9/28/2015. Support. R01CA A1 Intervening with smoking parents of inpatients to reduce

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1 Medical marijuana and the impact of marijuana policy on children Karen M. Wilson, MD, MPH, FAAP Associate Professor of Pediatrics Section Head, Pediatric Hospital Medicine University of Colorado School of Medicine Children s Hospital Colorado American Academy of Pediatrics, Julius B. Richmond Center of Excellence Disclosure: In the past 12 months, I have had no relevant financial relationships with the manufacturers of any commercial product or providers of commercial services discussed in this CME activity. Illustrated Surgeon General s Report on Smoking - Alfred 2Gescheidt, 1964 Support R01CA A1 Intervening with smoking parents of inpatients to reduce exposure (INSPIRE) Flight Attendant Medical Research Institute through a grant to the American Academy of Pediatrics Children s Hospital Colorado Research Institute 3 1

2 Julius B. Richmond Center of Excellence dedicated to protecting children from secondhand smoke, and ensuring that all clinicians ask the right questions about tobacco and SHS exposure Objectives Understand the definitions of marijuana related terminology List evidence based medical indications for marijuana Cite the current epidemiology of adolescent marijuana use Identify effective ways to counsel parents and patients about use of marijuana Describe the issues associated with legalization of marijuana in Colorado, including poisoning risk, secondhand marijuana smoke, and prenatal marijuana exposure AAP Marijuana Position Statement: Key Recommendations* Given the data supporting the negative health and brain development effects of marijuana in children and adolescents, ages 0 through 21 years, the AAP is opposed to marijuana use in this population. The AAP opposes medical marijuana outside the regulatory process of the US Food and Drug Administration. The AAP recognizes that marijuana may currently be an option for cannabinoid administration for children with life limiting or severely debilitating conditions and for whom current therapies are inadequate. *There are 10 total recommendations 2

3 Key Recommendations, cont. The AAP opposes legalization of marijuana because of the potential harms to children and adolescents. The AAP supports studying the effects of recent laws legalizing the use of marijuana to better understand the impact and define best policies to reduce adolescent marijuana use. The AAP strongly supports research and development of pharmaceutical cannabinoids and supports a review of policies promoting research on the medical use of these compounds. The AAP recommends changing marijuana from a Drug Enforcement Administration schedule I to a schedule II drug to facilitate this research. Key Recommendations, cont. The AAP strongly supports the decriminalization of marijuana use for both minors and young adults and encourages pediatricians to advocate for laws that prevent harsh criminal penalties for possession or use of marijuana. A focus on treatment for adolescents with marijuana use problems should be encouraged, and adolescents with marijuana use problems should be referred to treatment. The AAP discourages the use of marijuana by adults in the presence of minors because of the important influence of role modeling by adults on child and adolescent behavior.** **and the potential for secondhand marijuana smoke exposure Medical Marijuana States, By Year of Legalization 23 total, plus D.C.: California 1996 Alaska 1998 Oregon 1998 Washington 1998 Maine 1999 Colorado 2000 Hawaii 2000 Nevada 2000 Montana

4 Medical Marijuana States, By Year of Legalization, cont. 23 total, plus D.C.: Vermont 2004 Rhode Island 2006 New Mexico 2007 Michigan 2008 Arizona 2010 New Jersey 2010 D.C Delaware 2011 Connecticut 2012 Medical Marijuana States, By Year of Legalization, cont. 23 total, plus D.C.: Massachusetts 2012 Illinois 2013 New Hampshire 2013 New York 2014 Maryland 2014 Minnesota 2014 Decriminalization Typically, decriminalization means no prison time or criminal record for first time possession of a small amount for personal consumption. 19 States Each state law varies 4

5 What is marijuana? Cannabinoids Biologically active molecules Bind to CB1 and CB2 receptors: CB1 is found in the brain and nervous system CB2 is found in immune system cells Humans make endocannabinoids 2 FDA approved cannabinoids: Dronabinol Nabilone Chemotherapy related nausea 5

6 Sativex The third form of legal medical marijuana Cannabinoid based oral mucosal spray Approved in Canada and the United Kingdom for symptomatic relief of neuropathic pain in multiple sclerosis. Approved in Canada for patients with cancer pain. Testing underway in the US Sativex is rapidly absorbed and easy to titrate. Quick onset THC Tetrahydrocannabinol Primary psychoactive cannabinoid Marijuana plants Contains more than 200 cannabinoids Cannabidiol (CBD) Not psychoactive 2 major species: Sativa Indica Cross breeding Increased cannabinoid concentration Specific medicinal or recreational effects Increased CBD/lower THC 6

7 Combusted: Pipes Rolled Waterpipes How is marijuana used? 7

8 Aerosolized Side effects Increased HR and systolic BP Conjunctival injection Dry mouth Orthostatic hypotension Increased appetite and thirst Anxiety and panic attacks Memory loss Hallucinations Ataxia 8

