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Cannabinoid Hyperemesis Syndrome

Cannabinoid Hyperemesis Syndrome (aka Cannabis Hyperemesis Syndrome) is a new clinical diagnosis for a condition that affects some cannabis users. This condition is being identified in younger cannabis users who use cannabis regularly for extended periods of time (years). As the name implies, it is characterized by 'hyper-' (frequent) '-emesis' (vomiting).

While cannabis normally can help soothe nausea and vomiting, some individuals experience paradoxical effects on the gastrointestinal tract and central nervous system. This is the case for all types of cannabis, including hemp flower which can also trigger Cannabinoid Hyperemesis Syndrome.

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What is Cannabinoid Hyperemesis Syndrome?

The symptoms of Cannabinoid Hyperemesis Syndrome (CHS) are easily mistaken for another condition called Cyclic Vomiting Syndrome. Indeed, CHS has flown under the radar of the medical community for many years. Mayo Clinic began studying CHS in 2005, with the term term 'cannabinoid hyperemesis' being coined in a study just the year prior.

Cyclic Vomiting Syndrome is characterized by recurrent episodes of nausea, vomiting, and tiredness. Episodes can last anywhere from hours to 10 days. Allen, et al. (2004) discovered that in some cases of Cyclic Vomiting Syndrome, patients were younger (under 50) and long time chronic cannabis users (using 3-5 or more times per day). He and some other researchers will term them 'cannabis abusers,' but truly not all chronic cannabis users are abusers and the condition should concern anyone who uses cannabis regularly.

Ultimately, Allen and his research team found that if the patients did not consume cannabis the Cyclic Vomiting Syndrome would go away, and if they used cannabis again it would return [1]. This lead to the discovery of Cannabinoid Hyperemesis Syndrome.

Cyclic Vomiting vs Cannabinoid Hyperemesis

Some Cyclic Vomiting patients may also have marijuana use that should alert physicians to screen for Cannabinoid Hyperemesis Syndrome. But how do they tell them apart [2]?

  • Cyclic Vomiting Syndrome most often occurs in people with mood disorders
  • Cyclic Vomiting Syndrome also most often occurs in people with migraines or a family history of migraines
  • Gastric emptying in Cyclic Vomiting Syndrome is accelerated; in Cannabinoid Hyperemesis Syndrome it is delayed
  • Diagnosing CHS is difficult because its symptoms are shared among many conditions

Endoscopies, brain imaging, abdominal CT scans, and blood work are among the diagnostic tools used to diagnose Cannabinoid Hyperemesis Syndrome [2]. Even with insurance, these are costly to obtain. However, without them, it is near impossible to rule out the many other conditions with similar symptoms.

Cannabinoid Hyperemesis Syndrome Symptoms

One unique trait of Cannabinoid Hyperemesis Syndrome is a compulsion to take hot baths or showers frequently. This may sound rather silly, but it is likely the body urging people to do something that will help alleviate gastrointestinal discomforts. CHS progresses in three phases. The first is the 'prodromal' phase where the reason for symptoms is unclear. This is followed by the hyperemetic phase and recovery phase.

Prodromal Phase CHS Symptoms

  • Morning sickness-like symptoms
  • Frequent nausea and urges to vomit
  • Abdominal discomfort
  • No change to appetite
  • Risk of using more cannabis in an attempt to soothe symptoms
  • Can last months or even years

Hyperemetic Phase CHS Symptoms

  • Persistent nausea that lasts for hours
  • Episodes of vomiting that can last for hours
  • Frequent retching (gagging urge to vomit)
  • Abdominal pain
  • Weight loss and dehydration
  • The compulsion to take frequent hot showers or baths (many in a single day)
  • Loss of appetite
  • This phase generally lasts only 24 to 48 hours

Recovery Phase of CHS

  • Cannabis use must stop entirely
  • Weight and appetite recover
  • Nausea subsides and vomiting stops
  • Can take weeks or months depending on the amount of cannabinoids stored in the body

Cannabinoid Hyperemesis Syndrome Treatment

The only cure for Cannabinoid Hyperemesis Syndrome is to abstain from cannabis use entirely [2]. Without stopping cannabis use, no recovery can be made. Supportive care may be needed and many CHS sufferers do require hospitalization during the hyperemetic phase. IV fluids can help with the dehydration.

