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What is cannabinoid hyperemesis syndrome (CHS)?

What is cannabinoid hyperemesis syndrome?

Cannabinoid hyperemesis syndrome (CHS) is a condition that can occur in patients who have been using cannabis products regularly for several months or years. Let's break this concept down into its component parts so we can see what's behind it: 

Cannabinoids = the set of active substances in the cannabis plant.

Hyperemesis = excessive nausea and vomiting (hyper = excess, emesis = vomiting).

Syndrome = a set of symptoms that occur together but are not classified as a disease 

The exact cause of this condition is unknown, so it is considered a syndrome rather than a disease. However, we do know that it mainly affects people who use cannabis products regularly and for a long time. One study reported that only 3% of those suffering from symptoms that could be classified as CHS rarely use cannabis.  The remaining 97% were considered 'frequent users'. The results of the same study showed that 93% of patients who stopped using cannabis experienced a disappearance of symptoms within a few days. The majority of patients also reported that hot showers were the most effective way to relieve their symptoms (even temporarily).

 

 

There are three main phases of CFS, each with its own characteristic symptoms:

1. Prodromal phase

This is the first phase, which may persist for several months or even years before the syndrome moves on to the next phase. Most people experience nausea early in the morning along with abdominal pain.

2. Hyperemetic phase

People usually seek medical help at this stage and only now are they diagnosed with CHS.

Symptoms include:

  • Persistent or recurrent attacks of nausea
  • Vomiting
  • Abdominal pain
  • Dehydration
  • Food aversion

Vomiting at this stage can be strong and persistent. Sometimes the situation even forces patients to seek medical emergency. Excessive vomiting and lack of appetite can cause dehydration, electrolyte imbalance, anxiety, insomnia and weight loss. If left untreated, the problem can be dangerous.

3. Recovery phase

After stopping cannabis use, it may take a few days to change from the hyperemetic phase to the recovery phase. Once this has happened, symptoms of nausea and vomiting will gradually disappear and appetite will return. It may take several days or weeks for everything to return to normal. 

What are the symptoms of CHS?

The main symptoms of CHS are abdominal pain and vomiting. People affected by this condition experience repeated, often severe bouts of vomiting, followed by periods without any symptoms. 

Symptoms include:

  • Nausea (persistent or recurrent)
  • Vomiting (mild to intense)
  • Abdominal pain (usually in the middle of the abdomen)
  • Diarrhoea
  • Excessive thirst
  • Sweating
  • Anxiety
  • Dry mouth

There are many different medical conditions that have similar symptoms, so it is important that if you have been vomiting for more than three days, you see a doctor. If the patient is not given any treatment and continues to use cannabis despite the unwanted symptoms, they may develop much more serious side effects. The main cause of these more serious effects stems from dehydration or electrolyte imbalances in the body due to excessive vomiting. 

Examples of the effects of dehydration include:

  • Seizures
  • Kidney failure
  • Irregular heartbeat
  • Shock
  • Brain swelling
  • Muscle weakness

Other symptoms may include the development of tooth decay (caused by the breakdown of enamel by stomach acid), oesophagitis or Mallory-Weiss syndrome.

 

How common is CHS?

Current data suggest that CHS is very rare in people who use cannabis infrequently (several times a year) and only slightly more common in people who use cannabis only once or twice a month. One study looked at emergency room visits to determine the prevalence of CHS. They followed 2127 patients who visited an emergency room at a hospital in New York City. Only 155 of these patients reported using cannabis more than 20 times per month. Of this study group, 33% of the patients had experienced symptoms in the past that could be related to CHS. The problem with this study is that the criterion used to determine how often CHS might occur in infrequent cannabis users was only "nausea mild with hot showers." While it is true that hot showers often alleviate nausea caused by CHS, they can also help with other causes of nausea. 

What causes CHS?

There are three main theories about what may be causing CHS: 

1. Hypothalamic theory

The first theory states that frequent exposure to cannabinoids causes a change in the balance of the endocannabinoid system in the hypothalamus. The hypothalamus is the area of the brain responsible for regulating stress and body temperature. If receptor dysfunction (especially CB1 receptors) occurs, this can cause a change in the thermoregulatory setting of body temperature and affect the activity of the nearby nausea centre in the brain. This results in a reduction in body temperature and could also explain why hot showers are so effective for relieving symptoms.

CBD has been shown to increase the expression of CB1 receptors in this part of the brain, which may mean that this cannabinoid contributes to the onset of this disorder. However, it is actually THC that activates these receptors.

2. Theory of cannabinoid accumulation

The second theory suggests that the symptoms of CHS are caused by a toxic dose of cannabinoids.

When we take any substance into the body, it has to be broken down by the liver and kidneys. If we take in a larger amount of a substance for a longer period of time, it may begin to accumulate in the bloodstream before it is completely eliminated from the body.

Elevated concentrations of cannabinoids may be hidden for a long time, but eventually their levels reach a toxic threshold, which can trigger symptoms associated with CFS. In addition, cannabinoids are stored in fat. Once a person begins to lose weight as a result of the frequent vomiting caused by CHS, the fat loss releases more cannabinoids into the body, causing further deterioration of the condition

3. Theory of TRPV1

The last theory focuses on a separate type of receptor that many cannabinoids interact with, called TRPV1 or vanilloid receptors. These receptors are responsible for the "hot" sensation we experience when eating spicy foods and play a role in pain transmission, digestive system movement and temperature regulation.

