What Exactly is Cannabinoid Hyperemesis Syndrome?

Medical marijuana is used to treat a variety of disorders. One of its main benefits is the low incidence of side effects. Of the known negative effects, Cannabinoid Hyperemesis Syndrome, or CHS, is the most significant. It currently has just one guaranteed treatment: to stop using marijuana. At this point, it is believed to only affect people who are long-term heavy users under the age of 50, so most medical marijuana patients should not be at risk of experiencing CHS. If you think medical marijuana might help you, take our 5-minute eligibility survey to see if you pre-qualify. At your initial appointment, you can speak with a Florida medical marijuana doctor to determine what routes and products will be best for you.

What is Cannabinoid Hyperemesis Syndrome?

CHS is a cyclical disorder. The symptoms follow a rather predictable pattern: 

1. A symptom-free period of weeks to months.
2. The prodromal phase, which includes abdominal pain and early morning nausea. This phase can last months or even years. Patients may experience a fear of vomiting and increase their marijuana use in an attempt to ease the nausea.
3. Next is the hyperemetic phase. Nausea and belly pain are ongoing; there are repeated episodes of vomiting; the patient has a decreased appetite and can lose several pounds as a result of not eating; and dehydration is common. Patients can also experience increased thirst, flushing, sweating, and an alteration in body temperature. During the hyperemetic phase of CHS, the vomiting is often severe and intense, to the point of being almost more than the patient can bear. Patients find that taking hot showers or baths is effective for relieving their symptoms. This phase may continue until the patient completely stops using marijuana. 
4. Finally, the patient enters a recovery phase where the symptoms fade, their appetite returns, and they can eat normally. This can last from days to months for those who choose to continue using marijuana. Significantly decreasing the amount used can increase the amount of time between cycles, but currently the only way to stop the symptoms is to completely stop using marijuana. (1)

Marijuana often has an antiemetic effect on the body; in fact, it is used by cancer patients to help control or eliminate nausea and vomiting caused by chemotherapy and radiation treatments. However, for a small number of long-term marijuana users, a paradoxical reaction (one opposite of what is expected) occurs. The first published research on this condition occurred in Australia. Several patients presented at hospital emergency rooms with what had originally been thought to be Cyclical Vomiting Syndrome or CVS; these particular patients were discovered to be long-term heavy marijuana users. Though their symptoms were similar to a patient with CVS, there was one notable difference: when they stopped using marijuana, the symptoms stopped as well. 

A major obstacle to diagnosing Cannabinoid Hyperemesis Syndrome is the failure of patients to report marijuana use. In addition, since it is used to treat nausea and vomiting, many patients experiencing CHS may not associate their marijuana use with these symptoms. Patients coming to the ER with CHS may be subjected to an extensive battery of tests including a pregnancy test; a variety of blood tests; X-rays; gastric studies; checking for adequate kidney, liver and gallbladder function; ruling out ulcers or intestinal obstruction; and making sure there isn’t any sign of intestinal bleeding or digestive tract cancer. Sharing the duration, amount, and frequency of marijuana use with an ER physician can make a big difference in both diagnosis and treatment. 

What causes CHS?

While there are some theories as to the origins of Cannabinoid Hyperemesis Syndrome, the exact cause is unknown. Comparing the number of cases with how many people use significant amounts of marijuana over many years reveals it is not simply a consequence of heavy long-term use. Patients with CHS in one study did not show a higher concentration of cannabinoids in their system than other recreational marijuana users or a control group composed of other ER patients. (2)

