2 nd Annual Spring Conference May 11 th 2018

1. 2nd Annual Spring Conference May 11th 2018

2. 2018 Spring Education Conference May 11th 2018 Location:  Swedish Medical Center Conference Center 8:30 Registration/Light Breakfast provided by CTN 9:00 TPM/TNC PI Subcommittee Q &A 10:00 Cannabis in the Trauma Patient: What you need to know- Rachael Duncan 11:00 State Scoring Tool Update-Grace Sandeno 11:45 Lunch and Networking provided by Swedish Medical Center 12:45 Geriatric Trauma-Cecile D’Huyvetter 1:45 Case presentations                 Swedish/Montrose-Steve Clayton/Erin Houk                 Denver Health-Sherrie Peckham                 St. Anthony’s-Abbie Blackmore 2:45 Break 3:00 Breakout Sessions by Level                 Level 1 and 2- Regina Krell and Stephanie Vega Level 3- Adriana Heins and Erin Houk                 Level 4 and 5- Nancy Bartkowiak CTN Agenda

3. President: Mike Archuleta, Centura Trauma System • Vice President: Valerie Brockman, Castle Rock Adventist Hospital • Treasurer: Robbie Dumond, University of Colorado Hospital • Secretary: Wendy Hyatt, Swedish Medical Center 2018 Elected Officers

4. Educational Chair Nancy Bartkowiak St. Thomas More • Jodi Greenwood St. Mary’s Grand Junction • Mike Archuleta Centura Trauma • Sherry Peckham Denver Health • Rob Dumond UC Health • Wendy Hyatt • Swedish Educational Committee

5. This course is taught by physicians and nurses with the goal of enhancing a trauma center system of care and improving patient care . Whether a verified mature trauma center or a hospital preparing for designation, this course is designed to assist participants to create strategies, processes, and operations to support trauma center systems based upon their own environments.  The course is highly recommended for trauma medical directors, trauma program managers / coordinators, and administrators

6. TPM/TNC PI committee • Chair :Stephanie Vega UC Health • Wendy Erickson St. Francis • Robbie Dumond UC Health • Valerie Brockman Penrose • Sherry Peckham Denver Health • Missy Sorensen Swedish

7. Robert Hayes St Anthony’s • Angela Kedroutek Penrose Hospital • Robyn Wolverton UC Health • Darcy Martin Swedish • Mike Archuleta Centura Injury Prevention Committee

8. Valerie Brockman Castle Rock Adventist • Jodi Greenwood St. Mary’s Webpage Master

9. End of the YearCelebration TBATopicsVenue December 2018

10. CTN PI Subcommittee Q&A • CTN Spring Conference 05.11.2018

11. Cannabis in the Trauma Patient: What you need to know Rachael Duncan, PharmD BCPS BCCCP Clinical Pharmacist Swedish Medical Center

12. Faculty Disclosure • Conflict of Interest: None • Commercial Support: None

13. Learning Outcomes • Be informed about the current cannabis consumption trends in Colorado • Explain the pharmacologic effect of different forms and strains of cannabis • Summarize existing literature for the use of cannabis and describe research limitations • Understand the inpatient management of trauma patients that experience cannabis withdrawal syndrome

14. Colorado Department of Public Health & Environment 2016 Report colorado.gov/cdphe/marijuana-health-report

15. Public Health Approach • Medical marijuana legal since 2000 • Viewed as an individual doctor/patient decision outside scope of public health policy • Colorado became one of the first two states in the nation to legalize retail marijuana • Paradigm shift • Grouping marijuana with illicit drugs • Cocaine and heroin • Grouping marijuana with other legal substances • Alcohol, tobacco, prescription drugs colorado.gov/cdphe/marijuana-health-report

16. Marijuana Use Trends in Colorado Adults

17. Ever and current marijuana use among Colorado adults Retrieved from colorado.gov/cdphe/marijuana-health-report

18. Current marijuana use among adults: NSDUH 2006-2015 and BRFSS 2014-2015 Retrieved from colorado.gov/cdphe/marijuana-health-report

