Emergency department guidelines for managing cannabinoid hyperemesis syndrome | Research

The takeaway

New GRADE-based guidelines recommend haloperidol, droperidol, or topical capsaicin for CHS symptom management in the emergency department.

People interested in cannabis-related health risks, particularly heavy users who experience recurrent nausea and vomiting.

Very low certainty of evidence for both CHS treatment recommendations

What the researchers found

The GRACE-4 panel issued two CHS-specific recommendations: use of haloperidol or droperidol alongside standard antiemetics, and offering topical capsaicin as an additional option, both graded at very low certainty of evidence.

Why it matters

CHS is increasingly common in emergency departments, but until now there were no widely adopted evidence-based guidelines for its management. These recommendations give ER clinicians a structured approach to a condition that can be difficult to treat.

The numbers in context

Two CHS-specific recommendations issued. Both rated at very low certainty of evidence. Guidelines also covered alcohol withdrawal and alcohol use disorder across 6 total priority questions.

How the study worked

A writing team of emergency physicians and addiction medicine experts applied the GRADE framework to assess evidence and formulate recommendations on six priority questions, including two focused on CHS management in adult ED patients.

What this study cannot tell us

Both CHS recommendations carry very low certainty of evidence, meaning future research could substantially change these suggestions. The guidelines are also specific to adult ED patients and may not apply to other settings.

How to read the evidence

Based on GRADE methodology, the panel rated both CHS recommendations at very low certainty, meaning confidence in the estimated effect is limited and future studies may change conclusions.

When this study was published

Published in 2024. Represents the most current emergency medicine guidelines for CHS management.

The bigger picture

As cannabis use increases, CHS cases are rising in emergency departments. Having standardized clinical guidelines helps ensure consistent treatment and signals growing recognition of CHS as a distinct clinical entity.

Questions still open

How effective are haloperidol and capsaicin compared head-to-head for CHS? What is the optimal duration of CHS treatment in the ED? Are there patient subgroups who respond better to specific interventions?

Common questions

What is cannabinoid hyperemesis syndrome?

CHS is a condition seen in regular cannabis users involving cyclic episodes of severe nausea, vomiting, and abdominal pain. It typically resolves with cannabis cessation.

What treatments do these guidelines recommend for CHS?

The guidelines suggest haloperidol or droperidol in addition to standard antiemetics like ondansetron, and also suggest offering topical capsaicin as an add-on option.

How strong is the evidence behind these recommendations?

Both CHS recommendations are based on very low certainty evidence according to the GRADE framework, indicating the need for more research.

Read the original research

Guidelines for Reasonable and Appropriate Care in the Emergency Department (GRACE-4): Alcohol use disorder and cannabinoid hyperemesis syndrome management in the emergency department.

Academic emergency medicine : official journal of the Society for Academic Emergency Medicine, 31(5), 425-455

View on PubMed ↗Publisher’s paper ↗

Citation

Borgundvaag, Bjug; Bellolio, Fernanda; Miles, Isabelle; Schwarz, Evan S; Sharif, Sameer; Su, Mark K; Baumgartner, Kevin; Liss, David B; Sheikh, Hasan; Vogel, Jody; Austin, Emily B; Upadhye, Suneel; Klaiman, Michelle; Vellend, Robert; Munkley, Anna; Carpenter, Christopher R. (2024). Guidelines for Reasonable and Appropriate Care in the Emergency Department (GRACE-4): Alcohol use disorder and cannabinoid hyperemesis syndrome management in the emergency department.. Academic emergency medicine : official journal of the Society for Academic Emergency Medicine, 31(5), 425-455. https://doi.org/10.1111/acem.14911