9 Hemp Hemp: a low THC (<0.3%) strain of Cannabis sativa. Hemp is not utilized for psychoactive effects Consumer products: paper, textiles, clothing, health food, and bio fuel. Legally grown in a number of countries including Spain, China, Japan, Korea, France, and Ireland. Synthetic marijuana AKA Spice, K2 Chemical synthesized to mimic effects of marijuana First appeared in 2008 Smoked or ingested Cheap and available Chemicals changed continually to avoid bans Really, really bad 9

10 Medical Marijuana Active ingredients are THC and CBD Buds and leaves of the plant are smoked, vaporized, and/or cooked (and drunk or eaten) for their effects. THC or CBD can be assessed and manipulated. Charlotte s Web is a CBD based product with low (<0.3%) THC Evidence based Medical Indications for Marijuana Research has identified areas of therapeutic potential for these molecules, including analgesia in chronic neuropathic pain appetite stimulation in debilitating disease spasticity in multiple sclerosis cachexia THC and CBD have been utilized either alone or together Evidence based Medical Indications for Marijuana in Children and Adolescents Trial and error process Purity, dosage, effects, and side effects of medical marijuana are usually unknown There have been no published clinical trials on the use of medical marijuana in pediatric and adolescent populations 10

11 Future research Phase I III trials on the efficacy of CBD oil in treating pediatric epilepsy in children with Dravet and Lennox Gastaut syndromes Adolescent Brain Development The adolescent brain actually matures by the mid 20s. Marijuana users: Perform more poorly on tests of working memory, cognitive flexibility, and learning Worse attention Worse verbal function Use of substances may alter the developing brain Side effects from medical marijuana would be of special concern in adolescent patients. Current Epidemiology of Adolescent Marijuana Use Longitudinal Data Sets: 3 major sources: Youth risk behavior survey (CDC) Monitoring the future (U. of MI and NIDA) National survey of drug use and health (National household survey on drug abuse) (SAMHSA) 11

12 Monitoring The Future 2014: Lifetime Use (Ever Used) 8 th graders: 15.6% ( 0.9%) 10 th graders: 33.7% ( 2.2%) 12 th graders: 44.4% ( 1.1%) Approximately 100 million adults in the USA have ever used marijuana (Adult population about 250 million; total population about 320 million) Monitoring The Future 2014: Annual Use (Used in the Past Year) 8 th graders: 11.7% ( 1.0%) 10 th graders: 27.3% ( 2.5%)* 12 th graders: 35.1% ( 1.3%) *Significant Change from previous year Monitoring The Future 2014: Current Use (Used within the last 30 Days) 8 th grade: 6.5% ( 0.5%) 10 th grade: 16.6% (1.4%) 12 th grade: 21.2% (1.6%) 12

13 Monitoring The Future 2014: Daily Use 8 th graders: 1.0% ( 0.1%) 10 th graders: 3.4% ( 0.6%)* 12 th graders: 5.8% ( 0.6%) *Significant Change from previous year Counseling Adolescent Patients When adolescents ask for medical marijuana: Not legal in Kansas! Discuss past and current treatments for the particular health complaint Acknowledge that there may be perceived benefit from the use of marijuana for the health complaint Discuss lack of quality control for medical marijuana Counseling Adolescents, cont. Let patient know that if he/she is a minor, written parental consent is mandated Discuss healthier and better researched alternatives to help treat the health complaint Discuss potential addiction: Do you want to be in control, or do you want the drug to control you? 13

14 Counseling Parents When parents ask for medical marijuana for their children and adolescents: It is not legal in Kansas! Discuss past and current treatments for the particular health complaint Acknowledge that there may be perceived benefit from the use of marijuana for the health complaint Discuss the lack of quality control for medical marijuana Counseling Parents, cont. Point out the lack of evidence based medicine in children and adolescents for the use of medical marijuana Discuss healthier and better researched alternatives to help treat the health complaint Discuss dependence and addiction potential Emphasize role modeling behavior Experience with legalization Passed as an amendment to the Colorado Constitution Regulations created during 2013 Legal as of January 1, 2014 Sale and possession of limited quantities for >=21 years Use (and growing) limited to private areas No restrictions on use around children Taxation implemented Limited regulation around edibles; new regulations this year 14

15 Calls to Rocky Mountain Poison Control Center Data from the RMPCC via the CDPHE report: Monitoring Health Concerns Related to Marijuana in Colorado: years 9 17 years Medical Marijuana Legalized Medical Marijuana Commercialized Recreational Marijuana Legalized Other pediatric implications Maternal use in pregnancy Endorsed by some medical marijuana outlets Substitution for opiates? Secondhand marijuana exposure 12.5% of children hospitalized for bronchiolitis had someone in the home using marijuana Exposure in hospitalized children New data 15

16 Summary Increased availability Medical marijuana in children still unproven Adolescents should avoid marijuana use of any kind As should pregnant mothers! Acknowledgments AAP Julius B. Richmond Center of Excellence Janet Brishke Colorado Department of Public Health and the Environment Rocky Mountain Poison Control Center AAP: Impact of marijuana policies on youth: clinical, research and legal update. Ammerman S, Ryan S, and Adelman W. Pediatrics. 16