Cannabinoid hyperemesis syndrome
Cannabinoid hyperemesis syndrome is a disorder associated with long-term chronic cannabis use that is characterized by recurrent nausea, vomiting and colicky abdominal pain has been reported. These symptoms have been reported to be alleviated temporarily by taking a hot shower or bath or more permanently by abstaining from the use of cannabis. The syndrome is recognized by Allen and colleagues (2004), and Sontineni and colleagues (2009) offered simplified clinical diagnostic criteria [1][2]. The contributions made by these experts on the subject were pivotal in defining and characterizing the syndrome at a time when cannabis use is on the rise.
Epidemiology
Cannabinoid hyperemesis was first reported from Adelaide hills of South Australia[1]. Since the first recognition, several cases have been recognized worldwide[3]. Cannabis is by far the most widely cultivated, trafficked and used illicit drug. Half of all drug seizures worldwide are cannabis seizures.[4] The geographical spread of those seizures is also global, covering practically every country of the world. About 147 million people, 2.5% of the world population, consume cannabis, compared with 0.2% consuming cocaine and 0.2% consuming opiates. In the present decade, cannabis use has grown more rapidly than cocaine and opiate use. The most rapid growth in cannabis use since the 1960s has been in developed countries in North America, Western Europe and Australia. Cannabis has become more closely linked to youth culture and the age of initiation is usually lower than for other drugs[4]. Given such a widespread use of cannabis, the cannabinoid hyperemesis syndrome is afflicting large number of people and is steadily rising in its incidence[5].
Clinical presentation
Cannabis has been used recreationally for millennia. Some chronic negative health effects of the drug have only recently surfaced. The long-term and short-term toxicity of cannabis abuse is associated with pathological and behavioural effects leading to a wide variety of effects on the body systems and physiologic states[2]. The phenomenon of cannabinoid hyperemesis and clinical diagnosis remained obscure until recently even though its features were beginning to be understood by leading physicians worldwide. In spite of these early reports, an uncertainty remained among the doctors and scientists regarding the existence of the cannabinoid hyperemesis syndrome[6]. Sontineni and colleagues (2009) discuss the cannabinoid hyperemesis syndrome in their seminal paper [2] to offer guidelines for the clinical diagnosis. The suggested criteria for the diagnosis are - Essential feature: 1) history of regular cannabis use for years; Major clinical features of syndrome: 2) severe nausea and vomiting, 3) vomiting that recurs in a cyclic pattern over months and 4) resolution of symptoms after stopping cannabis use. In addition diagnosis has supportive features of - 1) compulsive hot baths with symptom relief; 2) colicky abdominal pain; and 3) no evidence of gall bladder or pancreatic inflammation. Since the publication of these clinical guidelines, the syndrome is more easily recognized and treated.
Sontineni's [2] criteria for the diagnosis of "cannabinoid hyperemesis syndrome"
| Essential | Cannabis use for years |
|---|---|
| Major | Severe nausea and vomiting
Vomiting that recurs in a cyclic pattern over months Resolution of symptoms after stopping cannabis use. |
| Supportive | Compulsive hot baths with symptom relief
Colicky abdominal pain No evidence of gall bladder or pancreatic inflammation |
One of the key feature that makes cannabinoid hyperemesis syndrome relevant to the health care systems and physicians is its acute nature with nausea and vomiting, frequently requiring emergency room visits. Such emergency room visits often necessitate expensive diagnostic evaluations especially if the physicians awareness of the cannabinoid hyperemesis syndrome is lacking. In 2002, Americans made 110.2 million total visits to hospital emergency rooms with abdominal pain leading as a cause, a 23 percent increase over the 90 million visits made in 1992 [7]. It is evident to see such an enormous increase in the number of emergency room visits increase the health care costs. Given the implications and lack of clarity, it is of major significance that, leading researchers in the field offer simplified clinical diagnostic guidelines to improve the recognition of the syndrome and increase awareness at a time when cannabis use is on the rise [8]. It is also suspected that cannabinoid hyperemesis that is observed in emergency room departments is probably the tip of the iceberg and a far larger numbers of milder symptoms do not come to attention in the broader community[9].
Pathogenesis
Various pathogenic mechanistic theories attempting to explain symptoms have been put forward. These theories fall into two themes; 1) dose dependent build up of cannabinoids and related effects of cannabinoid toxicity, and 2) the functionality of cannabinoid receptors in the brain and particularly in the hypothalamus (which regulates body temperature and the digestive system). But the mechanisms by which cannabis causes or controls nausea and the adverse consequences of long-term cannabis toxicity remain unknown and organic disease should not be ruled out as a possible cause[10].
The neurobiology of the compound has led to the discovery of an endogenous cannabinoid system [11]. The therapeutic potential of cannabinoids has been recognized and these compounds are utilized as anti-emetics. Several studies have demonstrated the therapeutic effects of cannabinoids for nausea and vomiting in the advanced stages of illnesses such as cancer and AIDS. Other therapeutic uses of cannabinoids are being demonstrated by controlled studies, including treatment of asthma and glaucoma, as an antidepressant, appetite stimulant, anticonvulsant and anti-spasmodic, research in this area should continue [4].
Management
Abstinence from cannabis use is the cornerstone of the treatment of cannabinoid hyperemesis syndrome. Appropriate counselling, patient education and substance abuse programs is recommended. During the acute episodes, attention must be directed to maintaining hydration and pain relief with antispasmodic agents and if necessary other analgesics.
References
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<references />, or <references group="..." />- ↑ 1.0 1.1 Allen JH, de Moore GM, Heddle R, Twartz JC. Cannabinoid hyperemesis: cyclical hyperemesis in association with chronic cannabis abuse. Gut. 2004 Nov;53(11):1566-70
- ↑ 2.0 2.1 2.2 2.3 Sontineni SP, Chaudhary S, Sontineni V, Lanspa SJ. World J Gastroenterol. 2009 March 14; 15(10): 1264–1266. [1]
- ↑ Roche, E. & Foster, P.N. (2005). Cannabinoid hyperemesis: Not just a problem in Adelaide Hills.
- ↑ 4.0 4.1 4.2 World health Organization, Cannabis - epidemiology.
- ↑ Fox News, New 'Severe Vomiting' Syndrome Linked to Chronic Pot Use.
- ↑ Byrne A, Hallinan R, Wodak A."Cannabis hyperemesis" causation questioned.Gut. 2006 Jan;55(1):132
- ↑ National Center for Health Statistics Data on Emergency Department Visits (reported on March 18, 2004; Advance Data Number 340. 35 pp. (PHS) 2004-1250).
- ↑ Chronic marijuana abuse linked to severe vomiting
- ↑ Cannabis users 'suffering new syndrome'
- ↑ NCPIC.Cannabinoid hyperemesis syndrome
- ↑ Davis M, Maida V, Daeninck P, Pergolizzi J. The emerging role of cannabinoid neuromodulators in symptom management. Support Care Cancer. 2007;15:63–71.
