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
New survey: 77% of Utah voters favor medical cannabis
Objectives Understand the adverse/toxic effects of marijuana and marijuana-derivatives Review the latest research Pregnancy and breastfeeding Unintentional pediatric exposures Adolescent use
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
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
Oregon
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
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
Unintentional Pediatric Exposures Pediatric ingestions
Association of unintentional pediatric exposures with decriminalization of marijuana in the United States. Ann Emerg Med. 2014; 63: 684-689.
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
The Colorado Experience 2005-2009 No ED visits by children for marijuana exposure 2009-2015 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)
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: 563-565 JAMA Pediatr 2013; 167
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
Exposure at a Party Ann Emerg Med. 2018;71:306-313
Food for Thought Food for Thought. Clin Toxicol. 2016; 54 (9): 817-818.
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): 840-846.
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
Unintentional Pediatric Exposures Pediatric ingestions Exposure to second hand smoke
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
Unintentional Pediatric Exposures Pediatric ingestions Exposure to second hand smoke Exposure to a hazardous environment
Unintentional Pediatric Exposures Pediatric ingestions Exposure to second hand smoke Exposure to a hazardous environment Impaired care giver/abuse/neglect
Examining the Relationship between Marijuana Use, Medical Marijuana Dispensaries, and Abusive and Neglectful Parenting Bridget Freisthler, Ph.D Child Abuse Negl. 2015 Oct; 48: 170 178. Drug-related child welfare cases have increased in Colorado, but connection to legalized marijuana is unclear Dec 2016
Child Protective Services
Adolescent Use of Marijuana
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
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
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.