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Legal Marijuana and Pediatric Exposure

2014; Elsevier BV; Volume: 64; Issue: 4 Linguagem: Inglês

10.1016/j.annemergmed.2014.08.010

1097-6760

Ėric Berger,

Child and Adolescent Health

On a partly sunny Friday afternoon in August, the Denver County Fair opened its gates with the usual attractions one might expect at such gatherings. There were dog competitions, live music performances, everything you could want on a stick, and square dancing. But this year, the fair, which expected to draw about 20,000 people to the National Western Complex, decided to add a new exhibit: the Pot Pavilion. In addition to offering a prize for the “best marijuana plant” there were “speed rolling” contests, Grateful Dead karaoke, and a best handmade bong contest. The celebration of pot culture also included an “edibles” category, which included such foods as brownies. The winning brownie was made of dark chocolate and walnuts. This, perhaps, is where a bit of marijuana’s darker side became apparent. Colorado’s marijuana legalization has benefited some of the state’s residents, and it’s certainly proven a major attraction at events such as the Denver County Fair. There’s also some evidence it has cut crime rates. But the drug’s legalization has also had some unpleasant adverse effects, perhaps most notably the ease with which children can now access the product, especially through edibles. This has resulted in a spike in emergency department (ED) visits for childhood marijuana exposure. In shops throughout the state, adults can purchase a variety of marijuana-infused goodies, from fudge, cookies, and brownies to hard candies, gelato, and gummy bears. “It may be too late to stem the rush toward legalization of recreational marijuana use and the proliferation of products that comes with it,” David Sack, MD, chief executive of Elements Behavioral Health, and a specialist in addiction medicine, editorialized this summer in the Los Angeles Times. “Instead,” Dr. Sack wrote, “we need to focus on better ways to protect children, combat the notion that marijuana is harmless and fund the much-needed additional research on medical uses for marijuana's chemical components, such as the promising cannabidiol, which may prove effective without producing a high.” In a historic departure from prohibition and punishment for marijuana use, Colorado’s Amendment 64 passed by a margin of 55% to 45% in 2012, allowing people aged 21 years or older to grow up to 3 immature and 3 mature cannabis plants and purchase up to an ounce of marijuana. Use of the drug is permitted in a manner similar to alcohol, with equivalent offenses to driving under the influence. Colorado’s EDs have been on the front lines of assessing, understanding, and dealing with the unintended consequences of the state’s new marijuana law, which went into effect on January 1, 2014. Essentially 3 types of patients have presented to EDs since the law’s passage. One of the groups, according to Andrew A. Monte, MD, an assistant professor of emergency medicine and medical toxicology at the University of Colorado–Denver and a toxicologist with the Rocky Mountain Poison and Drug Center, is patients in whom there’s been an exacerbation of chronic conditions, such as a seriously ill asthma patient coming in because he or she smoked marijuana. A second group is patients who have acute effects from eating too many edibles, with conditions such as very fast pulse rates, hallucinations, or cyclic vomiting. EDs have also treated patients who have burns associated with making butane hash oil, a potent and increasingly popular form of marijuana known for a giving a quick high. “In general when there’s increased availability of a drug, then there [are] increased health care encounters associated with that drug,” Dr. Monte said. “Let me quantify the amount of burden we’ve seen so far. It is not enormous. At the University of Colorado hospital, for example, I think we will see several patients on the weekend. For the most part, they are not overrunning the ED, and for the most part, they are easily treated with fluids and they go home.” But there is a third, potentially more troubling, group: children admitted to the ED. George Wang, MD, an emergency physician and toxicologist at Children's Hospital Colorado in Aurora, has been closely tracking this trend and published research on the topic. So far, there are no published data on ED traffic, either from adults or children, since marijuana was fully legalized at the beginning of 2014. However, before this, in a pair of studies, Dr. Wang found an increase in childhood marijuana exposure since Colorado’s marijuana laws were relaxed. The state originally passed a medical marijuana law in 2000, but in 2009 the state modified enforcement efforts. One study in the Journal of the American Medical Association Pediatrics,1Wang G.S. Roosevelt G. Heard H. Pediatric marijuana exposures in a medical marijuana state.JAMA Pediatr. 2013; 167: 630-633Crossref PubMed Scopus (146) Google Scholar published in 2013, found that between 2005 and 2009 there were no ED visits by children in Colorado for marijuana exposure. But after the law changed, between mid-2009 and 2011, there were 14 such visits. According to the research, children who had ingested the drug exhibited symptoms that ranged from respiratory problems and extreme sleepiness to difficulty walking. Many underwent expensive and extensive testing because physicians were not familiar with the possibility of marijuana causing these symptoms. Another study, published earlier this year in Annals of Emergency Medicine,2Wang G.S. Roosevelt G. Le Lait M.