Emergency Department Pediatric Visits in Alberta for Cannabis After Legalization.

BACKGROUND AND OBJECTIVES: Canada legalized nonmedical cannabis possession and sale in October 2018. In the United States, state legalization has been tied to an increase in cannabis-related emergency department (ED) visits; however, little research exists on provincial changes in pediatric visits after nationwide legislation. We compared pre- and postlegalization trends in pediatric cannabis-related ED visits and presentation patterns in urban Alberta EDs. METHODS: Retrospective National Ambulatory Care Reporting System data were queried for urban Alberta cannabis-related ED visits among patients aged <18 years from October 1, 2013, to February 29, 2020. Population subgroups included children (aged 0-11 years), younger adolescents (12 to 14 years), and older adolescents (15 to 17 years). We calculated interrupted time series, incident rate ratios (IRRs), and relative risk (RR) ratios to identify trend change. IRRs identified changes against growth-adjusted Alberta population, while RRs measured presentation pattern changes against prelegalization ED visits. RESULTS: Pediatric visit volume did not change postlegalization when accounting for preexisting volume trends. Unintentional ingestions increased in children (IRR: 1.77, 95% confidence interval [CI]: 1.42 to 2.20 and RR: 1.24, 95% CI: 1.05 to 1.47, respectively) and older adolescents (IRR: 1.36, 95% CI: 1.07 to 1.71 and RR: 1.48, 95% CI: 1.21 to 1.81, respectively). Presentation patterns remained similar, although older adolescent co-ingestant use decreased (RR: 0.77, 95% CI: 0.67 to 0.88), whereas hyperemesis cases increased (RR: 1.64, 95% CI: 1.13 to 2.37). CONCLUSIONS: Cannabis legalization has increased child and older adolescent unintentional cannabis ingestions, increasing child cannabis-related ED visits. Changes highlight need for public health interventions targeting pediatric exposures.

Unintentional cannabis poisoning in toddlers: A one year study in Marseille.

France is the country with the highest prevalence of cannabis use in Europe, despite the fact that cannabis has not been legalized. This prevalence is still increasing along with THC content in cannabis products. In the meantime, unintentional cannabis poisoning by ingestion in toddlers is constantly rising. The aim of this study was to document children's cannabis poisoning biologically and clinically. Plasma and urine samples were extracted by solid phase extraction and analyzed by liquid chromatography coupled to tandem mass spectrometry. Children under 4 years old admitted in pediatric emergency departments for cannabis intoxication between February 1st 2019 and January 31st 2020 were included in this study. Twenty-six children were included (14 female and 12 male), the mean age was 17 months (10-41 months). THC, 11-OH-THC and THC-COOH plasma concentrations ranged from 2.9 to 93 ng/mL, 2.6-65 ng/mL and 29-914 ng/mL, respectively. The most frequent symptoms were drowsiness and hypotonia. Six critical cases were observed: 5 coma and 1 respiratory depression. All children having THC plasma concentrations over 60 ng/mL were in coma. Cannabis poisoning in toddlers become more frequent, 9 cases/year were reported in Marseille in 2007 and 26 cases/year in this study. There is a rising in severe clinical cases, particularly coma. These observations could be explained by an increase in THC content in cannabis products, and a trivialization of cannabis consumption. The unintentional ingestion of cannabis by children is a serious public health concern, and cannabis legalization could worsen this problem.

Unwitting adult marijuana poisoning: a case series.

