Marijuana Potpourri - PEHSU · Cannabis Hyperemesis Syndrome Clinical diagnosis that has been...
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Marijuana Potpourri Updates on Pediatric Exposures, Prevention, Adolescent Use, CHS, Evidence for CBD, and Local Policy G. Sam Wang MD, FAAP Assistant Professor of Pediatrics University of Colorado Anschutz Medical Campus, Children’s Hospital Colorado Rocky Mountain Poison and Drug Center, Denver Health Hospital
Transcript of Marijuana Potpourri - PEHSU · Cannabis Hyperemesis Syndrome Clinical diagnosis that has been...
Marijuana PotpourriUpdates on Pediatric Exposures, Prevention, Adolescent Use, CHS, Evidence for
CBD, and Local Policy
G. Sam Wang MD, FAAP
Assistant Professor of Pediatrics
University of Colorado Anschutz Medical Campus, Children’s Hospital Colorado
Rocky Mountain Poison and Drug Center, Denver Health Hospital
• Update on pediatric exposures, prevention
• Discuss recent evidence on adolescent marijuana
use trends
• Evaluate recent clinical evidence of CBD for
pediatric epilepsy
• Evaluate hospital policy on Medical Marijuana for
Patients
Objectives
Pediatric Exposure
Figure 2. Number of Human Marijuana Exposure Calls* to Rocky Mountain Poison and Drug Center (RMPDC)by Age Groups from January 1, 2000 to December 31, 2015 in Colorado
‡Data without the generic marijuana code (0083000), no exposure listed, or the exposure description of MedicalReview Officer Information were excluded.
†Unknown age includes calls with ages recorded as teens, 20s, unknown adult (>=20 yrs), unknown child (<=19 yrs), andunknown age.
*Human marijuana exposure calls to RMPDC were determined by the presence of the generic code Marijuana - 0083000 from theNational Poison Data System.
25 Years and Older18-24 Years9-17 Years0-8 YearsUnknown Age†
18
47
18
18
59
15
20
23
72
15
18
17
19
72
15
50
36
16
44
17
18
20
68
15
15
16
57
16
42
29
20
32
93
19
18
16
30
86
16
30
18
34
109
26
34
23
35
123
44
42
31
91
221
49
62
25
78
227
No.
Mari
juana E
xposu
res
0
25
50
75
100
125
150
175
200
225
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015
Figure 5. Number of Human Marijuana Exposure Calls* to Rocky Mountain Poison and Drug Center (RMPDC)by Marijuana Type across Age Groups from July 1, 2014 to December 31, 2015 in Colorado
†Data without the generic marijuana code (0083000), no exposure listed, or the exposure description of MedicalReview Officer Information were excluded.
*Human marijuana exposure calls to RMPDC were determined by the presence of the generic code Marijuana - 0083000 from theNational Poison Data System.
Marijuana Type
Edible MarijuanaSmokable MarijuanaOther Marijuana
37
2212
21
36
2013
22
6
49 47
26
130 131
65
No.
Mari
juana E
xposu
res
0102030405060708090
100110120130140
Age Groups0-8 Years 9-17 Years 18-24 Years 25 Years and Older Total
Figure 5. Number of Human Marijuana Exposure Calls* to Rocky Mountain Poison and Drug Center (RMPDC)by Marijuana Type across Age Groups from July 1, 2014 to December 31, 2015 in Colorado
†Data without the generic marijuana code (0083000), no exposure listed, or the exposure description of MedicalReview Officer Information were excluded.
*Human marijuana exposure calls to RMPDC were determined by the presence of the generic code Marijuana - 0083000 from theNational Poison Data System.
Marijuana Type
Edible MarijuanaSmokable MarijuanaOther Marijuana
37
2212
21
36
2013
22
6
49 47
26
130 131
65
No.
Mari
juana E
xposu
res
0102030405060708090
100110120130140
Age Groups0-8 Years 9-17 Years 18-24 Years 25 Years and Older Total
Figure 5. Number of Human Marijuana Exposure Calls* to Rocky Mountain Poison and Drug Center (RMPDC)by Marijuana Type across Age Groups from July 1, 2014 to December 31, 2015 in Colorado
†Data without the generic marijuana code (0083000), no exposure listed, or the exposure description of MedicalReview Officer Information were excluded.
*Human marijuana exposure calls to RMPDC were determined by the presence of the generic code Marijuana - 0083000 from theNational Poison Data System.
Marijuana Type
Edible MarijuanaSmokable MarijuanaOther Marijuana
37
2212
21
36
2013
22
6
49 47
26
130 131
65
No.