 It has been suggested that chronic marijuana use leads to an increased amount of THC being stored in fat cells; when a certain level is reached, the ability to mediate the vomiting reflex is overridden and hyperemesis occurs. Marijuana decreases nausea and vomiting by acting on the central nervous system (CNS); however, it can also cause vomiting by slowing the rate at which the stomach empties, leading to an excess of stomach contents and gastric acid. Another theory is that over time the accumulation of THC has an effect on the hypothalamus, causing an interruption in the digestive process as well as the body’s ability to regulate temperature (possibly explaining the overwhelming urge to take hot showers or baths as a way to regain a balanced temperature throughout the body). People prone to developing Cyclical Vomiting Syndrome could be more susceptible to Cannabinoid Hyperemesis Syndrome. There may be a link between certain strains of marijuana and CHS. It could also be the result of toxins, pesticides, or other substances on the plant itself. Concentrates, often made from stems, leaves, and other leftover parts of the marijuana plant, may contain up to 10 times the pesticides found on buds; this could be a contributing factor. Only time and research will help identify if these factors are contributory or if there is an altogether different basis for CHS. 

Treating Cannabinoid Hyperemesis Syndrome

CHS does not respond to the same treatment as Cyclical Vomiting Syndrome. Medications such as Zofran and Reglan have little effect on nausea and vomiting. Pain medications offer no relief. Until the marijuana clears the patient’s system, the most effective ways to help are supportive ones. 

• IV fluids help replace fluids and electrolytes lost due to excessive vomiting. 
• Continuing hot showers or baths eases stomach pain. Caution and monitoring is needed, because patients have been known to use water so hot it has scalded their skin. (3)
• Another treatment option for abdominal discomfort is capsaicin cream. Applied to the stomach, arms, or back, it can help lessen the gastrointestinal symptoms associated with CHS within 5-10 minutes. Patients can be instructed on how to use this at home for future episodes if they choose to continue to use marijuana. (4)
• Haldol may help ease nausea, vomiting and abdominal pain when administered to patients in the hyperemetic phase of Cannabinoid Hyperemesis Syndrome. One such patient reported a complete resolution of her symptoms within one day of beginning a short treatment course of Haldol. (5)

Research on the benefits and side effects of medical marijuana has been limited around the world due to its categorization as a dangerous and addictive narcotic. In the USA it is grouped with heroin, LSD, ecstasy, mescaline, khat, bath salts, and other substances as a Schedule I substance. According to the Drug Enforcement Administration, or DEA, Schedule I narcotics have the following characteristics:

As a Schedule I narcotic, scientists and researchers in the United States have been unable to do large-scale legal research on marijuana; this includes not only its benefits and advantages, but possible side effects. Available information is either obtained from other countries where marijuana is legal or from statistics gained through data collected by doctors, emergency rooms, drug treatment programs, and patient reports. Further research on CHS depends on the ability of researchers to study how it affects those suffering with this disorder. 

1. https://www.cedars-sinai.org/health-library/diseases-and-conditions/c/cannabinoid-hyperemesis-syndrome.html
2. https://www.analyticalcannabis.com/articles/understanding-cannabis-hyperemesis-syndrome-311560
3. https://www.vice.com/en_us/article/xd5ppn/cannabinoid-hyperemesis-syndrome-weed-disease-810
4. https://epmonthly.com/article/topical-capsaicin-for-cannabinoid-hyperemesis-syndrome/
5. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4997062/
6. https://www.drugs.com/article/csa-schedule-1.html
7. https://www.leafly.com/news/health/what-is-cannabinoid-hyperemesis-syndrome/
8. https://jaoa.org/article.aspx?articleid=2094175
9. https://www.karger.com/Article/FullText/494992
10. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3576702/

Dr. Marissa Magsino

With over 25 years of specialty training in Internal Medicine, as well as fellowship training in Functional and Sexual medicine, Dr. Maginso added Plant Medicine (Medical Marijuana) to her niche practice as of 2017. She is licensed in the State of Florida and attended the University of the East (UERM) in Quezon City, Philippines as well as the University of Medicine and Dentistry in Newark, NJ.

She joined DocMJ in 2019 to align with a known group of compassionate physicians that empower their patients to be better versions of themselves. Her favorite hashtag is #powerpassionperformance, using the combination of optimized bioidentical hormones, medical marijuana, plasma therapies, and sexual wellness.

She is an author, speaker and community advocate for Medical Marijuana, Sexual Health, and the empowerment of mature women.