Know the Signs of Cannabinoid Hyperemesis Syndrome

• An increased number of emergency department visits, including for Cannabinoid Hyperemesis Syndrome, has been noticed since the legislation made marijuana legal in several states.  
• The symptoms of Cannabinoid Hyperemesis Syndrome can be severe and extremely painful. 
• Treatment can be tough, expensive, and time consuming for those experiencing the episodes.  

As legislation changes and more states legalize marijuana, there has been an uptick in marijuana-related emergency department (ED) visits. I’ve seen an increase in patients coming in for ingesting too many edibles and experiencing tachycardia and paranoia. Minors come in for the same reason, and poison control services are enlisted. People who don’t get their cannabis legally come in concerned it was laced with something like fentanyl. However, many visits are due to something most people aren’t even aware of, and they certainly don’t realize initially that their ED visit is marijuana related.  

Before legalization, marijuana had long been used for those undergoing chemotherapy to combat nausea, vomiting, and the inability to eat. People have used it for pain management, sleep issues, and, of course, recreationally. Now, with the widespread availability of cannabis from dispensaries and the potency of available strains, healthcare providers are seeing a rise in the harmful impacts of chronic use. ED nurses and doctors are increasingly faced with the challenges of treating patients with cannabinoid hyperemesis.  

Symptoms of Cannabinoid Hyperemesis Syndrome 

According to the Cleveland Clinic, patients experiencing cannabinoid hyperemesis syndrome, or CHS, experience intense, cyclical vomiting, abdominal pain, lack of appetite, and chronic nausea lasting for months on end. It affects those who have used cannabis for longer durations and use it once a week or more. The patients I’ve treated are everyday users.  

When the patient presents to the ED, they’re usually doubled over, screaming, dry heaving, and vomiting. Many of them come in by EMS, standard-issue vomit bag in hand, and are barely able to speak with their healthcare team. Their retching is so loud and violent it can be heard a hallway over. It’s a dramatic and miserable-looking experience.  

When CHS patients arrive in the ED, serious emergencies such as appendicitis, aortic dissection, and pancreatitis need to be ruled out. Often, patients undergo costly procedures such as CT scans and a battery of lab work to ensure their symptoms aren’t indicative of something much worse. Assessing the patient and obtaining a medical history can be challenging due to the patient’s condition. In addition, many patients either aren’t forthcoming about their weed consumption or don’t know to volunteer it as a contributing factor to their illness. Often, we see these patients over numerous ED visits with the same presentation before we can identify the cause of their hyperemesis.  

Cannabinoid Hyperemesis Treatment is Tough

The symptoms are challenging to treat, and much of the time, patients are discharged from the ED still feeling unwell. Over the years, I’ve administered a variety of medications for CHS, from Haldol to Reglan, none of them very effective. This is because the only “cure” for CHS is time and abstinence from marijuana or severely cutting down. Going on a marijuana “diet” isn’t foolproof either. Patients have reported smoking again after no cannabis consumption for months and then immediately find themselves back in the throes of CHS.  

When patients are told that chronic cannabis use is the root cause of their violent vomiting and abdominal pain, they are reluctant to believe it or vehemently disagree with the diagnosis. Some patients are relieved that they feel better after being sick for so long without a known cause. 

One woman I had seen in the ED weekly for over a month did accept it was her cannabis use causing her daily debilitating abdominal cramps, throwing up, and dry heaving. However, she maintained smoking weed was the only remedy for her chronic pain, so she continued to do so. This proves frustrating for ED and EMS staff, who are responding to and treating the same patients week after week. CHS adds another category of patients frequently accessing emergency services in extremely busy emergency departments where understaffing and nurse burnout are at an all-time high (no pun intended).  

Costly and Time-Consuming Visits

The visits are expensive and incredibly time-consuming for ED nurses. Labs need to be drawn at each visit to screen for electrolyte imbalance, and the patient’s nurse is monopolized as more and more medications are auditioned to try and control CHS symptoms. There is also continuous cleanup needed due to constant vomiting. Upon discharge, patients are often dissatisfied since they feel only mildly better or sometimes see no improvement.  

Many people, in general, and patients seeking ED services for CHS have no idea what it is. Since marijuana has long been used as a means to control nausea and vomiting, it seems counterintuitive that it can also be the cause. As EDs get busier and nurses continue to be stretched beyond their limits, education surrounding CHS will be imperative. 

The Bottom Line

Nurses should know how to identify CHS, educate their patients, and provide resources non-judgmentally. We can hope that through education and awareness, CHS ED visits will decrease, and those experiencing it will be able to make adjustments to improve their well-being.  

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