Cannabinoid Hyperemesis Syndrome: Diagnosis, Pathophysiology, and Treatment—a Systematic Review

Abstract

Cannabinoid hyperemesis syndrome (CHS) is a syndrome of cyclic vomiting associated with cannabis use. Our objective is to summarize the available evidence on CHS diagnosis, pathophysiology, and treatment. We performed a systematic review using MEDLINE, Ovid MEDLINE, Embase, Web of Science, and the Cochrane Library from January 2000 through September 24, 2015. Articles eligible for inclusion were evaluated using the Grading and Recommendations Assessment, Development, and Evaluation (GRADE) criteria. Data were abstracted from the articles and case reports and were combined in a cumulative synthesis. The frequency of identified diagnostic characteristics was calculated from the cumulative synthesis and evidence for pathophysiologic hypothesis as well as treatment options were evaluated using the GRADE criteria. The systematic search returned 2178 articles. After duplicates were removed, 1253 abstracts were reviewed and 183 were included. Fourteen diagnostic characteristics were identified, and the frequency of major characteristics was as follows: history of regular cannabis for any duration of time (100%), cyclic nausea and vomiting (100%), resolution of symptoms after stopping cannabis (96.8%), compulsive hot baths with symptom relief (92.3%), male predominance (72.9%), abdominal pain (85.1%), and at least weekly cannabis use (97.4%). The pathophysiology of CHS remains unclear with a dearth of research dedicated to investigating its underlying mechanism. Supportive care with intravenous fluids, dopamine antagonists, topical capsaicin cream, and avoidance of narcotic medications has shown some benefit in the acute setting. Cannabis cessation appears to be the best treatment. CHS is a cyclic vomiting syndrome, preceded by daily to weekly cannabis use, usually accompanied by symptom improvement with hot bathing, and resolution with cessation of cannabis. The pathophysiology underlying CHS is unclear. Cannabis cessation appears to be the best treatment

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Acknowledgements

We acknowledge the Colorado Department of Public Health and Environment Retail Marijuana Public Health Advisory Committee.

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Correspondence to Cecilia J. Sorensen.

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Funding and Financial Disclosures

Dr. Sorensen has no conflicts of interest to declare. Kristen DeSanto has no conflicts of interest to declare. Dr. Borgelt receives support from the Colorado Department of Public Health and Environment and the University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences. Dr. Phillips receives support from NIH on Drug Abuse R15 DA041656 and R01 DA034957, and Dr. Monte receives support from NIH 1 K23 GM110516 and NIH CTSI UL1 TR001082.

Appendix: Search strategies

Appendix: Search strategies

Cochrane Library (via Wiley Online Library)

  1. 1.

    MeSH descriptor: [Cannabinoids] explode all trees

  2. 2.

    MeSH descriptor: [Cannabis] explode all trees

  3. 3.

    MeSH descriptor: [Marijuana Abuse] explode all trees

  4. 4.

    MeSH descriptor: [Marijuana Smoking] explode all trees

  5. 5.

    MeSH descriptor: [Medical Marijuana] explode all trees

  6. 6.

    cannab*:ti,ab,kw (Word variations have been searched)

  7. 7.

    marijuana:ti,ab,kw (Word variations have been searched)

  8. 8.

    phytocannab*:ti,ab,kw (Word variations have been searched)

  9. 9.

    tetrahydrocannab*:ti,ab,kw (Word variations have been searched)

  10. 10.

    THC:ti,ab,kw (Word variations have been searched)

  11. 11.

    #1 or #2 or #3 or #4 or #5 or #6 or #7 or #8 or #9 or #10

  12. 12.

    MeSH descriptor: [Vomiting] explode all trees

  13. 13.

    emes*:ti,ab,kw (Word variations have been searched)

  14. 14.

    hypereme*:ti,ab,kw (Word variations have been searched)

  15. 15.

    vomit*:ti,ab,kw (Word variations have been searched)

  16. 16.

    #12 or #13 or #14 or #15

  17. 17.

    #11 and #16

Results: 34

Embase (via Embase.com)

  1. 1.

    ‘cannabinoid’/exp

  2. 2.