STUDY PURPOSE: With increasing state legalization, marijuana use has become commonplace throughout much of the United States. Existing literature on unintentional exposure focuses primarily on children.We report on a cluster of adults with unwitting marijuana exposure. METHODS: A cluster of cases were referred to the Medical Toxicology Service after ingesting marijuana-contaminated food at a family event. We conducted a retrospective analysis of twelve subject charts and a qualitative analysis with six of these subjects who willingly consented to be interviewed about their experiences. The study was approved by the Institutional Review Board. RESULTS: Three of the subjects (25%) required prolonged observation due to persistent symptoms. Eleven (92%) were urine immunoassay positive for tetrahydrocannabinol (THC). Two subjects (17%) tested positive for ethanol in their blood. Common symptoms experienced by the subjects included confusion (50%), difficulty speaking (67%), nausea (25%), tremors (17%), and feelings of unreality (33%). All interviewed subjects reported sleepiness and three (50%) reported a negative impact on work. Subjects also reported multiple emotions, including anger, confusion, disbelief, and helplessness. None of the cases resulted in admission for critical care or death. CONCLUSIONS: Our series illuminates effects of unwitting and/or unintentional marijuana exposure in adults. Unintentional marijuana poisonings have increased, but legal and regulatory barriers have limited the study of marijuana outside highly controlled conditions. While the marijuana exposure in this study did not result in admission for critical care or death, it did result in psychological distress and adversely affected work in some cases.

Acute cannabis intoxication in the emergency department: the effect of legalization.

BACKGROUND: On October 17, 2018, the Cannabis Act decriminalized the recreational use of cannabis in Canada. This study seeks to determine how legalization of cannabis has impacted emergency department (ED) visits for acute cannabis intoxication. METHODS: We conducted a retrospective chart review at an academic ED in Hamilton, Ontario. We assessed all visits with a cannabis-related ICD-10 discharge code 6 months before and after legalization (October 17, 2018) to determine cases of acute cannabis intoxication. The primary outcome was the rate of ED visits. Secondary outcomes included number of visits distributed by age, length of stay, co-ingestions, and clinical course in the emergency department (investigations and treatment). RESULTS: There was no difference in the overall rate of ED visits following legalization (2.44 vs. 2.94 visits/1000, p = 0.27). However, we noted a 56% increase in visits among adults aged 18-29 (p = 0.03). Following legalization, a larger portion of patients required observation without interventions (25% vs 48%, p < 0.05). Bloodwork and imaging studies decreased (53% vs. 12%, p < 0.05; 29% vs. 2%, p < 0.05); however, treatment with benzodiazepines increased (24% vs. 51%, p < 0.05). CONCLUSIONS: Legalization was not associated with a change in the rate of cannabis-related ED visits in our study. More research is needed regarding changing methods of cannabis ingestion and trends among specific age groups.

Pediatric cannabis poisonings in France: more and more frequent and severe.

CONTEXT: Accidental pediatric cannabis poisonings are an incidental effect of cannabis use. The average THC content of cannabis resin and the number of consumers are rising sharply in the USA and in most European countries. The objective is to study the evolution of prevalence and severity of pediatric exposures to cannabis in France. METHOD: This is a retrospective observational study of cases detected by French poison centers between January 1st 2010 and December 31st 2017 of cannabis exposure by ingestion in children aged ten or younger. The clinical severity was assessed using the Poisoning Severity Score (PSS). The criteria used for assessing the overall severity were as follows: PSS ≥ 2, admission to pediatric intensive care, coma and respiratory depression (univariate and multivariate logistic regression). RESULTS: A total of 965 cases of poisoning were covered. The annual average number of cases was 93 between 2010 and 2014 and 167 between 2015 and 2017. The median age was 15 months (range, 6 months-10 years) and the sex ratio was 1:1. The form of cannabis ingested was mainly resin (75%). During the period covered by the study, 26.1% of children (n = 252) presented with a PSS ≥ 2, 4.5% (n = 43) coma, 4.6% (n = 44) with respiratory depression and 11.7% (n = 113) were admitted into pediatric intensive care (out of 819 hospitalizations). No fatal cases were reported. In comparison to the 2010-2014 period, the length of hospital stays was significantly higher (p < 0.0001) and the comas were significantly deeper (lower score on the Glasgow coma scale, p < 0.005) in 2015-2017. Following adjustments made for the sex, age and weight of the children, the data show that the severity of the poisonings was significantly greater in 2015-2017 in terms of PSS score, the number of comas and monitoring in intensive care (p < 0.001). CONCLUSION: The data indicates a significant increase in the number of cases of pediatric exposure to cannabis and a rise in the seriousness of poisonings between 2010 and 2017.

