Just a Band-Aid: The Inadequate Response to Cannabis Use Disorder in Youth

A 15-year-old with a history of generalized anxiety disorder, oppositional defiant disorder, attention deficit disorder, social anxiety disorder, and daily cannabis use for the past 2 years was admitted to the pediatric inpatient unit for dehydration and abdominal pain secondary to persistent emesis in the setting of cannabinoid hyperemesis syndrome (CHS). This was their seventh hospitalization in 17 months in addition to 9 visits to the emergency department (ED) for similar complaints. Additional history was notable for iatrogenic QTc prolongation from prior administration of antiemetics including ondansetron, metoclopramide, and haloperidol.CHS is a disorder characterized by cyclic abdominal pain and persistent emesis in the setting of prolonged, high-dose cannabis use.1–3 The overall prevalence of CHS is largely unknown, given the lack of definitive criteria or diagnostic testing; however, self-reported symptoms and prevalence of vomiting-related ED visits have shown an increase in areas where cannabis is newly legalized or commercialized.4,5 The pathogenesis remains unclear but may be multifactorial, involving cannabinoid metabolism, exposure dose, tolerance, and pharmacodynamics at both central and peripheral cannabinoid receptors.1,2 This disorder is considered a variant of cyclical vomiting syndrome, characterized by compulsive hot bathing or showers to relieve pain and emesis, with a lack of symptoms between acute episodes.1–3 Acute treatment for CHS involves fluid repletion; antiemetic therapy, typically with dopamine antagonists; and pain control.1–3 Long-term management involves a multidisciplinary approach that ultimately requires total cessation of cannabis use.1,2 Expenditures associated with delayed diagnosis, exhaustive testing, and treatment for CHS are estimated to be over $70 000 per patient, according to a retrospective observational study.6 While it is difficult to ascertain the exact costs, there is a significant financial burden on both the patient and the health care system.While admitted to the pediatric inpatient unit, the patient was treated with intravenous fluids, antiemetic therapy, and pain control. Given limited options for antiemetic therapy due to QTc prolongation history, they were treated with aprepitant with some positive but limited effect. Aprepitant is a medication typically used for chemotherapy-induced vomiting and has been reported in the literature to have potential benefits for patients with CHS.6The patient was evaluated by the addiction medicine team and diagnosed with severe substance use disorder (SUD). The SUD had resulted in many school absences, continued substance use at home, significant familial stress, and multiple hospitalizations and ED visits. The addiction medicine team recommended inpatient rehabilitation for the SUD, which both the patient and parents agreed to. There are 3 sites for inpatient substance use rehabilitation in minors in the state, and none accept public insurance. A single-use agreement was attempted and not approved. At discharge, a referral was placed for an intensive outpatient program. The patient’s caregivers were unable to take the patient to these appointments due to long work hours and other childcare obligations. In the 4 months since discharge, the patient has not had access to the recommended inpatient rehabilitation; they have had 6 ED presentations, 2 of which have resulted in admission, for CHS symptoms due to continued cannabis use (Figure 1).Our case highlights the challenge in breaking the cycle of severe SUD in an adolescent unable to access recommended rehabilitation due to lack of insurance coverage and the concomitant low-value care from symptom control and harm from QT-prolonging antiemetics.Standard antiemetics are often ineffective for the acute treatment of CHS, and high-quality evidence for pharmacologic treatment of this syndrome is limited.3,7 Most available literature on CHS exists primarily within adult populations and describes benzodiazepines, haloperidol, and capsaicin as somewhat therapeutic, but literature in pediatric populations is severely lacking.Traditional antiemetics, such as ondansetron, do not target cannabinoid receptors and are not reliable in the treatment of CHS.7 Haloperidol, another frequently used medication, can cause dystonic reactions, which then require more pharmacotherapy to treat the side effects.7 Most antiemetics cause QT interval prolongation, which can result in serious arrhythmias such as Torsades de pointes and intensive care unit hospitalizations.7 Nontraditional antiemetics, such as benzodiazepines, carry the risks of paradoxical agitation, confusion, and respiratory depression, as well as risk of misuse and dependence, particularly in patients already known to