    ‘cannabis’/exp

  3. 3.

    ‘cannabis addiction’/exp

  4. 4.

    ‘cannabis use’/exp

  5. 5.

    ‘medical cannabis’/exp

  6. 6.

    cannab*:ab,ti

  7. 7.

    marijuana:ab,ti

  8. 8.

    phytocannab*:ab,ti

  9. 9.

    tetrahydrocannab*:ab,ti

  10. 10.

    thc:ab,ti

  11. 11.

    #1 OR #2 OR #3 OR #4 OR #5 OR #6 OR #7 OR #8 OR #9 OR #10

  12. 12.

    ‘vomiting’/exp

  13. 13.

    emes*:ab,ti

  14. 14.

    hypereme*:ab,ti

  15. 15.

    vomit*:ab,ti

  16. 16.

    #12 OR #13 OR #14 OR #15

  17. 17.

    #11 AND #16

  18. 18.

    #11 AND #16 AND [english]/lim AND [2000-2015]/py AND [embase]/lim

Results: 1099

Ovid Medline (Ovid MEDLINE (1946-current), Ovid MEDLINE In-Process & Other Non-Indexed Citations, and Ovid MEDLINE Daily)

  1. 1.

    exp Cannabinoids/

  2. 2.

    exp Cannabis/

  3. 3.

    exp Marijuana Abuse/

  4. 4.

    exp Marijuana Smoking/

  5. 5.

    exp Medical Marijuana/

  6. 6.

    cannab$.mp.

  7. 7.

    marijuana.mp.

  8. 8.

    phytocannab$.mp.

  9. 9.

    tetrahydrocannab$.mp.

  10. 10.

    THC.mp.

  11. 11.

    or/1-10

  12. 12.

    exp Vomiting/

  13. 13.

    emes$.mp.

  14. 14.

    hypereme$.mp.

  15. 15.

    vomit$.mp.

  16. 16.

    or/12-15

  17. 17.

    11 and 16

  18. 18.

    limit 17 to (english language and yr=“2000 - 2015”)

Results: 341

PubMed

  1. 1.

    “Cannabinoids”[Mesh]

  2. 2.

    “Cannabis”[Mesh]

  3. 3.

    “Marijuana Abuse”[Mesh]

  4. 4.

    “Marijuana Smoking”[Mesh]

  5. 5.

    “Medical Marijuana”[Mesh]

  6. 6.

    cannab*

  7. 7.

    marijuana

  8. 8.

    phytocannab*

  9. 9.

    tetrahydrocannab*

  10. 10.

    THC

  11. 11.

    #1 OR #2 OR #3 OR #4 OR #5 OR #6 OR #7 OR #8 OR #9 OR #10

  12. 12.

    “Vomiting”[Mesh]

  13. 13.

    emes*

  14. 14.

    hypereme*

  15. 15.

    vomit*

  16. 16.

    #12 OR #13 OR #14 OR #15

  17. 17.

    #11 AND #16

  18. 18.

    (#11 AND #16) AND “english”[Language] AND (“2000”[Date - Publication]: “2015”[Date - Publication])

Results: 357

Web of Science

  1. 1.

    TS=cannab*

  2. 2.

    TS=marijuana

  3. 3.

    TS=phytocannab*

  4. 4.

    TS=tetrahydrocannab*

  5. 5.

    TS=THC

  6. 6.

    #1 OR #2 OR #3 OR #4 OR #5

  7. 7.

    TS=emes*

  8. 8.

    TS=hypereme*

  9. 9.

    TS=vomit*

  10. 10.

    #7 OR #8 OR #9

  11. 11.

    (#6 AND #10) AND LANGUAGE: (English) Timespan=2000-2015

Results: 323

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Sorensen, C.J., DeSanto, K., Borgelt, L. et al. Cannabinoid Hyperemesis Syndrome: Diagnosis, Pathophysiology, and Treatment—a Systematic Review. J. Med. Toxicol. 13, 71–87 (2017). https://doi.org/10.1007/s13181-016-0595-z

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Keywords

  • Cannabinoid hyperemesis syndrome
  • Cyclic vomiting syndrome
  • Cannabis
  • Marijuana