Certain cannabinoids have been shown to downregulate TRPV1 receptors. It is therefore hypothesised that frequent exposure to these cannabinoids may cause TRPV1 receptor downregulation, leading to the symptoms associated with this disease. This explains the need to shower with hot water to normalise TRPV1 activity and alleviate the symptoms of CHS. It may also explain why, for example, capsaicin ointments, another TRPV1 agonist, are so effective in providing relief from this condition. 

Which cannabinoids contribute to CHS?

It is not yet clear which cannabinoids directly induce the symptoms associated with CHS. Current evidence points to THC as the primary activator of endocannabinoid receptors.

However, other cannabinoids may also contribute to these effects. 

Can cannabidiol (CBD) cause CHS?

It is not clear whether CBD may also cause CHS, but early evidence suggests that it may contribute to the development of existing CHS symptoms. CBD has been shown to increase the expression of CB1 receptors in the hypothalamus. This effect could enhance the progression of CHS through the hypothalamic theory described above. Other studies have shown that lower doses of CBD are antiemetic, but higher doses can actually induce vomiting. This supports the idea that CBD may cause CHS through the aforementioned theory of cannabinoid accumulation. This means that if a cannabis user experiences CHS, they should avoid the use of all cannabis products, including non-psychoactive cannabis dietary supplements. Researchers are currently trying to find out which cannabinoids cause this condition and which do not. 

Can Delta 8 THC cause CHS?

There are two forms of THC - delta 9 THC and delta 8 THC. By far the most common form is the delta 9 isomer, which has already been confirmed as one of the main causes of CHS. But what about the less common isomer delta 8 THC? At present, there is virtually no research on what effect delta 8 THC has on CHS. There are differences in the effects of delta 8 THC and delta 9 THC on the body, but they still act on the same receptors and produce the same effects. It is therefore very likely that delta 8 THC has the same or similar effects on the ECS that induce CHS. 

 

Can it cause both CHS and CHG?

CBG (cannabigerol) has been shown to counteract some of the anti-nausea effects of THC. Some preliminary studies suggest that this cannabinoid may contribute to the pathophysiology of CHS.

How is CHS diagnosed?

CHS is a syndrome, which means that it is a set of symptoms that often accompany each other but may not have the same underlying cause. Diagnosing a syndrome is much harder than diagnosing a disease that has a specific, identifiable cause. As a result, the diagnosis of CHS is made by ruling out other possible causes rather than by testing for the disorder itself.

This condition is still not well researched and was first identified only in 2004. As more and more places make cannabis legal, the incidence of this disease is increasing. As a result, its diagnosis is improving significantly. Doctors have the following tests to rule out other possible causes of the problem:

Blood tests - to check for anemia, infection or leukemia.

Electrolyte test - to check for dehydration or hyperkalemia.

Liver tests - to check for signs of liver disease.

Pregnancy test - to assess possible symptoms caused by morning sickness.

Urine tests - to check for signs of drug use, infection or kidney disease X-ray or ultrasound of the abdomen - to check for physical causes of pain and vomiting CT head or functional MRI - to check for other neurological disorders that may explain symptoms.

They will also want to know when you last used cannabis or cannabis products (including delta 8 THC or CBD) and how often and for how long you used them. They may also ask about doses or ask you to bring in a packet of the products you are taking so they can check them. They will probably also ask about other medications, family history and whether you have been sexually active.

How is CHS treated?

The best treatment for this condition is to stop using all cannabis products.

Scientists are currently trying to better understand this condition, but from the data we have, it appears to be partly permanent. This means that patients who suffer from CHS will have the same symptoms again if they use cannabis products again, even after a longer break. The rest of the treatment involves managing symptoms and preventing the more dangerous side effects associated with dehydration and electrolyte imbalances that can result from frequent vomiting.

Treatment for CHS may include:

  • Intravenous fluid administration (for dehydration)
  • Antiemetics (drugs that prevent vomiting)
  • Administration of painkillers
  • Proton pump inhibitors
  • Frequent hot showers
  • Anti-anxiety drugs (e.g. benzodiazepines)
  • Herbal remedies (e.g. ginger or warm ointments)
  • Dopamine antagonists
  • Discontinuation of all opioid medications

Cannabinoids and the endocannabinoid system

There are many active substances in the cannabis plant. The main components are THC (tetrahydrocannabinol) and CBD (cannabidiol). Both of these active substances act through a series of receptors known collectively as the endocannabinoid system (ECS). The ECS is responsible for regulating neurological, gastrointestinal, renal, cardiovascular and immune functions. It is closely involved in monitoring and maintaining the balance of these critical systems.

Every living organism on Earth has an ECS. The body makes hormone-like compounds called endocannabinoids to relay messages between ECS receptors. We need this system to survive; without it, we lose the ability to maintain the body's balance (homeostasis). Cannabinoids from the cannabis plant, such as THC and CBD, are similar in shape and structure to our own endocannabinoids. This allows them to interact with the ECS by activating or altering receptors. As a result, cannabis has health benefits. CBD, for example, increases ECS activity in the brain, leading to the suppression of pain, nausea and reduced electrical activity associated with anxiety. THC also increases ECS activity in the brain, but in a different way. It stimulates the CB1 endocannabinoid receptors that control serotonin levels. 

Summary: What is CHS?

CHS stands for Cannabinoid Hyperemesis Syndrome. Over time, the body becomes resistant to the effects of the active ingredients in cannabis. In this condition, cannabis use causes a dramatic increase in nausea and vomiting and can cause abdominal pain, dehydration, dizziness and a range of other symptoms. The only known treatment for CHS is to stop using cannabis. After stopping use, the symptoms usually go away within two days, but for some people it can take several months. There is very little research into this condition and we still do not know exactly what causes it and which cannabinoids are involved.

 

 

Author: Canatura

PHOTO: Shutterstock

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