Cannabis and synthetic cannabinoid poison control center cases among adults aged 50+, 2009-2019.

OBJECTIVES: Older (aged 50+) cannabis users are growing in numbers, but research on poison control center (PCC) cases has not focused on them. In this study, we examined: (1) changing trends in cannabis forms reported in PCC cases; (2) demographic and clinical factors associated with different cannabis forms; and (3) associations between cannabis forms and medical outcomes. METHODS: We used the American Association of Poison Control Centers' National Poison Data System (NPDS), January 1, 2009-December 31, 2019, to examine the 5201 cases aged 50+ in which cannabis was the only or primary substance. Following descriptive analyses, multinomial logistic regression was fit to examine associations of three cannabis forms (dried/undried plant, other preparations, and synthetic cannabinoids/e-cigarettes for cannabis delivery) with cases' demographic and clinical characteristics, and binary logistic regression was fit to examine associations of medical outcomes (major/potentially major vs. nonmajor) with cannabis forms. RESULTS: Cannabis-related cases involving older adults increased 18-fold (from 61 to 1074) between 2009 and 2019. Compared to plant forms, other preparations had 51.24 times greater odds of appearing in 2018-2019 than in 2009-2011 (95% CI = 27.74-94.67), and synthetic cannabinoids/e-cigarettes had 2.19 times greater odds of appearing in 2014-2015 (95% CI = 1.64-2.93) but lower odds of appearing in 2016-2017 (RRR = 0.67, 95% CI = 0.50-0.89). Other preparations were positively associated with older age, adverse reactions, and suicide attempts but negatively associated with medical cannabis legal states. Synthetic cannabinoids/e-cigarettes were positively associated with being male, intentional misuse/abuse, and chronic use. Compared to plant forms, major medical outcomes/death were less likely among those who used other preparations (OR = 0.75, 95% CI = 0.56-0.99) but more likely among those who used synthetic cannabinoids/e-cigarettes (OR = 2.07, 95% CI = 1.60-2.66). CONCLUSIONS: Although PCC cannabis cases involving older adults are relatively few, cases of other cannabis preparations than plant forms increased rapidly in recent years while cases of synthetic cannabinoids decreased. The rate of major medical outcomes also appears to be high.

Is there an interest for hair analysis in non-intentional pediatric cannabis intoxication?

BACKGROUND AND OBJECTIVES: The incorporation of drugs in the hair of young children differs from that of adults and the metabolism of cannabis cannot be the same. Our primary objective was to analyze the distribution of the different cannabinoids in children's hair samples. The secondary objective was to correlate the intensity of toxic environmental exposure to cannabinoid metabolite levels. METHODS: This was a prospective, single-center, observational pilot study of a pediatric cohort. Included subjects were all children less than 6 years of age admitted to a tertiary pediatric emergency unit for proven cannabis intoxication during the reference period. A hair strand was sampled within 12h of emergency admission. RESULTS: Forty-one pediatric patients were consecutively enrolled. Hair analysis showed that 34 children were positive for Δ9-THC (range 0.06-284.4ng/mg); 41 % of them were also positive for THC-COOH (range 0.26-2.76pg/mg). Depending on the Δ9-THC concentration (>1ng/mg), 39 % of the children could be considered exposed to an intensely toxic environment. The rate of THC-COOH detection steadily increased from 2015 to 2018 (18 %, 40 %, 50 %, 58 % for each consecutive year). Children intensely exposed weighed less on admission (p=0.02), had more comatose presentations (p=0.02), and more previous social issues (75 % versus 12 %, OR 22.0, p=0.0002). CONCLUSION: Hair testing in this context indirectly shows the intensity of children's toxic environmental exposure by the cannabinoid metabolite threshold. This was very helpful during the collegial examination of the toddlers' environment and led to a full investigation and to appropriate decisions concerning social measures.

Marijuana and the Pediatric Population.

