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Rocky Mountain High

Rocky Mountain High. Jenna Gantner , DO. Cannabis Sativa Marijuana. Weed, joint, doobie, cannabis, reefer, fatty, pot, dope, herb, mary jane, grass, skunk, cheeba , blunt, jolly green, roach…. Marijuana. As of June 2017, there were 491 retail marijuana stores in the state of Colorado

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Rocky Mountain High

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  1. Rocky Mountain High Jenna Gantner, DO

  2. Cannabis SativaMarijuana • Weed, joint, doobie, cannabis, reefer, fatty, pot, dope, herb, mary jane, grass, skunk, cheeba, blunt, jolly green, roach…

  3. Marijuana • As of June 2017, there were 491 retail marijuana stores in the state of Colorado • 392 Starbucks • 208 McDonald’s

  4. Objectives • Discuss uses for marijuana- which are evidence based, which are bogus • (spoiler alert- it is not a secret cure for cancer) • Public health risks and benefits of marijuana legalization • (expect to see an uptick in fashion that includes pot leaves) • Things you can expect to see coming to an ER near you if marijuana is legalized in your state and what to do about them • (Haldol is your friend) Probably needs IV Haldol

  5. Marijuana • 147 million people use (2.5% of world population) • Most widely cultivated, trafficked and abused illicit substance • Active ingredients (2,3) • THC (delta-9-tetrahydrocannabinol) • Behavioral effects • Cannabidiol • Non psychoactive Cannabis. Management of substance abuse. World Health Organization. http://www.who.int/substance_abuse/facts/cannabis/en/ (Accessed on October 15, 2018).

  6. Mechanism of Action • Cannabidiol • G protein coupled receptors • CB1- modulates epileptiform and seizure activity • May inhibit glutamate release • CB2- expressed in immune system Gururajan, A and Malone D. Does cannabidiol have a role in the treatment of schizophrenia? Schizophrenia research volume 176, issue 2-3, October 2016 pg 281-290.

  7. Marijuana ingestion • Inhaled • Effects in 15-30 min, last 4h • Effect mirrors serum thc concentration • Sx at 2-3mg inhaled thc • Effects mitigated by technique • Duration of puffing, inhalation depth, breathholding • Ingested • Peaks in 30 min- 3h, lasts 12h • 5-20mg thc cause sx in naïve user

  8. Your guide to not sounding like an old, dorky doctor in the pot shop • Bud- flower of mature plant, contain cannabinoids • Joint- MJ rolled in cigarette paper • Blunt- dump tobacco out of cigarette and fill with MJ • Bong- glass, ceramic of plastic apparatus to smoke. Filters air through water • Dab- small quantity of concentrate (wax, oil or shatter) “dabbed” with a heat source to produce vapor which is inhaled • Fatty- opposite of a Pinner. • Oil- (aka hash oil, butane honey oil, wax, shatter, budder)- MJ extract, gold color. Created through extraction process.

  9. …but how do you make those delicious cookies

  10. Legalization • Medicinal versus recreational • 1996 California Proposition 215 • First state to allow medical MJ • 33 states now have comprehensive public medical marijuana/cannabis programs • 1973 Oregon decriminalized cannabis • $100 fine • 2012- CO and WA legalize recreational National Congress of State Legislatures. State Medical Marijuana Laws. 11/8/18. http://www.ncsl.org/research/health/state-medical-marijuana-laws.aspx

  11. Legalization • Still federally illegal • Schedule 1 • USDOJ expects states to create "strong, state-based enforcement efforts.... and will defer the right to challenge their legalization laws at this time." • Can’t technically write a prescription for it • “referral” “recommendation” because of federal prescription prohibition • Need to fill at a dispensary

  12. Legalization • Local jurisdictions can ban medical and/or recreational MJ businesses • Statewide 66% have

  13. Legalization in Colorado • Medical Marijuana • Amendment 20 (2000) • Up to 2 oz, cultivate up to 6 plants (3 mature) • Patient registry/ID cards • Allows dispensaries • Does not recognize out of states patients • Conditions recognized • Cachexia, cancer, chronic pain, chronic nervous system disorders, seizures, glaucoma, hiv/aids, MS, other disorders characterized by spasticity and nausea

  14. Legalization in Colorado • Recreational • Amendment 64 • Dec 10, 2012 • Legal to have and use up to 1 ounce for any purpose >21 • 6 plants, half mature • Jan 1, 2014 • First place anywhere in the world to allow legal MJ sales to anyone over 21 for any purpose • Specially licensed stores

