Editorial: cannabis use disorders at the emergency department, a sign of a growing cannabinoid emergency

For almost 20 years, the use of cannabis has been associated with episodes of nausea and vomiting of cyclic character.1 Since 2016, cannabinoid hyperemesis syndrome (CHS) has been included in the Rome IV criteria of disorders of gutbrain interaction (DGBI). This syndrome is distinguished from other DGBI characterised by nausea and vomiting by its cessation after a prolonged period of cannabis withdrawal.2 Among doctors in emergency departments (EDs), there is an awareness of drug use and abuse as a potential aetiology involved in diverse acute symptoms. To them, the study by Andrews et al3 provides some clinically useful insights from Canada, and to some extent also the USA, regarding cannabis users. Treatment prevalence of CHS at EDs in Canada, when defined by a concurrent recording of ICD10 codes identifying nausea and vomiting (R11) and a cannabisrelated mental health disorder (F12), doubled comparing 2021 to 2017. Combining this observation with other data from the study, highlighting that most cannabis users with upper gastrointestinal symptoms also meet criteria for a cannabis use disorder, the personal and societal burden can be expected to rise if these patients are not addressed by other means than treatment of adverse symptoms. This is substantiated by the paradox that further cannabis use is a means to treat the sneaky gastrointestinal symptoms associated with cannabis abuse. It is important to understand that the study by Andrews et al represents the subpopulation of cannabis users who have a gastrointestinal symptom severity that warrants visits to an ED or are recognised as having upper gastrointestinal symptoms by themselves or their doctor. Complementary knowledge for the same geographic region is given by a crosssectional populationbased internet survey collected in 2015 in Canada, USA and UK.4 In this study, no difference in the proportion of cannabis use was present when comparing those with a cyclic vomiting pattern to those experiencing a chronic nausea and vomiting symptom profile. The proportions of cannabis users reporting that hot baths relieved nausea and vomiting were also similar regardless of whether specific CHS diagnostic criteria were met or not. To some extent, one might suspect that the less precise CHS definition used by Andrews et al provided by the use of the ICD10 code for nausea and vomiting probably also included a larger group of sufferers from the gastrointestinal side effects of cannabis use. Considering the trend for a more liberal legalisation policy, the increased availability of cannabis in many parts of the world, and the associated increase in its use,5 it is important to improve treatment options beyond the ED for those affected by a cannabisrelated mental health disorder. Identifying cannabis as a potential aetiology for any chronic nausea and vomiting disorder, not only CHS, could be one way of reaching out to a group of patients who, to a large extent, have already developed a cannabis use disorder of significance.