Emergency Department Visits for Cannabis Hyperemesis Syndrome Among Adolescents
Division of Emergency Medicine, Boston Children’s Hospital, Boston, Massachusetts
Harvard Medical Toxicology Program, Boston Children’s Hospital, Boston, Massachusetts
Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
Abstract
This cross-sectional study assesses trends in emergency department encounters for cannabis hyperemesis syndrome among adolescents.
Article notes
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Received 2025 Feb 25; Accepted 2025 May 8; Collection date 2025 Jul.
Introduction
Cannabis remains the most commonly used illicit substance among adolescents, with evidence showing that recreational cannabis legalization (RCL) with the presence of an active dispensary is associated with an increase in the frequency of use among active users.1,2 An increasingly recognized complication of chronic cannabis use is cannabis hyperemesis syndrome (CHS), a variant of cyclic vomiting syndrome that arises in susceptible individuals with chronic cannabis use.3 This study aims to assess trends in emergency department (ED) encounters for CHS among adolescents, stratified by state RCL status.
Methods
This was a retrospective cross-sectional study of adolescent (13 to 21 years) ED encounters for CHS between January 1, 2016, to December 31, 2023. Data were obtained from the Pediatric Health Information System (PHIS) database. ED encounters were identified based off of a principal code for nausea or vomiting, and at least 1 secondary diagnostic code matching a cannabis-related concern (eMethods in Supplement 1).4 The presence of RCL with an active dispensary was defined as the exposure (eMethods in Supplement 1). Our primary outcome was the yearly frequency of CHS encounters per 1 000 000 ED encounters in state-years with and without RCL. To assess temporal trends, we estimated a series of population-averaged negative binomial regression models. Effect size estimates were expressed as incident rate ratios (IRR) and 95% CIs (eMethods in Supplement 1). The institutional review board at Boston Children’s Hospital determined that this study was exempt from review because it used only deidentified patient data and met criteria for waiver of informed consent. The study followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline. Data were analyzed from September 2024 to October 2024 using STATA version 18.0 (StataCorp).
Results
Between January 1, 2016, to December 31, 2023, we identified 4571 encounters of CHS, with a median (IQR) age of 17.0 (16.0-18.0) years (Table). In the entire cohort, CHS encounters increased by 49.0% (95% CI, 43.7%-54.6%) per year, from 160.4 (95% CI, 113.2-207.6) per 1 000 000 ED visits in 2016 to 1968.3 (95% CI, 1580.1-2356.5) per 1 000 000 ED visits in 2023. Encounters for CHS increased by 32.5% (95% CI, 24.6%-40.9%) per 1 000 000 ED encounters per year in states with RCL and by 49.3% (95% CI, 42.6%-56.3%) in states without RCL (Figure). The overall rate per 1 000 000 ED encounters for CHS in states with and without RCL were 1909.5 (95% CI, 1572.9-2246.2) per 1 000 000 ED encounters and 834.0 (95% CI, 698.2-969.0) per 1 000 000 ED encounters, respectively.
| Demographic and clinical characteristics | Total sample (n = 4571) | Encountersa | |
|---|---|---|---|
| Non-RCL (n = 3005) | RCL (n = 1566) | ||
| Age categories, y | |||
| 13-18 | 3684 (80.6) | 2490 (82.9) | 1194 (76.2) |
| 19-21 | 887 (19.4) | 515 (17.1) | 372 (23.8) |
| Age, median (IQR), y | 17.0 (16.0-18.0) | 17.0 (16.0-18.0) | 17.0 (16.0-18.0) |
| Sex | |||
| Female | 2888 (63.2) | 1946 (64.8) | 942 (60.2) |
| Male | 1682 (36.8) | 1058 (35.2) | 624 (39.8) |
| Race or ethnicity | |||
| Hispanic | 1298 (28.4) | 582 (19.4) | 716 (45.7) |
| Non-Hispanic Black | 1132 (24.8) | 913 (30.4) | 219 (14.0) |
| Non-Hispanic White | 1769 (38.7) | 1314 (43.7) | 455 (29.1) |
| Otherb | 372 (8.1) | 196 (6.5) | 176 (11.2) |
| Insurance status | |||
| Public | 2878 (63.0) | 1800 (59.9) | 1078 (68.8) |
| Private | 1338 (29.3) | 917 (30.5) | 421 (26.9) |
| Other | 355 (7.8) | 288 (9.6) | 67 (4.3) |
| Patient urbanicity (based on zip code) | |||
| Not urban | 266 (5.9) | 190 (6.4) | 76 (4.9) |
| Urban or suburban | 4264 (94.1) | 2792 (93.6) | 1472 (95.1) |
| Overall child opportunity level | |||
| Very low | 1433 (31.4) | 980 (32.7) | 453 (28.9) |
| Low | 935 (20.5) | 587 (19.6) | 348 (22.2) |
| Moderate | 789 (17.3) | 558 (18.6) | 231 (14.8) |
| High | 774 (17.0) | 506 (16.9) | 268 (17.1) |
| Very high | 634 (13.9) | 369 (12.3) | 265 (16.9) |
| Disposition | |||
| Discharged | 2666 (58.3) | 1654 (55.0) | 1012 (64.6) |
| Floor or observation unit | 1878 (41.1) | 1336 (44.5) | 542 (34.6) |
| ICU | 27 (0.6) | 15 (0.5) | 12 (0.8) |
Discussion
In this cross-sectional analysis of adolescents aged 13 to 21 years, ED visits for CHS increased more than 10-fold during the study. Increases were observed regardless of the state’s RCL status. Limitations of the study include use of an administrative database that may not be generalizable to other populations, and the use of a combination of International Statistical Classification of Diseases and Related Health Problems, Tenth Revision codes to identify cases.
CHS is poorly described in the adolescent population.5,6 A study that described trends in CHS among youth 15 to 24 years between 2006 to 2020 found that ED visits increased from 6.8 per 1 000 000 population in 2006 to 173.2 per 1 000 000 population in 2020, corresponding to a mean annual increase of 28.1% (95% CI, 26.7%-30.2%).6 In our sample, we found an increase of 49.0% per year, which likely reflects a different study period and different patient population. A study examining the association of cannabis legalization with ED encounters for CHS in Ontario, Canada, found that commercialization of cannabis during the COVID-19 pandemic was not associated with increased ED visits for CHS in adolescents 15 to 18 years, however, cases increased throughout the study period.4
In conclusion, we found that ED encounters for CHS are increasing both in states with and without RCL, although there were a greater number of cases in RCL states. Additional studies are needed to assess the association of RCL on adolescent CHS to help inform policy makers who are considering RCL.
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References
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References
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