Rolling Into the ER: Figuring Out Cannabis in the Emergency Department

Review Author: Abanoub Sorial, MD

Introduction:

Due to the increasing rate of legalization of marijuana and its widespread use in the World, differentiating between pathologies related to chronic marijuana use, such as Cannabinoid Hyperemesis Syndrome (CHS) and Cannabis Withdrawal Syndrome (CWS), has become a significant public health concern. It is crucial for emergency department physicians to recognize these conditions, as both can present with similar symptoms. Accurately diagnosing them improves patient outcomes, prevents unnecessary treatments, and reduces the risk of recurrence, ultimately leading to more effective care.

How recognize and diagnose CHS and CWS?

Key clinical history findings:

CHS: onset of symptoms is less than 24 hours from last consumption, compulsive showers for symptom relief, tolerance developing with increasing doses, and symptoms worsening with cannabis consumption.

CWS: onset of symptoms is greater than 24 hours after cessation, with psychiatric symptoms due to withdrawal, dose-related severity of symptoms, and symptoms improvement with cannabis consumption. 

CHS diagnostic criteria (Rome IV): The criteria must be fulfilled for the last 3 months, with symptom onset occurring at least 6 months before diagnosis. It is characterized by stereotypical episodic vomiting, which resembles cyclic vomiting syndrome (CVS) in terms of onset, duration, and frequency. Symptoms typically appear after prolonged, excessive cannabis use, and vomiting episodes are relieved by sustained cessation of cannabis consumption. Additionally, it may be associated with pathologic bathing behavior, such as prolonged hot baths or showers.

CWS diagnostic criteria (DSM-5):  It requires the presence of at least three symptoms within one week of reducing or ceasing cannabis use. These symptoms include irritability, anger or aggression, nervousness or anxiety, sleep difficulty, decreased appetite or weight loss, restlessness, depressed mood, and somatic symptoms causing significant discomfort.

Acute management summary:

CHS:

·       Benzodiazepines (e.g., lorazepam) may be effective, but evidence is limited.

·       Haloperidol (0.05–0.1 mg/kg IV/IM) and droperidol (0.625 mg IV/IM) are the most promising antiemetics.

·       Despite the black box warning for long QT syndrome, neuroleptics can be used in CHS at low doses, with a pre-administration ECG recommended.

·       Neuroleptics help reduce agitation and have antiemetic properties.

·       Capsaicin (topically on forearms and abdomen) can relieve abdominal pain by interacting with TRPV1 receptors, combating hypothermia, and redistributing blood flow.

·       Proton pump inhibitors (PPIs) reduce the risk of esophageal and gastric mucosal lesions due to excessive vomiting.

·       Hot showers can reduce anxiety and help confirm the CHS diagnosis.

·       The only long-term treatment for CHS is abstinence from cannabis.

CWS:

·       Zolpidem (12.5 mg) and nabilone both help reduce cannabis withdrawal-related sleep disruption, but their combination effectively alleviates overall withdrawal symptoms.

·       Low physical activity increases the risk of relapse into cannabis use within a week after a quit attempt, compared to moderate/high physical activity levels. Encourage exercise on discharge.

·       Gabapentin (1200 mg/day) has an acceptable safety profile, significantly reducing cannabis use and withdrawal symptoms.

·       Dronabinol (20 mg twice a day) for 8 weeks, tapered over 2 weeks, has shown effectiveness in managing cannabis withdrawal.

·       Behavioral interventions such as Motivational Enhancement Therapy (MET), Cognitive Behavioral Therapy (CBT), and Contingency Management (CM) can help individuals reduce problematic cannabis use. Possible psychiatry referral on discharge.

·       Oral THC capsules (10 mg/day) reduce cannabis withdrawal symptoms and cravings.

Therapeutic Algorithm Chart:  

FBC, full blood count; U&Es, urea and electrolytes blood test; LFT, liver function tests; BGT, blood glucose test; PPI, proton-pump inhibitors; MET, motivational enhancement therapy; CBT, cognitive behavioral therapy.

Read the full article here.

Reference:

Razban M, Exadaktylos AK, Santa VD, Heymann EP. Cannabinoid hyperemesis syndrome and cannabis withdrawal syndrome: a review of the management of cannabis-related syndrome in the emergency department. Int J Emerg Med. 2022 Sep 8;15(1):45. doi: 10.1186/s12245-022-00446-0. PMID: 36076180; PMCID: PMC9454163.