San Diego emergency medicine experts created a consensus treatment guideline for cannabinoid hyperemesis syndrome | Research

The takeaway

An expert consensus panel in San Diego developed a CHS treatment guideline recommending capsaicin as first-line treatment, noting that haloperidol and olanzapine provide complete symptom relief in limited studies, while urging clinicians to avoid opioids and educate patients that only cannabis cessation provides lasting relief.

Emergency physicians treating CHS; hospital administrators developing CHS protocols; patients with recurrent CHS episodes.

Capsaicin recommended as first-line treatment; opioids should be avoided

What the researchers found

The San Diego Emergency Medicine Oversight Commission, county health services, and Kaiser Permanente toxicology created an expert consensus guideline for CHS treatment.

Key recommendations:

- Treatment should focus on symptom relief and patient education about cannabis cessation.

- Topical capsaicin (the active compound in chili peppers) is recommended as a first-line treatment. It is readily available and mimics the symptom relief patients seek from hot showers.

- Antipsychotics (haloperidol and olanzapine) have been reported to provide complete symptom relief in limited case studies.

- Conventional antiemetics including antihistamines, serotonin antagonists, dopamine antagonists, and benzodiazepines may have limited effectiveness.

- Emergency physicians should avoid opioids if CHS diagnosis is certain.

- Cannabis cessation is the only intervention that provides complete, lasting symptom relief.

The guideline was designed to reduce unnecessary opioid exposure, minimize healthcare resource use, and improve patient safety.

Why it matters

CHS patients often receive repeated ED visits with expensive workups, unnecessary procedures, and opioid prescriptions that do not address the underlying problem. A standardized treatment guideline can reduce costs, improve outcomes, and avoid contributing to opioid exposure.

The numbers in context

Capsaicin recommended as first-line. Haloperidol and olanzapine reported to provide complete relief in limited studies. Conventional antiemetics described as having limited effectiveness.

How the study worked

Expert consensus panel including emergency medicine oversight, public health, and medical toxicology. Literature review informing guideline development.

What this study cannot tell us

Consensus-based guideline rather than evidence-based practice guideline. Underlying evidence is primarily case reports and case series. No randomized controlled trials of CHS treatments existed at the time of publication.

How to read the evidence

Moderate. Expert consensus from multiple institutions, but limited by the preliminary state of CHS treatment evidence.

When this study was published

Published in 2018. CHS treatment evidence has continued to accumulate, with capsaicin and haloperidol gaining wider acceptance.

The bigger picture

This guideline represents one of the first formal institutional efforts to standardize CHS management. As CHS prevalence increases with cannabis legalization, consistent treatment approaches become essential for emergency departments.

Questions still open

Will randomized trials validate capsaicin as first-line CHS treatment? Is topical capsaicin as effective as IV haloperidol for acute symptom relief? How many ED visits can be prevented with proper CHS education?

Common questions

Why does capsaicin help with CHS?

Capsaicin activates TRPV1 receptors, the same receptors stimulated by hot water. This likely explains why CHS patients instinctively seek hot showers. Topical capsaicin cream applied to the abdomen can provide similar relief without the risks of prolonged hot bathing.

Why should opioids be avoided in CHS?

Opioids do not effectively treat CHS nausea and vomiting, can worsen nausea in some cases, and expose patients to addiction risk. CHS patients who visit the ED repeatedly may accumulate significant opioid exposure without benefit.

Read the original research

Cannabinoid Hyperemesis Syndrome: Public Health Implications and a Novel Model Treatment Guideline.

The western journal of emergency medicine, 19(2), 380-386

View on PubMed ↗Publisher’s paper ↗

Citation

Lapoint, Jeff; Meyer, Seth; Yu, Charles K; Koenig, Kristi L; Lev, Roneet; Thihalolipavan, Sayone; Staats, Katherine; Kahn, Christopher A. (2018). Cannabinoid Hyperemesis Syndrome: Public Health Implications and a Novel Model Treatment Guideline.. The western journal of emergency medicine, 19(2), 380-386. https://doi.org/10.5811/westjem.2017.11.36368