Cannabis in the Community

Transcription

1 Department of Pediatrics Cannabis in the Community The Unintended Consequences of Increased Marijuana Availability on the Pediatric Population Karen Buchi, MD Professor of Pediatrics Chair, University Medical Marijuana/Opioid Taskforce

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3 New survey: 77% of Utah voters favor medical cannabis

4 Objectives Understand the adverse/toxic effects of marijuana and marijuana-derivatives Review the latest research Pregnancy and breastfeeding Unintentional pediatric exposures Adolescent use

5 Definitions Marijuana: dried leaves, flowers, stems, seeds from plant Cannabis sativa Cannabis: bioactive substances from plant Cannabinoids: bind to cannabinoid receptors THC (delta-9-tetrahydrocannabinol): mind altering chemical Cannabidiol (CBD) Hashish: pressed resin

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8 Marijuana Direct Effects Psychological effects the high Physiologic effects Increased heart rate, dry mouth, impaired perception, impaired motor skills Acute toxicity Panic attacks, paranoid thoughts, and hallucinations CNS depression: lethargy, confusion, ataxia Respiratory depression, coma, seizures Chronic Hyperemesis syndrome

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10 Challenges Potency of marijuana much higher today Perception of risk based on older data Little known about dose Route of consumption Plant variability Serving size issues Quality assurance unknown

11 Pregnancy and Lactation THC crosses placenta Lower concentrations than maternal serum Distributes to breast milk Higher concentrations than maternal serum Unknown if it can disrupt the development of the endogenous cannabinoid system NOT recommended in pregnancy or while breastfeeding

12 Unintentional Pediatric Exposures Pediatric ingestions

13 Association of unintentional pediatric exposures with decriminalization of marijuana in the United States. Ann Emerg Med. 2014; 63:

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15 Unintentional Ingestions Case reports of 114 children Ages: 8 mo 12 years (mean 25.2 months) Ingestion Type Cannabis resin - 38% Cookies 13% Joints 13% Symptoms Lethargy 71% Ataxia 14% PICU admission 18% Intubated 6% hashish resin J Pediatr 2017;190:142-52

16 The Colorado Experience No ED visits by children for marijuana exposure Hospital 2.3 cases per 100,000; up from 1.2 per 100,000 Poison Control Center Calls increased 5-fold Wang, et al. JAMA Pediatr Sep 6;170(9)

17 Colorado Children s Hospital 5 toddlers (November 2009 March 2010) Lethargy, bradycardia (1) Extensive work-ups 4/5 source had medical card 14 children (January 2005-December 2011) Family source in 8/14 (4 grandparents) 2 admitted to PICU; 1 respiratory depression Extensive workups Child Abuse & Neglect 2011; 35: JAMA Pediatr 2013; 167

18 6 year old boy Seattle Children s Hospital Abdominal pain and vomiting after eating a large snack Lethargy, confusion, hallucinations Extensive work-up Cookie was the culprit 5 year old girl Evaluation for an unwitnessed head injury Extensive work-up Chocolate was the culprit 7 month old Evaluation for increasing lethargy and vomiting Extensive work-up due to history of a fall from a bed the night before Work-up negative; urine positive for THC Mother used medical marijuana while pregnant and breastfeeding Jl Emerg Med 2017; 53: e119-e123, 2017

19 Exposure at a Party Ann Emerg Med. 2018;71:

20 Food for Thought Food for Thought. Clin Toxicol. 2016; 54 (9):

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23 Edibles Top states: CO, WA, OR High rate of healthcare facility evaluation 90% with adverse outcomes 1% major 33% moderate 57% minor Exposure rates highest in < 6 years Characterization of edible marijuana product exposures reported to United States poison centers. Clin Toxicol 2016; 54 (9):

24 Edible Challenges Impact in all ages Pharmacokinetics and pharmacodynamics What is a serving size? Child resistant packaging Recreational products versus medical Rules vary by state

25 Unintentional Pediatric Exposures Pediatric ingestions Exposure to second hand smoke

26 Passive Inhalation Marijuana smoke contains Particulates, volatile organic compounds, polycyclic aromatic hydrocarbons, aromatic amines Studies in adults show significant passive absorption Case report in 13 month old Long-term effects not studied to date

27 Unintentional Pediatric Exposures Pediatric ingestions Exposure to second hand smoke Exposure to a hazardous environment

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30 Unintentional Pediatric Exposures Pediatric ingestions Exposure to second hand smoke Exposure to a hazardous environment Impaired care giver/abuse/neglect

31 Examining the Relationship between Marijuana Use, Medical Marijuana Dispensaries, and Abusive and Neglectful Parenting Bridget Freisthler, Ph.D Child Abuse Negl Oct; 48: Drug-related child welfare cases have increased in Colorado, but connection to legalized marijuana is unclear Dec 2016

32 Child Protective Services

33 Adolescent Use of Marijuana

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35 Adolescent Use Perceptions of safety Effects on neurodevelopment Cognitive/behavioral health issues Hyperemesis syndrome Marijuana use disorders Age of onset THC potency Frequency of use

36 Evidence for the risks and consequences of adolescent cannabis exposure Early onset use is associated with Deficits of cognition and memory Higher prevalence of affective and psychotic disorders Transition to abuse of other drugs Seen disproportionately in those with earlier and heavier use Research is challenging Levine, et. Adol Psych March 2017

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38 Summary There are increased pediatric exposures when marijuana availability increases. These exposures can lead to emergency room visits and hospitalizations. Exposures in adolescence may have long-lasting neurodevelopmental effects. Increased awareness of these unintended consequences is needed. We need to proactively develop education campaigns and regulations to protect the pediatric population.