Mari
juana E
xposu
res
0102030405060708090
100110120130140
Age Groups0-8 Years 9-17 Years 18-24 Years 25 Years and Older Total
• 1 mo – 2 yo
• Jan 2013 – April 2014 with bronchiolitis
• 43 Children
• Parents completed questionnaire
• Of children identified been exposed to marijuana
smokers, 16% had trace amounts of THC
metabolites
• 21% vs 10% before and after legalization
Marijuana Exposure in Children
Hospitalized for Bronchiolitis
Wilson, K et al. Pediatric Academic Societies Annual Meeting. 2016. Baltimore, MD
Universal Symbol
• House Bill 1436
• Banning THC-infused gummies in the shape
of humans or fruit
• Marijuana taxes
• Research
• Child welfare and legal maternal use of
marijuana
• Marijuana use in schools
Other
Adolescent Use
Monitoring the Future Survey
Monitoring the Future Survey
Health Kids Colorado Survey
Figure 1: Marijuana-Related ED/UC Annual
Visits
Figure 2: Rate of Marijuana-Related ED/UC
Visits Associated with Cannabis per 1,000
patients
Impact of Marijuana Legalization in Colorado on
Adolescent Emergency Department (ED) Visits
Table 1: Common Associated ICD Diagnosis codes
Table 2: Common Marijuana Co-Ingestants
Cannabis Hyperemesis Syndrome (CHS)
Cannabis Hyperemesis Syndrome
Clinical diagnosis that has been described in
patients who use cannabis chronically
Significant nausea, abdominal pain, and
cyclic vomiting—often relieved by hot bathing
Most patients receive significant medical
evaluation without significant findings and
are refractory to standard medical therapies
Cannabis Hyperemesis Syndrome
The pathophysiology of CHS is not well
understood at this time.
In some circumstances, cannabis has
antiemetic effects; ergo the concept of it
causing hyperemesis is counterintuitive
disturbance of the hypothalamic-pituitary-
adrenal axis TRPV1
Cannabis Hyperemesis Syndrome
IVF
Antiemetics
Haloperidol
Capsascin Cream
Cessation of MJ use
Cannabidiol and Pediatric Epilepsy
Four controlled studies, mainly in the 1970s,
examined the effect of CBD on seizures.
However, while two of the studies found
limited improvements, all four suffered from
methodological flaws, including small sample
size and, in some cases, inadequate blinding
Does not activate CB1/CB2
Animal Studies
Medical Marijuana Legalization
Cannabidiol
“Premium Hemp” Extracts
Cannabis products
Metals
Fungus
Potency
Pesticies
Establishing Hospital Policy
Tricky Issue #1: Federal Law
• Colorado: Initiative 20 and Amendment 64
• MMJ remains a Schedule I controlled substance
• The Controlled Substances Act officially prohibits manufacture, distribution, dispensation, possession
• The Controlled Substances Act does not distinguish between medical and recreational MMJ use
• Department of Justice enforcement discretion…Trump vs. Obama
Tricky Issue #2: Hemp versus Marijuana
• Federal law defines Hemp as dry weight
Cannabis with THC concentration <0.3%.
Section 7606 of the Agricultural Act of
2014. Industrial designation.
• Cannabidiol products CANNOT be
marketed as dietary supplements. Section
201(ff)(3)(B)(ii) of the FD&C Act
Tricky Issue #3: What Our Families are
Using• Pre-clinical, laboratory studies have shown
anti-inflammatory properties to non-THC
cannabinoids.
• There are purported anti-seizure effects of
cannabinoids.
• Low or very-low THC preparations are
products of choice for families with
chronically ill children.
• Our families are often confused by the
complexity of state and federal law.
Medical Marijuana: Provides criteria and procedures for the therapeutic use of Medical MMJ products while patients are inpatient.
• Release of liability signed by families.
• Providers acknowledge use. Not an endorsement.
• Not on-formulary but appears in Medication Administration Record in EHR.
• CHCO will not provide or give product.
• Attending physician can decide that use is not allowed.
• No inhaled preparations are allowed.
Patient Use
Provider Involvement
• “Acknowledgment” of use protects
providers from
administration/handling/prescription
• No CHCO providers currently possess
prescriptive ability for Medical MMJ
Ongoing Challenges
• Catchment area includes all or part of 7
states.
• Assessment of safety of child.
• Understanding potential interactions of
medical MMJ and other prescribed drugs.
• Avoiding conflict between families and
primary treatment teams.
• Address major education gaps for families.
Cannabinoid Education Service Unique Consultation Service/Family
Centered Response
Reporting
Ongoing Challenges
Reporting Aspects – MMJ and
Children.
Colorado Children’s Code 19-1-103
(III) Any case in which a child is a child in need of services because the child's parents, legal guardian, or custodian fails to take the same actions to provide adequate food, clothing, shelter, medical care, or supervision that a prudent parent would take. The requirements of this subparagraph (III) shall be subject to the provisions of section 19-3-103.
(VII) Any case in which a child tests positive at birth for either a schedule I controlled substance, as defined in section 18-18-203, C.R.S., or a schedule II controlled substance, as defined in section 18-18-204, C.R.S., unless the child tests positive for a schedule II controlled substance as a result of the mother's lawful intake of such substance as prescribed.
(2015 Lexis Nexis C.R.S. 19-1-103 (2013)
Marijuana is still a scheduled 1 controlled substance in the state definition, this hasn’t changed with the law
Reporting Aspects – MMJ and Children
To Department of Human Services
Clinical Social Work
• Families are not assessed for “abuse or neglect” based on MMJ
use only
Clinical Social Work -NICU Reports
• Every case that tests positive (meconium and UTS at birth)
• MOC that verbally report use while breast feeding, (needs to
report 21 days of without MJ use before breast feeding again)
• MOC that report use while pregnant, 0-14 weeks
Ingestions