-C. et al.Association of unintentional pediatric exposures with decriminalization of marijuana in the United States.Ann Emerg Med. 2014; 63: 684-689Abstract Full Text Full Text PDF PubMed Scopus (101) Google Scholar found that call volume for unintentional pediatric marijuana exposure to poison centers increased by 30.3% between 2005 and 2011 in states in which laws decriminalizing marijuana had been passed, whereas there was little change in states in which the drug was illegal. Since the January 1 passage of the new law, there has been anecdotal evidence that this trend in pediatric marijuana exposure is continuing, or possibly even accelerating. “It’s interesting because the practitioners here are pretty used to it by now,” Dr. Wang said. “We see several cases a month, and they all present with unexplained somnolence. They come in unresponsive or really, really sleepy.” Invariably, Dr. Wang said, parents or grandparents say the child got into an edible. “As I said, we are not seeing it every day, but I think it’s a startling change in trend that we have to pay attention to,” he added. “We have to continue to monitor it. As the industry gets bigger and more commonplace in the household, with increased availability we’re going to be seeing more of these kids coming in. We’re going to have to figure out if this poses some serious threats to public health.” The US marijuana industry is expected to exceed $3 billion, and with the state of Washington passing a law similar to that passed in Colorado, and others considering joining them, these states are embarking on a public health experiment of sorts. The Colorado Department of Public Health and Environment is watching the state’s hospitalization data to determine whether these pediatric exposure trends continue. “We’re concerned about that,” said Mike Van Dyke, PhD, chief of Environmental Epidemiology, Occupational Health, and Toxicology Section at the department. “This is definitely something that’s first and foremost on our minds when it comes to legalization of marijuana.” There is a 3-month lag in data collection, so the department received only the first 3 months’ worth of hospitalization data in June. Preliminary reviews of these early data suggest an increase in ED visits for marijuana exposure, Van Dyke said. Public health officials are also working with hospitals in the state to try to determine how current hospitalization data capture these kinds of trends. From a public health standpoint, one key task is reducing the access children have to marijuana. “One thing we have to work with is 30, 40, or even 50 years of public health work in terms of tobacco control,” Van Dyke said. “A lot of that was really important in terms of where we started from.” Lessons learned from tobacco—such as not using cartoons to advertise products, no direct advertising to kids, and no big signs in stores—have already been crafted into regulations. And after discovering a loophole in the marijuana law that went into effect on January 1, the state government moved quickly within a few months to strengthen the state's packaging requirements and make the opening of edibles child-resistant. Colorado’s governor, John Hickenlooper, addressed these issues in his State of the State address in early January: “Just as we must implement the voters’ wishes on marijuana, we are obligated to make sure that children and parents understand brain development and the risks of underage use,” he said. “We are committed to securing a safe, regulated, and responsible environment. This will be one of the great social experiments of this century, and while not all of us chose it, being first means we all share a responsibility to do it properly.” Van Dyke is responsible for preparing a report looking into all of the effects of marijuana on the state’s health system, which he said will be published on January 31, 2015. The report will include the first 9 months’ worth of health data. “I expect there will be a lot of people who want to read that report,” he said, in something of an understatement. When it comes to health care and the legalization of marijuana, there is not only the general effect on the health care system but also the uncertain effect of increased exposure on a larger number of children, and greater potential for chronic use of marijuana by teenagers. Already some studies in this area have raised concerns that marijuana, although having some benefits for adults, may pose some problems for children. For teens, studies have shown that the drug may disrupt the brain development process in chronic users, especially when it comes to memory retention. There have also been links to mental health problems, including schizophrenia. In one study published last year by the journal Schizophrenia Bulletin,3Smith M.J. Cobia D.J. Wang L. et al.Cannabis-related working memory deficits and associated subcortical morphological differences in healthy individuals and schizophrenia subjects.Schizophr Bull. 2014; 40: 287-299Crossref PubMed Scopus (50) Google Scholar brain abnormalities and memory problems were observed during the individuals' early twenties, 2 years after they stopped smoking marijuana. “The study links the chronic use of marijuana to these concerning brain abnormalities that appear to last for at least a few years after people stop using it,” said lead author Matthew Smith, PhD, an assistant research professor in psychiatry and behavioral sciences at Northwestern University Feinberg School of Medicine. “With the movement to decriminalize marijuana, we need more research to understand its effect on the brain.” Dr. Monte, the medical toxicologist, echoed those concerns. Although he expects ED visits to stabilize over time after an initial “spike,” he said he is more concerned about the possibility of adverse effects on public health over the long term. “What the public health burden is we don’t know,” he said. “We absolutely do have increased availability and utilization, and we won’t know that for a decade or more if there might be impacts for things like cancer. There are some known risks that we’ve already identified, such as decreased cognitive development in children, but I worry about the unknowns.” At the same time, there needs to be a nuanced message from the public health department, he said, noting that marijuana does have health benefits in adults. “The key here is that physicians should have a balanced view,” he said. “This is a decision that has been made by the Colorado public, and we need to respect that. But just as we need to educate the public about wearing a seat belt, and not drinking and driving, we need to educate them about precautions for marijuana.” One area of education needed, Dr. Wang said, is that the “no big deal” perception of marijuana doesn’t extend to children. At least a couple of patients treated at Children's Hospital Colorado, he said, required mechanical ventilations for breathing irregularities and had to be intubated. “As states allow retail medical marijuana, health care providers need to be vigilant and continue to monitor this and make sure it doesn’t become more of an issue,” he said. “I don’t think the public realizes how sick some of these kids can get. Our clinical experience has shown that they can get very sick.”