  15. $ Calendar Year Total MJ Sales Total to Date 2014 $683,523,739 $683,523,739 2015 $995,591,255 $1,679,114,994 2016 $1,307,203,473 $2,986,318,467 2017 $1,507,702,219 $4,494,020,686 2018 $1,545,691,080 $6,039,711,766 Self reported by businesses

  16. $- Per §39-28.8-501(6), C.R.S., "To increase transparency, the marijuana enforcement division shall include a link on its website that describes the disposition of the retail marijuana excise tax revenue and how the revenue from the fund was appropriated for the fiscal year 2015-16 and each fiscal year thereafter” (FY) 2017-18 the first $40M of the Retail Marijuana Excise Tax revenue was distributed to the Public School Capital Construction Assistance Fund (PSCCAF) administered by the Colorado Department of Education's Building Excellent Schools Today (BEST) program. Excise tax collections in excess of $40M, $27.8M for FY 2017-18, were transferred to the Public School Fund.

  17. $ Written into amendment 64 The BEST health, safety and security issues asbestos removal, new roofs, building code violations, and poor indoor air quality. grants are competitive awarded annually in most cases must be supplemented with local district matching funds.

  18. Cannabis in South Dakota • Medical MJ • Ballot initiatives • 2006- failed 52-47 • 2010- failed 63-36 • 2016- initiative failed to make the ballot • 2018- initiative failed to make the ballot

  19. Cannabis in South Dakota • New Approach South Dakota- Medical Cannabis supported most recent attempted initiative • “an initiated measure to legalize marijuana for medical use” • Qualifying patients have • “debilitating medical condition” • Obtain registration card from the state department of health • May designate a caregiver who also needs a registration card • 3oz and a MINIMUM of 6 plants • Legalizes testing, manufacturing and cultivation facilities • Legalizes dispensaries • Must also register w DOH

  20. But it failed

  21. How to buy your weed in Colorado • Any resident or non resident over 21 with a valid ID • 1 oz at a time • Stores may be open 8a-12a • Bring cash • Don’t take it home • But if you have to your best bet is sealed in the trunk of your car • Have you seen the airport dogs?

  22. So What?

  23. Driving while high • Expressed consent • By driving in Colorado you give permission for blood or breath test • >5ng of THC= DUI • 69% of MJ users report driving under the influence in the past year • 27% report driving intoxicated daily • 30-40% of rec and med users don’t think it influences their ability to drive safely • 10% think it improves their driving https://www.codot.gov/news/2018/april/cdot-survey-reveals-new-insight-on-marijuana-and-driving

  24. Driving while high • Driver + for MJ in accident w/ death • more than doubled from 55 deaths in 2013 to 123 deaths in 2016. • 2013-16 Marijuana-related traffic deaths increased 66 percent • During the same time period, all traffic deaths increased 16 percent. • In 2009 9% of traffic deaths had + MJ on driver • By 2016, that number has more than doubled to 20 percent. The legalization of Marijuana in Colorado: the Impact. Rocky Mountain High Intensity Drug Trafficking area. Oct 2017.

  25. Marijuana and your fetus • Of pregnant MJ users most cite nausea as reason for use • Fear of effects of prescription meds on developing fetus

  26. Marijuana and your fetus • Fetal plasma THC levels 10-30% maternal levels • Prolonged fetal clearing • Animal models demonstrate miscarriage, low birth weight, developmental delays, and birth defects. Grotenhermen, F. Pharmacokinetics and pharmacodynamics of cannabinoids. ClinPharmacokinet. 2003;42(4):327-60. Hennessy, G. Marijuana and Pregnancy . The American Journal on Addictions, 27: 44–45, 2018

  27. Marijuana and your fetus • Fetus brains shouldn’t be exposed to MJ • Endocannabinaoid system development • The exogenous supply of cannabinoids resulting from THC exposure can adversely affect fetal growth as well as structural and functional neurodevelopment • Adversely effects neuro development through teen • dysregulated arousal • motor difficulties at birth • disturbed sleep • memory impairment • aggression • other developmental and behavioral concerns in childhood Jaques  SC, Kingsbury  A, Henshcke  P,  et al.  Cannabis, the pregnant woman and her child: weeding out the myths.  J Perinatol. 2014;34(6):417-424 . Huizink  AC.  Prenatal cannabis exposure and infant outcomes: overview of studies.  Prog Neuropsychopharmacol Biol Psychiatry. 2014;52:45-52. 