Most anti-emetic therapies do not help with nausea and vomiting from CHS though [2]. Stomach acid suppression medications (proton pump inhibitors) are said to help. Capsaicin creams may also help reduce pain when applied to the abdomen. Without treatment, complications like kidney failure, electrolyte problems, and skin burns from hot water can occur.

Why Hot Showers Work for CHS

Frequent hot showers and bathing are a sign that something more than Cyclic Vomiting Syndrome is at play. People who have Cannabinoid Hyperemesis Syndrome will indeed feel a strong urge to take hot baths and showers. Why is that?

Hot showers can alleviate symptoms like nausea, vomiting, abdominal pain, and decreased appetite in CHS [2]. It isn't known for sure why, but researchers suspect that it has something to do with the way cannabis influences body temperature.

Cannabis use can create an imbalance in the body's systems that regulate temperature (thermoregulation) through its effect on the hypothalamus region of the brain [2]. It's thought that cannabis increases core body temperature but reduces skin temperature.

Cannabinoids and CHS

To be clear, it is the cannabinoids in the cannabis plant that trigger Cannabinoid Hyperemesis Syndrome. Using any type of cannabinoid product like CBD oil, THC oil, and even CBG products will all trigger CHS in those with the condition.

THC and Cannabinoid Hyperemesis Syndrome

THC is stored in body fat and can be released when you feel stressed or are food-deprived [2]. This 're-intoxication effect' is significant because it can take daily cannabis users months for THC to naturally be eliminated from their bodies. For those with Cannabinoid Hyperemesis Syndrome, this can mean a long wait for the body to recover.

Cannabinoid Hyperemesis Syndrome and CBD & CBG

Animal studies have shown that the effects of CBD that relieve nausea and vomiting are only seen at low doses [2]. High doses of CBD will actually increase nausea and vomiting. CBG can also alter the anti-emetic effects of CBD and could potentially increase nausea and vomiting. CBD and CBG are both of concern for those with Cannabinoid Hyperemesis Syndrome. Affected individuals are encouraged to refrain from using any type of cannabinoid or cannabis-derived product.

Cannabinoids in the Gastrointestinal System

When the CB1 receptor is activated by cannabinoids (especially THC), gastric acid secretion is reduced, the esophageal sphincter (throat valve) relaxes (allowing reflux), intestinal motility is altered, and pain and inflammation can occur [2]. The sum of these responses means that your body does not digest food as quickly.

It is a bit of a paradox that THC has anti-emetic properties because these conditions normally lead to nausea and vomiting (as CHS patients experience) [2]. When used at low doses under medical guidance, THC is surprisingly good at reducing nausea and vomiting though. This paradox is thought to be related to the actions of THC in the central nervous system and not its influence on the GI system.

Cause of Cannabinoid Hyperemesis Syndrome

Based on these basic actions of cannabinoids in the body, there are three theories on the cause of CHS. In reality, it may be some of many reasons or something completely different. CHS has not been studies well enough yet to say for sure. However, here are the threee suspected root causes:

  1. Toxicity from the dose-dependent buildup of cannabinoids
  2. Alterations to the cannabinoid receptors in the brain, especially the hypothalamus (which regulates body temperature and the digestive system)
  3. Direct effect of stimulation to GI tract cannabinoid receptors

Living With Cannabinoid Hyperemesis Syndrome

People who are living with Cannabinoid Hyperemesis Syndrome will have periods of remission [2]. With the promordal phase lasting months to years, it can take a long time for people with CHS to experience acute symptoms. Since many cannabis users utilize cannabinoids to compact nausea and vomiting, they are likely to increase use and unknowingly worsen their conditions.

CHS is also a difficult condition to pin down because it can take years for it to fully emerge and is difficult to diagnose. If you are a daily long-time cannabis product user, it is important to be aware of this condition so you do not accidentally make yourself more ill by consuming more of the cannabinoids that are making you sick.

References

  1. Allen, J. H., De Moore, G. M., Heddle, R., & Twartz, J. (2004). Cannabinoid hyperemesis: cyclical hyperemesis in association with chronic cannabis abuseGut53(11), 1566-1570.
  2. Galli, J. A., Sawaya, R. A., & Friedenberg, F. K. (2011). Cannabinoid hyperemesis syndromeCurrent drug abuse reviews4(4), 241–249.

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