Cannabinoids, the psychoactive compounds in marijuana, are one of the most commonly used substances in the United States. In this review, we summarize the impact of marijuana on child and adolescent health and discuss the implications of marijuana use for pediatric practice. We review the changing epidemiology of cannabis use and provide an update on medical use, routes of administration, synthetic marijuana and other novel products, the effect of cannabis on the developing brain, other health and social consequences of use, and issues related to marijuana legalization.

Setting the baseline: a description of cannabis poisonings at a Canadian pediatric hospital prior to the legalization of recreational cannabis. / Établissement d'une base de référence : description des intoxications au cannabis dans un hôpital pédiatrique canadien avant la légalisation de la consommation de cannabis à des fins récréatives.

INTRODUCTION: This study describes the events and circumstances preceding children aged 16 years or younger being treated for cannabis poisoining in the emergency department (ED) of a Canadian pediatric hospital. METHODS: We extracted cannabis poisoning treated in the ED at British Columbia Children's Hospital (BCCH) between 1 January, 2016 and 31 December, 2018, from the Canadian Hospitals Injury Reporting and Prevention Program (CHIRPP) database. The poisonings were distinguished by the inadvertent or intentional ingestion of cannabis. We reviewed the hospital's electronic health information system and the patients' health records to obtain additional information on the context, including spatial and temporal characteristics. RESULTS: Of the 911 poisonings treated at BCCH, 114 were related to intentional cannabis use (12.5%). Fewer than 10 poisonings resulted from inadvertent ingestions by children and the median age for these was 3 years. All inadvertent ingestion occurred at home and involved cannabis belonging to the patient's family. The vast majority of poisonings resulted from the intentional use of cannabis only (28.9%) or cannabis use with other psychoactive substances (co-ingestions; 71.1%). The median patient age was 15 years. Most patients reported consuming cannabis through inhalation with peers. Cannabis and co-ingestion poisonings were more often reported on weekdays than weekends. The consumption of cannabis leading to poisoning more often occurred in private residences. Patients with cannabis poisoning more often sought medical treatment themselves or were helped by their family. CONCLUSION: The characteristics of cannabis poisonings among children are described for the three-year period prior to recreational cannabis legalization in Canada in order to set a baseline for future comparisons. Implications for improving injury prevention initiatives and policies are discussed.

The association between recreational cannabis commercialization and cannabis exposures reported to the US National Poison Data System.

BACKGROUND AND AIMS: Recreational cannabis has been legalized in 11 states and District of Columbia (DC) in the United States. Among these, 10 states further permitted retail sale to provide a legal supply to adults. This study examined the associations of cannabis exposures with recreational cannabis legalization and commercialization. DESIGN: Secondary data analysis of state-quarter level cannabis exposures during 2010-17 in the United States. Linear regressions with a difference-in-differences design were used to compare pre- and post-legalization trends in states that legalized recreational cannabis to contemporaneous trends in states that did not legalize recreational cannabis. SETTING: United States, including all 50 states and DC. CASES: Cannabis exposures reported to the US National Poison Data System. MEASUREMENTS: The primary outcome was state age-adjusted cannabis exposures reported to the US National Poison Data System per 1 000 000 population per quarter. The two policy variables of interest included (1) the enactment of recreational cannabis legalization (i.e. removing penalties for adults' possession of cannabis in a small amount for recreational use) and (2) the initiation of recreational cannabis commercialization (i.e. providing a legal supply of cannabis to adults through licensed dispensaries). FINDINGS: The association between a state's enactment of recreational cannabis legalization and its changes in cannabis exposures was statistically non-significant overall. After controlling for recreational cannabis legalization, however, the initiation of recreational cannabis commercialization was associated with 5.06-5.80 more exposures per 1 000 000 population per quarter (67-77% increase relative to the pre-legalization average), depending on the composition of comparison states. The increase associated with commercialization was higher among minors than adults (7.97-9.53 versus 3.83-4.21 more exposures), higher among males than females (6.16-7.56 versus 3.76-3.91 more exposures) and higher among exposures with medical consequences than those without medical consequences (4.09-4.79 versus 0.97-1.01 more exposures). CONCLUSION: An increase in cannabis exposures reported to the US National Poison Data System was observed following recreational cannabis commercialization in the United States.

