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Young-Wolff KC, Does MB, Mian MN, Sterling SA, Satre DD, Campbell CI, Silver LD, Alexeeff SE, Cunningham SF, Asyyed A, Altschuler A. Clinician perspectives on adolescent cannabis-related beliefs and behaviors following recreational cannabis legalization. Addict Behav 2024; 156:108046. [PMID: 38744214 PMCID: PMC11265203 DOI: 10.1016/j.addbeh.2024.108046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Revised: 04/11/2024] [Accepted: 04/26/2024] [Indexed: 05/16/2024]
Abstract
BACKGROUND As more states legalize cannabis, studies are needed to understand the potential impacts of recreational cannabis legalization (RCL) on adolescents from the perspective of clinicians who care for them. METHODS This qualitative study characterized clinician perspectives on whether cannabis legalization is associated with changes in adolescents' cannabis use beliefs, behaviors, and consequences. Semi-structured qualitative interviews were conducted with 32 clinicians in a large healthcare organization from 9/6/2022-12/21/2022. Video-recorded interviews were transcribed and analyzed using thematic analysis. RESULTS The 32 participants (56.3 % female, mean [SD] age, 45.9 [7.6] years; 65.3 % non-Hispanic White) were from Addiction Medicine (n = 13), Psychiatry/Mental Health (n = 7), Pediatrics (n = 5), and the Emergency Department (n = 7). Clinicians described post-RCL increases in adolescent cannabis use, use of non-combustible modes and high-potency products, and younger age of first use. Clinicians reported social, physical, and policy changes, including changes in social norms, appealing advertisements, marketing, and easier access. Many noted fewer perceived harms among adolescents and greater self-medication post-RCL. They described how RCL contributed to increased parental cannabis use and permissiveness around adolescent use. Finally, many described post-RCL increases in cannabis hyperemesis syndrome, and several noted increased cannabis-related psychosis and acute intoxication, and decreased court-mandated treatment. CONCLUSIONS Clinicians from diverse specialties described post-RCL increases in adolescent cannabis use and cannabis-related consequences, alongside changes in social norms, access, marketing and advertisements, and decreased perceptions of harms. Findings can inform strategies to support adolescents in the context of increased cannabis availability and acceptability post-legalization and support the development of hypotheses for broader-scale quantitative work.
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Affiliation(s)
- Kelly C Young-Wolff
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, United States; Department of Psychiatry and Behavioral Sciences, Weill Institute for Neurosciences, University of California, San Francisco, CA, United States.
| | - Monique B Does
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, United States
| | - Maha N Mian
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, United States; Department of Psychiatry and Behavioral Sciences, Weill Institute for Neurosciences, University of California, San Francisco, CA, United States
| | - Stacy A Sterling
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, United States; Department of Psychiatry and Behavioral Sciences, Weill Institute for Neurosciences, University of California, San Francisco, CA, United States
| | - Derek D Satre
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, United States; Department of Psychiatry and Behavioral Sciences, Weill Institute for Neurosciences, University of California, San Francisco, CA, United States
| | - Cynthia I Campbell
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, United States; Department of Psychiatry and Behavioral Sciences, Weill Institute for Neurosciences, University of California, San Francisco, CA, United States
| | | | - Stacey E Alexeeff
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, United States
| | - Sarah F Cunningham
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, United States
| | - Asma Asyyed
- Regional Offices, Kaiser Permanente Northern California, Oakland, CA, United States
| | - Andrea Altschuler
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, United States
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2
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Walsh PS, Dupont AS, Lipshaw MJ, Visotcky A, Thomas DG. Cannabis Legalization and Resource Use for Ingestions by Young Children. Pediatrics 2024; 153:e2024065881. [PMID: 38690624 PMCID: PMC11153323 DOI: 10.1542/peds.2024-065881] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Accepted: 03/27/2024] [Indexed: 05/02/2024] Open
Abstract
OBJECTIVE In conjunction with widening legalization, there has been a rapid rise in unintentional cannabis ingestions in young children. We sought to determine if the legal status of recreational cannabis was associated with resource use in young children with cannabis poisoning. METHODS This retrospective cross-sectional study of the Pediatric Health Information System included emergency department encounters between January 2016 and April 2023 for children <6 years of age with a diagnosis indicating cannabis ingestion. The primary exposure was recreational cannabis legalization status in the state in which the encounter occurred. We used logistic regression models to determine the association of recreational cannabis legality with resource utilization outcomes, adjusting for demographic covariates. RESULTS We included 3649 children from 47 hospitals; 29% of encounters occurred in places in which recreational cannabis was legal. Compared with environments in which recreational cannabis was illegal, cannabis-legal locations had lower uses of advanced neuroimaging (24% vs 35%; adjusted odds ratio [aOR], 0.65; 95% confidence interval [CI]: 0.55-0.77), lumbar puncture (1.6% vs 3.8%; aOR, 0.42; 95% CI: 0.24-0.70), ICU admission (7.9% vs 11%; aOR, 0.71; 95% CI: 0.54-0.93), and mechanical ventilation (0.8% vs 2.9%; aOR, 0.30; 95% CI: 0.14-0.58). Urine testing was more common in places in which recreational cannabis was legal (71% vs 58%; aOR, 1.87; 95% CI: 1.59-2.20). CONCLUSIONS State-level legalization of recreational cannabis was associated with a significant decrease in the utilization of advanced medical resources in cases of cannabis intoxication in children. These findings suggest the need for a focus on policies and procedures to minimize invasive testing in cases of cannabis intoxication in children.