  28. Marijuana and your infant • Breast milk levels of THC up to 8x maternal serum concentration Seriously?! Sheryl A. Ryan, Seth D. Ammerman, Mary E. O’Connor, COMMITTEE ON SUBSTANCE USE AND PREVENTION, SECTION ON BREASTFEEDING. Marijuana Use During Pregnancy and Breastfeeding: Implications for Neonatal and Childhood Outcomes. PediatricsSeptember 2018, VOLUME 142 / ISSUE 3

  29. Marijuana and your infant • 85% of lactation consultants encouraged breastfeeding in moms who used MJ • AAP and ACOG recommend against it • Academy of breastfeeding medicine changed recs in 2009 and 2015 •   “data…not strong enough to recommend not breastfeeding with any marijuana use” • “possible long-term neurobehavioral effects.” Reece-Stremtan  S, Marinelli  KA.  ABM clinical protocol #21: guidelines for breastfeeding and substance use or substance use disorder, revised 2015.  Breastfeed Med. 2015;10(3):135-141

  30. Marijuana and your kid • Accidental ingestion • after legalization of recreational marijuana use in Colorado • annual calls to the regional poison control center for pediatric marijuana exposure increased 34 percent on average to 6 cases per 100,000 population • twice the rate for the rest of the United States Wang GS, Le Lait MC, Deakyne SJ, Bronstein AC, Bajaj L, Roosevelt G. Unintentional Pediatric Exposures to Marijuana in Colorado, 2009-2015. JAMA Pediatr. 2016;170(9):e160971

  31. Marijuana and your kid Median age:3 Ingestion Dried plants, edibles Wang GS, Hoyte, C., Roosevelt G. The Continued impact of marijuana legalization on Unintentional Pediatric Exposures to Marijuana in Colorado, 2009-2015. JAMA Pediatr. 2018

  32. Marijuana and your kid • Overall hospital admission rates steady 2009-15 to 2016-17 • ICU admissions slightly less • Attributed to • 100 mg package limit • 10 mg serving size • Rules on intuitive dose serving sizes of edible products Marijuana Enforcement Division, Colorado. Industry-wide bulletin: 14-10. https://www.colorado.gov/pacific/sites/default/files/14-10_IndustryBulletin-Attachments_1.pdf. Accessed May 21, 2018

  33. Marijuana and your teens • Teen visits for MJ have quadrupled since legalization • Impact of marijuana legalization in Colorado on adolescent emergency visits, presented May 8 2017 at mascone west convention center in san Francisco • ER and UC visits ages 13-21 • January 2005- June 2015

  34. Marijuana and your teens • Colorado vs Washington (2017) • 253,902 8th graders, measured perceived harmfulness and MJ use • 400 schools, self administered questionnaires • In Washington 8th and 10th graders use increased 2% and 4.1% • Significantly greater than states without legalization • Significantly greater than Colorado • In Washington, perceived harmfulness decreased 14.2% (8th graders) and 16.1% (10th graders) • Both Colorado and states without legalized MJ had decreased perceived harmfulness of 4.9% and 7.2% • Conclusion: Education works Cerda, M et al. Association of state recreational marijuana laws with adolescent marijuana use. JAMA Pediatr. 2017 Feb 1; 171(2):142-149.

  35. Marijuana and your teen • 2014-15 Colorado #1 in the nation!!!!!! • In youth marijuana use in the past month

  36. This is your brain on weed • Psychosis • experiences of perceptual aberration, ideas with unusual content and feelings of persecution • Followed 2566 Canadian students • Age 13-16 • Questionnaire completed yearly x4 years • Daily or weekly use at 159% increased risk • Poor inhibitory control • Literature review- youth who started MJ use <18yo and had psychotic symptoms at or prior to age 25 • 17 studies included • MJ use associated, in dose dependent fashion, with emergent and severity of psychotic symptoms and functional impairment • But they do show higher level social function Bagot, KS., Milin, R., Kaminer, Y. Adolescent initiation of cannabis use and early-onset psychosis. SubstAbus. 2015; 36(4):524-33.

