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Will primary prevention strategies reduce the incidence of cannabinoid hyperemesis syndrome?

It may not be included in the differential diagnosis and can seem like it's cyclic vomiting syndrome, but a cannabinoid hyperemesis syndrome diagnosis can be found through diligent history and compassionate care.

When an adolescent presents to a pediatric primary care office and provides a history of recurring, sudden onset vomiting episodes that are separated by symptom-free intervals, have you placed cannabinoid hyperemesis syndrome (CHS) on the list of differential diagnoses along with cyclic vomiting syndrome (CVS)? Although pediatric providers are aware of the diagnosis of CVS and the rather rare presentation, many current textbooks do not include a discussion of CHS or list it as a possible diagnosis when discussing cyclic vomiting.1,2 Thus, CHS may not be listed as a potential differential diagnosis for CVS, even though cannabis use has increased. Eighteen states along with Washington DC and Guam have legalized marijuana for medicinal use in children and teenagers and for recreational use for those aged older than 21 years. Drs. Klembczyk, Calihan and Alinsky article, “Diagnosis and treatment of cannabinoid hyperemesis syndrome,”provides a comprehensive analysis of CHS including the acute management and pharmacotherapy.3 In addition, they describe insights for pediatric primary care providers for the care of adolescents who use cannabis and/or are diagnosed with cannabis use disorder (CUD).

Difference in presentations for CVS and CHS

Children and adolescents presenting with CVS present with a history of recurring, sudden onset vomiting attacks but are separated by symptom free intervals of weeks to months, and often, by history, not related to cannabis use.1 In contrast, adolescents presenting with CHS experience 3 clinical phases beginning with a prodromal phase of morning nausea and a history of cannabis use.3 Another major difference between CVS and CHS is that those presenting with CHS present to the emergency room. Although children and adolescents may present with a first episode of CVS to the ED, often they present to primary care and once other diagnoses are ruled out, for the first episode a diagnosis of viral syndrome may be made. For the diagnosis of CVS, the pattern of sudden vomiting accompanied by free intervals that leads to the diagnosis. Providers who routinely ask about drug use will find that for CVS, the adolescents do not routinely report frequent drug use while those presenting with CHS have a history of drug use.

Evidence-based primary preventive practices to reduce cannabis use

The CRAFFT tool is a well validated screening tool for use with adolescents from 12- to 21-years-old and is recommended by the American Academy of Pediatrics (AAP) for routine use in pediatric clinical practices.4 The CRAFFT tool is self-administered and covers a variety of topics including the use of alcohol, marijuana, and drugs, both legal and illegal, used by teens to experience a ‘high feeling.’ Adolescent responses on the CRAFFT tool provide opportunities for providers to implement primary preventive management services at that moment in time, when specific risky behaviors are identified. Drs. Klembczyk, Calihan and Alinsky also discuss the use of the evidence-based AAP recommendations for Screening, Brief Intervention, and Referral to Therapy (SBIRT) tool in clinical practice. Providers are trained to safely and effectively use the SBIRT tool in clinical practice. With the increased availability of marijuana in 18 states, pediatric providers should develop specific office-based policies for the use and interpretation of the CRAFFT and SBIRT tools and specific interventions to protect the adolescents in their practices.

Pediatric providers who use shared decision-making strategies with parents of pre-teens should be encouraged to discuss with their children their house rules about drug and alcohol use. Providers, especially in states where marijuana is legal, should discuss with parents how to protect their preteens and adolescents from accessing marijuana if they use it in their home. The providers approach to adolescent care that is open and attentive during history taking is a critical component for establishing a trusting relationship, especially when asking sensitive questions about drug and alcohol use. Adolescent responses to these questions provides numerous opportunities for providers to talk about effective the adolescent can avoid drug and alcohol exposure and/or help the adolescent determine effective ways to change these behaviors when identified.

References

1. Garzon Maaks DL, Starr NB, Brady MA, Gaylord NM, Driessnack M, Duderstadt, CG. (2020).Burn’s Pediatric primary care, (7th ed.).St. Louis, MO: Elsevier.

2. Berkowitz, CD. (ED.). American Academy of Pediatrics, Berkowitz’s pediatrics: a primary care approach. Author.

3. Klembczyk K, Calihan, J, Alinsky RH. Diagnosis and treatment of cannabinoid hyperemesis syndrome. Contemporary Pediatrics, April 2022.

4. Boston Children’s Hospital. (2018). CRAFFT. Accessed April 20, 2022. https://crafft.org/