Cannabis intoxication after accidental ingestion in infants: urine and plasma concentrations of Δ-9-tetrahydrocannabinol (THC), THC-COOH and 11-OH-THC in 10 patients.

Introduction: Accidental cannabis poisoning after oral ingestion in infants is an emerging cause of intoxication with well-known clinical aspects but few data exist regarding the levels of cannabinoids in plasma and urine. Here, we present data on the concentrations of Δ-9-tetrahydrocannabinol (THC) and metabolites in plasma and/or urine in 10 infants after cannabis intoxication.Materials and methods: Cannabinoids were detected using an automated immunochemical method and quantified using liquid chromatography coupled with mass spectrometry.Results: Ten infants were admitted after cannabis poisoning. THC, THC-COOH and 11-OH-THC plasma levels ranged from 4.4 to 127 ng/mL, from 28 to 433 ng/mL and from 2 to 59.8 ng/mL, respectively. THC-COOH urine levels ranged from 748 to 5689 ng/mL. The most common symptoms were drowsiness, hypotonia, behavioural disorder and tachycardia.Discussion: No correlation between plasma concentrations and symptoms could be found, but the concentration of THC-COOH in the two patients who experienced seizures was higher than 3000 ng/mL. This series of cases of accidental intoxication in infants showed high THC and metabolites concentrations in urine and plasma.

Marijuana exposures in Colorado, reported to regional poison centre, 2000-2018.

The objective was to evaluate trends in marijuana exposures reported to the Colorado regional poison centre (RPC). Human exposures cases from the Colorado RPC obtained from 1 January 2000 through 31 December 2018 using generic marijuana exposure codes. There were 2221 marijuana exposures, with an increase in exposures by 11.2 cases per year (p<0.0001). Annual cases remained steady since 2014 (p=0.22), with a 19.4% increase in 2018 compared with 2017. Since 2014, the largest increase was in children age 0-8 years (p<0.0001). Edible marijuana exposures increased by 9.6 exposures per year from 2015 to 2018 (p=0.04). After observing an increase in Colorado RPC marijuana exposure cases in 2010 and 2014, annual exposures have been stable through 2017, with the first increase in legalised recreational sales era in 2018. There are specific concerns for the paediatric population and exposures involving edibles, as these cases continue to increase.

Intoxication From Accidental Marijuana Ingestion in Pediatric Patients: What May Lie Ahead.

Marijuana is the most commonly used illicit drug. In young children, there are relatively few reports in the literature of acute marijuana intoxication. Here, we describe the case of a previously healthy 2-year-old girl who presented with clinical seizures. A urine toxicology screen showed elevated levels of tetrahydrocannabinol. The source of the drug was not identified. After a short stay in the hospital, the patient fully recovered with only supportive measures. In this report, we also summarize all domestic and international cases of marijuana intoxication in children younger than 6 years, in conjunction with the number of exposures in children of similar age identified by the US National Poison Data System. This report highlights what is becoming a more common problem. As cannabis continues to be decriminalized across the United States with its increasingly diverse modes of delivery, the potential for accidental exposure in infants and young children also rises. Clinicians should now routinely consider marijuana intoxication in children who present with acute neurological abnormalities.

Acute Cannabis Toxicity.

The change in legal status of cannabis (the botanical species Cannabis sativa, commonly known as marijuana) in the United States has had significant impact on pediatric drug exposures. In states with decriminalization of recreational and medicinal use of cannabis, emergency department visits and poison control center calls for unintentional pediatric cannabis intoxication are on the rise in the last few decades. Exploratory or unintentional ingestions of cannabis-containing products (as opposed to those derived from synthetic cannabinoids, which may mimic the structure and/or function of cannabis, but are not the focus of this article) can lead to significant pediatric toxicity, including encephalopathy, coma, and respiratory depression. With the increasing magnitude of the public health implications of widespread cannabis use, clinicians who care for pediatric patients routinely must be adept in the recognition, evaluation, management, and counseling of unintentional cannabis exposure.