19. Current marijuana use among Colorado adults by age categories Retrieved from colorado.gov/cdphe/marijuana-health-report

20. Current marijuana use among Colorado adults by gender Retrieved from colorado.gov/cdphe/marijuana-health-report

21. Daily or near daily use of alcohol, tobacco, and marijuana among Colorado adults Retrieved from colorado.gov/cdphe/marijuana-health-report

22. Summary of Trends • Past month marijuana use among adults > national average • 1/4 adults age 18-25 reported past month marijuana use • 1/8 use daily or near-daily • #s are consistent since legalization • Continue to be disparities in marijuana use based on race/ethnicity for adolescents and sexual orientation for both adults and adolescents colorado.gov/cdphe/marijuana-health-report

23. Pharmacology Mechanism of action, metabolism, drug interactions

24. Pharmacodynamics • Phytocannabinoids • THC (tetrahydrocannabinols), CBD (cannabidiols), CBN (cannabinols), CBG (cannabigerols), CBC (cannabichromenes), CBV (cannabivarins), THCV (tetrahydrocannabivarins) • THC and CBD of primary interest • THC = very psychoactive • CBD = minimally psychoactive Bridgeman MB. P T 2017 42 (3): 180-188.

25. THC vs CBD Retrieved from zamnesia.com Jul 8, 2017

26. Receptors • Cannabinoid receptor Type 1 (CB1) and Type 2 (CB2): Most common GPCRs in human brain • CB1 = central nervous system • CB2 = immune system • Very high TI (LD50/TI50) • Cannabis > 10,000 • EtOH = 10 • ASA = 20 • Morphine = 70 Bridgeman MB. P T 2017 42 (3): 180-188.

27. Endocannabinoid System Retrieved from marijuana.com Jul 7, 2017

28. Endocannabinoid System Retrieved from www.trichomelabs.com Jul 8, 2017

29. Review of Cannabinoids • THC and CBD • THC: CB1, CB2 partial agonist • Very psychoactive, psychedelic • CBD: Cannabinoid antagonist, CB2 inverse agonist • Also serotonin, opioid, nuclear, and other effects • Not directly psychoactive • Very pharmacologically active Bridgeman MB. P T 2017 42 (3): 180-188.

30. Cannabis Forms • Synthetic cannabinoids (CB1 agonists) • FDA-approved “medications” • Spice, K2 • Extracts • Botanical cannabis • Medical dispensaries • Recreational dispensaries

31. Synthetic Cannabinoids • Dronabinol • Nabilone • Both are pharmaceutical CB-1 agonists Bridgeman MB. P T 2017 42 (3): 180-188. Images retrieved from www.weedist.com Jul 8, 2017

32. Dronabinol (Marinol) • Synthetic delta-9-THC • Naturally occurring component of Cannabis sativa L. • Reversible effects on appetite, mood, cognition, memory, and perception • Dose-related, increasing in frequency with higher dosages, subject to great interpatient variability Bridgeman MB. P T 2017 42 (3): 180-188.

33. Dronabinol (Marinol) • Pharmacokinetics: • Onset 0.5-1 hr • Peak effect 2-4 hrs • Duration 4-6 hrs • AEs: Tachycardia, orthostatic hypotension • FDA-Approved Indications: Anorexia, chemotherapy- induced nausea Bridgeman MB. P T 2017 42 (3): 180-188. Image retrieved from www.weedist.com Jul 8, 2017

34. Nabilone (Cesamet) • Synthetic delta-9-THC • Natural occurring component of Cannabis sativa L. • Similar PKs and AEs as Dronabinol • FDA-Approved Indications: Chemotherapy-induced N/V, chemotherapy-induced N/V prophylaxis Pergolizzi JV. Cancer ChemotherPharmacol2017; 79 (3): 467-477. Image retrieved from www.weedist.com Jul 8, 2017

35. Synthetic Cannabinoids • Originally experimental • Europe in 2005 • United States in 2009 • Spice, K2 • Schedule 1 as of March 2011 • JWH-018, JWH-073, JWH-200, CP-47, 497, cannabicyclohexanol • > 60 different known compounds

