Capsaicin for Cannabis Hyperemesis

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Nurses Edition Commentary

Lisa Chavez, RN and Kathy Garvin, RN

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Jonathan W. -

•Cannabinoid hyperemesis syndrome. Haloperidol is gaining some traction in the treatment of CHS.

I wonder if CHS is due to insecticides spayed on the plants. Anticholinergics are used in insecticide poisoning, so that may account as to how Haldol works.
Please ask ER docs to get acetylcholine esterase levels on CHS so we can see if phosphate insecticides are the cause of the emesis.
Jon Wasserberger MD , Medical Toxicology

David Z. -

Interesting theory Johnathan. I recently discussed your thoughts with friend and tox-guru Dr. Amit Gupta MD. Most insecticides are organochlorines and sodium channel blockers although that's not to say that they are all cholinesterase inhibitors. I like haldol and think it's a great anti-emetic particularly with difficult to treat conditions such as gastroparesis and chronic pain. As for ordering acetylcholinesterase levels, it's a send-out at my shop and takes about a week to get the results. Probably, best reserved for confirmed cases of organophosphate poisoning to aid with long term pralidoxime therapy. Thanks for your thoughtful question.
David Zodda MD, FACEP

zareth i. -

Hi guys,
Zareth Irwin here from the very green city of Portland, OR (get it?).

Great segment on CHS (which is being seen much more frequently), and it's treatment.

I know Rob would find this hard to believe, but we see a ton of patients with CHS. While anecdotal, my personal case series is far larger than the study mentioned here, and I have had great results with topical capsaicin. Both my EM and IM colleagues have found the same (as evidenced by our hospital being completely out of topical capsaicin last week).

I'm such a believer in topical capsaicin for CHS, that In conjunction with a pharmacist and one of my EM colleagues, we have started producing a proprietary strength of topical capsaicin mixed with essential oils (Dr. Z's Weed Cream).

I would just like to add a few thoughts:

1. The pathophysiology of how this works means that you don't need to apply the capsaicin to the abdomen. That is how most of our nurses initially applied it, but patients didn't tolerate it well. We now recommend that you apply to one of the shoulders. It's much better tolerated, and patients can still wipe it off if they don't like it (unlike the back).

2. The strengths commonly seen are 0.025%-0.075%, with a high potency form coming in 0.1% form (I have not seen this strength in the hospital setting). I think the episode stated that the 0.075% is the less potent strength , but it is actually the more potent strength that you will see in your hospitals. Personally we chose to make a 0.04% strength, as it seems that it may be more effective than the 0.025%, but better tolerated than 0.075% form. It does burn depending on where you apply it, but can be treated with topical betadiene if the patient cannot tolerate it.

A few other things:
1. This syndrome is somewhat unique in that an over the counter medication seems to work better than most anything else we can give in the ED. These patients are hard to treat with their refractory symptoms and scromiting (screaming + vomiting), so if we can educate them about capsaicin in addition to cessation, it will be best for all of us.

2. My Ob/Gyn wife is now seeing CHS in pregnant patients. Topical capsaicin is especially useful in these patients, due to its safety profile compared to the other treatments (perfectly safe to ingest or rub hot peppers on yourself in pregnancy).

3. This condition has recently hit the lay press as well (NY Times, Business Insider among others). All EPs will start seeing more of it.

If anyone has experiences to share or questions about topical capsaicin, feel free to email me directly. And check out our website where we will continue to post studies, review articles, treatment tips etc.


David Z. -

Thank you for your thoughtful review and best of luck on you proprietary capsaicin cream. I agree that application sites may vary. Obviously palms, soles, face, neck, and of course genitals should be avoided. We have concentrations at my shop of 0.025%. I have found this concentration to be well tolerated and effective. Thanks again for your comments!

zareth i. -

Thank you, and thanks for educating us all.

David Z. -

Pleasure. Thanks for listening!

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