly, safe opioid management includes having the reversal medication naloxone available. If adolescents or families have opioids at home, they should be prescribed naloxone and educated in proper use. The National Institute on Drug Abuse and 

 have information on obtaining and administering naloxone.

There are multiple resources for families regarding safe medication management. The FDA, Partnership to End Addiction, and American Association of Poison Control Centers have information on safe medication management.

 The FDA has a searchable database of medicine takeback programs.

The Centers for Disease Control and Prevention also sponsors Up and Away, an education program for families on safe medication storage.

 The Partnership to End Addiction sponsors a helpline for family concerned about a loved one’s substance use.

 Families should be advised to call Poison Control (1-800-222-1222) if they are concerned about accidental or intentional ingestion. For prescribers, Search and Rescue is an education campaign with resources and information to help reduce medication misuse.

The opioid epidemic and increase in related hospitalizations and overdose deaths have brought the importance of medication management at home into sharp focus. Although many prescription medications seem benign, misuse of the medicine cabinet can have significant consequences for adolescents. As trusted experts in children’s well-being, pediatricians should educate families on appropriate medication management to reduce the potential danger of the medicine cabinet and ensure a safe, healthy home.

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The medicine cabinet can be a potential source of prescription drugs for teenagers to misuse. This article offers advice on discussing the hazards of such misuse with adolescents.

Rachel H. Alinsky, MD, MPH

Articles

Diagnosis and treatment of cannabinoid hyperemesis syndrome

The adolescent and the medicine cabinet