36. Synthetic Cannabinoids • Full CB1, CB2 agonists • Nausea, vomiting, increase in HR and BP, anxiety, agitation, hallucinations • Many different compounds = many different reactions • Risk of rhabdomyolysis, seizures possible • Will not result (+) for THC on a urine drug test

37. Extracts • Nabiximols (THC and CBD) • Sativex oral mucosal spray • Epidiolex (CBD extract) • 2 ongoing Phase III studies in pediatric epilepsy Images retrieved from www.slideshare.net/ucsdavrc Jul 8, 2017

38. Botanical Cannabis Strains • Cannabis Sativa • THC > CBD • Indica • THC = CBD • Rhuderalis • THC < CBD Retrieved from www.marijuanadoctors.com Jul 9, 2017

39. Botanical Cannabis • Leaving the realm of medication: • Established evidence base, clear indications, pharmaceutical preparations, clinical trials, established dosing, known side effects • Enter the realm of “medicinals”: • Evolving evidence base, few trials, no dosing, unclear side effects, exaggerated claims, and no clinical control

40. Routes of administration

41. Scientific literature review on potential health effects of marijuana use Colorado Report

42. Literature review • Establish • Criteria for studies to be reviewed • Review studies and other data • Make recommendations for policies intended to protect consumers of marijuana or marijuana products and the public • Collect Colorado-specific data that reports adverse health events involving marijuana use from the all-payer claims database, hospital discharge data, and behavioral risk factors colorado.gov/cdphe/marijuana-health-report

43. Research gaps • Important research gaps related to population-based health effects of marijuana use were identified during the literature and data review process • Based on • Common limitations of existing research • Exposures or outcomes not sufficiently studied • Issues important to public education or policymaking colorado.gov/cdphe/marijuana-health-report

44. Research gaps • Common theme among research gaps = need for studies with better defined marijuana-use histories and practices • Frequency, amount, potency, and method of marijuana use, length of abstinence, and a standardized method for documenting cumulative lifetime marijuana exposure • Separately evaluate effects for less frequent users vs daily or near-daily users • Consider evaluating separately by age group, sex, or other characteristics when health effect being studied could differ among groups • Ex: by age for CV effects, by sex for mental health effects colorado.gov/cdphe/marijuana-health-report

45. Research gaps • Additional research using marijuana with THC levels consistent with currently available products • Research to ID improved testing methods for impairment either through alternate biological testing methods or physical tests of impairment • Research to better characterize the pharmacokinetics/ pharmacodynamics, potential drug interactions, health effects, and impairment related to newer methods of marijuana use such as edibles and vaporizing as well as other cannabinoids such as cannabidiol (CBD) colorado.gov/cdphe/marijuana-health-report

46. Indications and Uses The evidence

47. National Report • The Health Effects of Cannabis and Cannabinoids: The Current State of Evidence and Recommendations for Research • The National Academies of Sciences, Engineering, and Medicine • Extensive search of literature databases to identify relevant articles published since the 1999 release of the National Academies report Marijuana and Medicine: Assessing the Science Base • Published January 2017 nationalacademies.org/CannabisHealthEffects

48. Conclusion • “Despite increased cannabis use and a changing state-level policy landscape, conclusive evidence regarding the short- and long-term health effects – both harms and benefits – of cannabis use remains elusive.” nationalacademies.org/CannabisHealthEffects

49. Conclusive or Substantial Evidence • Treatment for chronic pain in adults (cannabis) • Antiemetics in the treatment of chemotherapy-induced nausea and vomiting (oral cannabinoids) • Improving patient-reported multiple sclerosis spasticity symptoms (oral cannabinoids) nationalacademies.org/CannabisHealthEffects

50. Moderate Evidence • Improving short-term sleep outcomes in individuals with sleep disturbances associated with • Obstructive sleep apnea • Fibromyalgia • Chronic pain • Multiple sclerosis (cannabinoids, primarily nabiximols) nationalacademies.org/CannabisHealthEffects