be vulnerable to substance use.7,8 Topical capsaicin remains an option for treatment but is often discontinued because of patient intolerance due to the burning sensation.3,9 Aprepitant, an NK1 receptor antagonist, may be a potentially effective treatment for CHS; however, evidence is limited at this time.10 Unfortunately, hospitalization can result in a deleterious cycle of attempting to treat nausea and then treating the side effects of the medications. Nonpharmacological therapy that universally provides temporary relief to patients with CHS is hot showers, the mechanism of which is not fully understood. This is also not without risk in a hospital setting (fall risk, syncope, structural damage from water).3Anecdotally, a common mantra in treating CHS is that “the patient will tell us when they are ready to go,” which raises the possibility that pharmacotherapy is not expediting discharge, time may be the only acute treatment, and we are, in fact, only causing harm.Alcohol, nicotine, and cannabis remain the most common substances used by adolescents.11 In a study of 12th graders, investigators reported that the most endorsed methods of obtaining cannabis included being given for free by friends or bought from friends or a drug dealer/stranger and less commonly from a relative.12 The use of alcohol, nicotine, and cannabis can be a precursor to other illicit drug use among adolescents, and addressing the use of these substances serves as a form of prevention for other illicit drug use when it comes to teenagers.11With prevention at the core of pediatrics as a guiding principle, the American Academy of Pediatrics (AAP) has recommended legislative and agency action to improve coverage of, payment for, and access to substance use prevention, early intervention, and treatment services.13 Specific requests include legislation that promotes parity between medical services and substance use services, ensuring adequate oversight of the Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) standard in state Medicaid programs and managed care plans to ensure they are offering the continuum of medically necessary substance use services, from prevention to treatment, for children and adolescents as required by law.13Residential treatment facilities are one treatment option for adolescents with SUDs.13 While there has been preliminary research in support of residential treatment for improved outcomes of youth with co-occurring psychiatric disorders and SUD, there remains a dearth of research in this area.14 This said, there is more evidence for the efficacy of residential treatment programs for youth with other medical-psychiatric diagnoses such as eating disorders, particularly in patients with more severe baseline symptoms, low motivation for recovery, low family involvement, and failure or inaccessibility of outpatient management.15,16 As expected, substance use rehabilitation options for adolescents are limited and costly.13 Using the Substance Abuse and Mental Health Services Administration’s treatment locator and search engine advertising data, investigators identified 160 residential addiction treatment facilities that treated adolescents with opioid use disorder as of December 2022.13 In 23 states, investigators did not identify an adolescent residential treatment center that accepted Medicaid.13 The mean monthly reported cost of treatment in the study was $26 353, which is twice the annual federal poverty level in 2022 for a single-person household in the United States ($13 590).13In this era of widespread cannabis use, a better approach to high-value care is recognition that a small but significant proportion of children under 18 years will develop SUD from cannabis use and that this population is expected to grow further in the setting of increased legalization and commercialization. These patients have been overlooked in research and face a lack of evidence-based approaches to their illness. Instead, they risk facing prolonged and frequent hospitalizations, as well as complications of pharmacotherapy with unclear benefit and potential for harm. As the only definitive treatment of CHS is cannabis cessation, this population is a wakeup call to the need for effective substance use treatment in minors and the need for better access to adolescent SUD treatment, including residential treatment with rehabilitation regardless of insurance status. Otherwise, adolescents with CHS will continue to seek hospitalization for temporary relief, return to continued substance use, and present repeatedly to the hospital, without meaningful progress made toward cessation and recovery.The authors acknowledge Deepa Camenga, MD, MHS, FAAP, Associate Professor of Emergency Medicine, Director of the Yale Program in Addiction Medicine, for her input and advocacy for teens with substance use disorders.