Prevalence and correlates of cannabis poisoning diagnosis in a national emergency department sample.

BACKGROUND: One of the primary cannabis-related reasons individuals seek emergency medical care is accidental cannabis poisoning. However, our understanding of the incidence and characteristics of those who receive emergency medical care due to cannabis poisoning remains limited. We address this gap by examining up-to-date information from a national study of emergency department (ED) data. METHODS: The data source used for this study is the Nationwide Emergency Department Sample (NEDS). An International Classification of Diseases (ICD-10-CM) diagnostic code was used to identify accidental poisoning by cannabis (T40.7 × 1A) as specified by healthcare providers. Logistic regression was employed to examine the relationship between ED admission for cannabis poisoning, sociodemographic factors, and mental health disorders. RESULTS: In 2016, an estimated 16,884 individuals were admitted into EDs in the United States due to cannabis poisoning, representing 0.014% of the total ED visits for individuals ages 12 and older. Individuals who sought care for cannabis poisoning were more likely to be young, male, uninsured, experience economic hardship, reside in urban central cities, and experience mental health disorders as compared to individuals admitted for other causes. Among cases that included the cannabis-poisoning code, many also had codes for accidental poisoning due to other substances such as heroin (4.7%), amphetamine (10.8%), cocaine (12.9%), and benzodiazepine (21.3%). CONCLUSIONS: Despite the limitations of ICD-10 data, findings provide new evidence suggesting that practitioners be attuned to the prevention and treatment needs of high-risk subgroups, and that screening for mental health problems should be standard practice for individuals diagnosed with cannabis poisoning.

Incidence of Pediatric Cannabis Exposure Among Children and Teenagers Aged 0 to 19 Years Before and After Medical Marijuana Legalization in Massachusetts.

Importance: Pediatric health care contacts due to cannabis exposure increased in Colorado and Washington State after cannabis (marijuana) policies became more liberal, but evidence from other US states is limited. Objective: To document the incidence of pediatric cannabis exposure cases reported to the Regional Center for Poison Control and Prevention (RPC) before and after medical marijuana legalization (MML) in Massachusetts. Design, Setting, and Participants: Cross-sectional comparison of pediatric cannabis exposure cases 4 years before and after MML in Massachusetts. The exposure cases included those of 218 children and teenagers aged between 0 and 19 years, as reported to the RPC from 2009 to 2016. Census data were used to determine the incidence. Data analysis was performed from November 12, 2018, to July 20, 2019. Exposure: Cannabis products. Main Outcomes and Measures: Incidence of RPC-reported cannabis exposure cases, both single substance and polysubstance, for the age group of 0 to 19 years, and cannabis product type, coingestants, and clinical effects. Results: During the 8-year study period (2009-2016), the RPC received 218 calls involving cannabis exposure (98 single substance, 120 polysubstance) in children and teenagers aged 0 to 19 years, representing 0.15% of all RPC calls in that age group for that period. Of the total exposure cases, males accounted for 132 (60.6%) and females 86 (39.4%). The incidence of single-substance cannabis calls increased from 0.4 per 100 000 population before MML to 1.1 per 100 000 population after (incidence rate ratio, 2.4; 95% CI, 1.5-3.9), a 140% increase. The age group of 15 to 19 years had the highest frequency of RPC-reported cannabis exposures (178 calls [81.7%]). The proportion of all RPC calls due to single-substance cannabis exposure increased overall for all age groups from 29 before MML to 69 afterward. Exposure to edible products increased after MML for most age groups. Conclusions and Relevance: Pediatric cannabis exposure cases increased in Massachusetts after medical marijuana was legalized in 2012, despite using childproof packaging and warning labels. This study provides additional evidence suggesting that MML may be associated with an increase in cannabis exposure cases among very young children, and extends prior work showing that teenagers are also experiencing increased cannabis-related health system contacts via the RPC. Additional efforts are needed to keep higher-potency edible products and concentrated extracts from children and teenagers, especially considering the MML and retail cannabis sales in an increasing number of US states.