  37. Marijuana coming to your ER • Yearly rate ER visits for MJ increased 35% from 2011-12 to 2014-5.

  38. Cannabinoid hyperemesis syndrome(CHS) • MJ use 40-50% in adult males with cyclical vomiting syndrome • Rome IV criteria made this a novel condition (May 2016) • First described in 2004 • Diagnosis • Clinical suspicion • Sudden episodes of vomiting and abd pain • Last 1-5d • Periumbilical and epigastric pain • Alleviated by hot shower • Relief with MJ cessation • Scromiting Blumenthrath, C et al. cannabinoid hyperemesis and the cyclic vomiting syndrome in adults: recognition, diagnosis, acute and long-term treatment. Ger Med Sci. 2017; 15:doc6. Published online 2017 Mar 21. Hayes, W et al. Cyclic vomiting syndrome: diagnostic approach and current management strategies. ClinExpGastroenterol. 2018; 11:77-84.

  39. CHS • Mechanism unclear • Downregulation of brain CB1, overstimulation of gut CB1 • Slow gastric emptying • Lipophilic • Chronic use leads to elevated levels • CB1 receptor in hypothalamus • Central nausea

  40. CHS • Why do hot showers work? • Change in core body temp via thermoregulatory center of hypothalamus • Cutaneous steal syndrome • Warm bath diverts blood flow from splanchnic system • Why don’t all MJ users have this syndrome • Genetic polymorphism in cytochrome p450 responsible for cannabinoid metabolism Fradkov, E., Gurvits, G. The Use of Cannabinoids in Colitis: hyperemesis syndrome. Inflammatory Bowel Diseases, 15 June 2018.

  41. CHS • “rare” “very rare” ??? • May be skewed by severity of symptoms • May 31- August 10 2015 • Convenience sample • Used MJ >20d/ month • 155/2127 patients included, 32.9% reported CHS sx in the past month Habboushe, J. et al. The Prevalence of Cannabinoid Hyperemesis Syndrome Among Regular Marijuana Smokers in an Urban Public Hospital. . Basic and clinical pharmacology and toxicology. 12, Jan 2018.

  42. CHS • Admissions to hospital • All hospital admissions in CO from 2010-2014 with dx of CVS • Increased CHS related hospitalizations 46% Bhandari, S, Pinky J, Lisdahl, K, Hillard, C, Venkatesan, T. Recent trends in cyclic vomiting syndrome- associated hospitalizations with liberalization of cannabis use in the staete of Colorado.

  43. CHS • Treatment • Haldol • D2 receptor antagonism • Commonly used post op anesthesia for n/v. • Topical capsaicin • transient receptor potential vanilloid subtype 1 (TRPV1) • Responds to MJ, capsaicin and heat • Quit weed Moon, A., Buckley, S., Mark, N. Successful treatment of cannabinoid hyperemesis syndrome with topical capsacin. ACF Case Rep J. 2018; 5 e3. Lapoint J. Case series of patients treated for cannabinoid hyperemesis syndrome with capsaicin cream. ClinToxicol (Phila). 2017;52:707. Jones JL, Abernathy KE. Successful treatment of suspected cannabinoid hyperemesis syndrome using haloperidol in the outpatient setting. Case Rep Psychiatry. 2016;2016:3614053.

  44. Cannabis use disorder • DSM V • Using more • Want to quit • Time to obtain • Cravings • Messes up home, school or work • Interpersonal problems • Giving up social relationships • Physically hazardous • Use despite knowledge of detriments • Tolerance • Withdrawal

  45. Cannabis use disorder • 1/10 people who use become dependent • Risk increasing use • Early initiation and regular adolescent use= risk factors for: • later problematic use • impaired mental health • Delinquency • Lower educational achievement, • Risky sexual behavior • Criminal offending Copeland, J and Swift, W. Cannabis use disorder: epidemiology and management. International review of psychiatry. Vol 21, 2009. issue 2.

  46. Cannabis use disorder • 2007-17 top admissions for addiction: • 1) alcohol (average 13,551) • 2) marijuana (average 6,712) • 3) methamphetamine (average 5,578), • 4) heroin (average 3,024).

  47. Pediatric ingestion • 3yo presents with parents for sudden onset lethargy with ataxia • Systematic review of >3k articles, 44 included (2017) • 71% present w lethargy • 14% ataxia • Also common tachycardia, mydriasis, hypotonia Richards JR, Smith NE, Moulin AK. Unintentional Cannabis Ingestion in Children: A Systematic Review J Pediatr. 2017 Nov;190:142-152.

  48. Pediatric ingestion • All admitted through ER • Average LOS 27h • 18% PICU • 6% intubated

  49. Pediatric ingestion • #1 answer to all toxicology cases • Supportive care • Airway, benzos for seizures • Evaluate for coingestion • Consider CPS

  50. Adult marijuana use • Pneumothorax • Pneumomediastinum • Asthma exacerbation

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