Mental Health-related Emergency Department Visits Associated With Cannabis in Colorado

International Perspectives on the Implications of Cannabis Legalization: A Systematic Review & Thematic Analysis

The legality, recreational and medical use of cannabis varies widely by country and region but remains largely prohibited internationally. In October 2018, Canada legalized the recreational use of cannabis—a move many viewed as controversial. Proponents of legalization have emphasized the potential to eradicate the marijuana black market, improve quality and safety control, increase tax revenues, improve the availability of medical cannabis, and lower gang-related drug violence. Conversely, opponents of legalization have stressed concerns about cannabis’ addictive potential, second-hand cannabis exposure, potential exacerbation of underlying and established mental illnesses, as well as alterations in perception that affect safety, particularly driving. This systematic review synthesizes recent international literature on the clinical and public health implications of cannabis legalization.

Cannabis-related emergencies in children and teens

PURPOSE OF REVIEW

To examine the spectrum of emergency department presentations associated with cannabis use or misuse that are currently seen in the pediatric population.

RECENT FINDINGS

There is a growing concern that pediatric emergency department visits related to cannabis are on the rise, especially given rapidly changing legislation on cannabis and its broad availability in certain areas. These concerns are substantiated in the current literature, as the evidence mounts for an array of emergency department presentations of intentional or accidental cannabis use. The range of presentations documented in the recent literature spans gastrointestinal, psychiatric and cardiorespiratory effects, in addition to traumatic injuries and accidental ingestions by younger children. Complications of chronic cannabis use, such as 'cannabis hyperemesis syndrome', depression, psychosis or cognitive impairment, are now recognized outcomes and even more are likely to emerge.

SUMMARY

An array of cannabis-related symptoms is possible from acute use or exposure. Common presentations include acute intoxication, hyperemesis, depression and acute physical injuries from impaired psychomotor function. Uncommon presentations include cardiorespiratory effects, and a range of symptoms in young children that include hyperkinesis and coma. Clinical vigilance is needed to suspect and clinically diagnose cannabis exposure in the emergency department.

Mental health in elite athletes: International Olympic Committee consensus statement (2019)

Mental health symptoms and disorders are common among elite athletes, may have sport related manifestations within this population and impair performance. Mental health cannot be separated from physical health, as evidenced by mental health symptoms and disorders increasing the risk of physical injury and delaying subsequent recovery. There are no evidence or consensus based guidelines for diagnosis and management of mental health symptoms and disorders in elite athletes. Diagnosis must differentiate character traits particular to elite athletes from psychosocial maladaptations.

Management strategies should address all contributors to mental health symptoms and consider biopsychosocial factors relevant to athletes to maximise benefit and minimise harm. Management must involve both treatment of affected individual athletes and optimising environments in which all elite athletes train and compete. To advance a more standardised, evidence based approach to mental health symptoms and disorders in elite athletes, an International Olympic Committee Consensus Work Group critically evaluated the current state of science and provided recommendations.

Acute Illness Associated With Cannabis Use, by Route of Exposure: An Observational Study

BACKGROUND

Little is known about the relative harms of edible and inhalable cannabis products.

OBJECTIVE

To describe and compare adult emergency department (ED) visits related to edible and inhaled cannabis exposure.

DESIGN

Chart review of ED visits between 1 January 2012 and 31 December 2016.

SETTING

A large urban academic hospital in Colorado.

PARTICIPANTS

Adults with ED visits with a cannabis-related International Classification of Diseases, Ninth or 10th Revision, Clinical Modification (ICD-9-CM or ICD-10-CM), code.

MEASUREMENTS

Patient demographic characteristics, route of exposure, dose, symptoms, length of stay, disposition, discharge diagnoses, and attribution of visit to cannabis.

RESULTS

There were 9973 visits with an ICD-9-CM or ICD-10-CM code for cannabis use. Of these, 2567 (25.7%) visits were at least partially attributable to cannabis, and 238 of those (9.3%) were related to edible cannabis. Visits attributable to inhaled cannabis were more likely to be for cannabinoid hyperemesis syndrome (18.0% vs. 8.4%), and visits attributable to edible cannabis were more likely to be due to acute psychiatric symptoms (18.0% vs. 10.9%), intoxication (48% vs. 28%), and cardiovascular symptoms (8.0% vs. 3.1%). Edible products accounted for 10.7% of cannabis-attributable visits between 2014 and 2016 but represented only 0.32% of total cannabis sales in Colorado (in kilograms of tetrahydrocannabinol) during that period.

LIMITATION

Retrospective study design, single academic center, self-reported exposure data, and limited availability of dose data.

CONCLUSION

Visits attributable to inhaled cannabis are more frequent than those attributable to edible cannabis, although the latter is associated with more acute psychiatric visits and more ED visits than expected.

PRIMARY FUNDING SOURCE

Colorado Department of Public Health and Environment.

Syndromic Surveillance of Emergency Department Visits for Acute Adverse Effects of Marijuana, Tri-County Health Department, Colorado, 2016-2017

OBJECTIVES

In Colorado, legalization of recreational marijuana in 2014 increased public access to marijuana and might also have led to an increase in emergency department (ED) visits. We examined the validity of using syndromic surveillance data to detect marijuana-associated ED visits by comparing the performance of surveillance queries with physician-reviewed medical records.

METHODS

We developed queries of combinations of marijuana-specific International Classification of Diseases, Tenth Revision (ICD-10) diagnostic codes or keywords. We applied these queries to ED visit data submitted through the Electronic Surveillance System for the Early Notification of Community-Based Epidemics (ESSENCE) syndromic surveillance system at 3 hospitals during 2016-2017. One physician reviewed the medical records of ED visits identified by ≥1 query and calculated the positive predictive value (PPV) of each query. We defined cases of acute adverse effects of marijuana (AAEM) as determined by the ED provider's clinical impression during the visit.

RESULTS

Of 44 942 total ED visits, ESSENCE queries detected 453 (1%) as potential AAEM cases; a review of 422 (93%) medical records identified 188 (45%) true AAEM cases. Queries using ICD-10 diagnostic codes or keywords in the triage note identified all true AAEM cases; PPV varied by hospital from 36% to 64%. Of the 188 true AAEM cases, 109 (58%) were among men and 178 (95%) reported intentional use of marijuana. Compared with noncases of AAEM, cases were significantly more likely to be among non-Colorado residents than among Colorado residents and were significantly more likely to report edible marijuana use rather than smoked marijuana use ( P < .001).

CONCLUSIONS

ICD-10 diagnostic codes and triage note keyword queries in ESSENCE, validated by medical record review, can be used to track ED visits for AAEM.