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Affiliation(s)
- Patrick S. Walsh
- Department of Pediatrics, Section of Pediatric Emergency Medicine
| | - Amanda S. Dupont
- Department of Pediatrics, Section of Pediatric Emergency Medicine
| | - Matthew J. Lipshaw
- Division of Emergency Medicine, Cincinnati Children’s Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Alexis Visotcky
- Division of Biostatistics, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Danny G. Thomas
- Department of Pediatrics, Section of Pediatric Emergency Medicine
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3
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Kelly LE, Rieder MJ, Finkelstein Y. Medical cannabis for children: Evidence and recommendations. Paediatr Child Health 2024; 29:104-121. [PMID: 38586483 PMCID: PMC10996577 DOI: 10.1093/pch/pxad078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Accepted: 04/20/2023] [Indexed: 04/09/2024] Open
Abstract
Interest in using cannabis products for a medical purpose in children under the age of 18 years is increasing. There are many medical cannabis products available that can include cannabidiol (CBD) or delta-9-tetrahydrocannabinol (THC), or both. Despite many therapeutic claims, there are few rigorous studies to inform the dosing, safety, and efficacy of medical cannabis in paediatric clinical practice. This statement reviews the current evidence and provides recommendations for using medical cannabis in children. Longer-term (2-year) reports support the sustained tolerability and efficacy of cannabidiol therapy for patients with Lennox-Gastaut and Dravet syndromes. CBD-enriched cannabis extracts containing small amounts of THC have been evaluated in a small number of paediatric patients, and further research is needed to inform clinical practice guidelines. Given the widespread use of medical cannabis in Canada, paediatricians should be prepared to engage in open, ongoing discussions with families about its potential benefits and risks, and develop individualized plans that monitor efficacy, reduce harms, and mitigate drug-drug interactions.
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Affiliation(s)
- Lauren E Kelly
- Canadian Paediatric Society, Drug Therapy Committee, Ottawa, Ontario, Canada
| | - Michael J Rieder
- Canadian Paediatric Society, Drug Therapy Committee, Ottawa, Ontario, Canada
| | - Yaron Finkelstein
- Canadian Paediatric Society, Drug Therapy Committee, Ottawa, Ontario, Canada
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4
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Kelly LE, Rieder MJ, Finkelstein Y. Les données probantes et les recommandations sur le cannabis à des fins médicales chez les enfants. Paediatr Child Health 2024; 29:104-121. [PMID: 38586491 PMCID: PMC10996578 DOI: 10.1093/pch/pxad077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Accepted: 04/20/2023] [Indexed: 04/09/2024] Open
Abstract
L'intérêt envers l'utilisation des produits du cannabis à des fins médicales chez les enfants de moins de 18 ans augmente. De nombreux produits du cannabis à des fins médicales contiennent du cannabidiol, du delta-9-tétrahydrocannabinol ou ces deux produits. Malgré les nombreuses prétentions thérapeutiques, peu d'études rigoureuses guident la posologie, l'innocuité et l'efficacité du cannabis à des fins médicales en pédiatrie clinique. Le présent document de principes passe en revue les données probantes à jour et expose les recommandations sur l'utilisation du cannabis à des fins médicales chez les enfants. Les rapports à plus long terme (deux ans) souscrivent à la tolérabilité et à l'efficacité soutenues d'un traitement au cannabidiol chez les patients ayant le syndrome de Lennox-Gastaut ou le syndrome de Dravet. Les extraits de cannabis enrichis de cannabidiol qui renferment de petites quantités de delta-9-tétrahydrocannabinol ont été évalués auprès d'un petit nombre de patients d'âge pédiatrique, et d'autres recherches devront être réalisées pour éclairer les guides de pratique clinique. Étant donné l'utilisation répandue du cannabis à des fins médicales au Canada, les pédiatres devraient être prêts à participer à des échanges ouverts et continus avec les familles au sujet de ses avantages potentiels et de ses risques, ainsi qu'à préparer des plans individuels en vue d'en surveiller l'efficacité, de réduire les méfaits et de limiter les interactions médicamenteuses.
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Affiliation(s)
- Lauren E Kelly
- Société canadienne de pédiatrie, comité de la pharmacologie, Ottawa (Ontario)Canada
| | - Michael J Rieder
- Société canadienne de pédiatrie, comité de la pharmacologie, Ottawa (Ontario)Canada
| | - Yaron Finkelstein
- Société canadienne de pédiatrie, comité de la pharmacologie, Ottawa (Ontario)Canada
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Tam K, Harris M, Golden J, Perlman E. A Family With Acute Altered Mental Status: Call for Action. Clin Pediatr (Phila) 2024:99228241249363. [PMID: 38676462 DOI: 10.1177/00099228241249363] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/29/2024]
Affiliation(s)
- Kelvin Tam
- Department of Pediatrics, Zucker School of Medicine, Cohen Children's Medical Center, Queens, NY, USA
| | - Matthew Harris
- Department of Pediatrics, Zucker School of Medicine, Cohen Children's Medical Center, Queens, NY, USA
| | - Jonathan Golden
- Department of Pediatrics, Zucker School of Medicine, Cohen Children's Medical Center, Queens, NY, USA
| | - Elise Perlman
- Department of Pediatrics, Zucker School of Medicine, Cohen Children's Medical Center, Queens, NY, USA
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6
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Rebbe R, Malicki D, Siddiqi N, Huang JS, Putnam-Hornstein E, Laub N. Child Protection System Interactions for Children With Positive Urine Screens for Illicit Drugs. JAMA Netw Open 2024; 7:e243133. [PMID: 38512254 PMCID: PMC10958236 DOI: 10.1001/jamanetworkopen.2024.3133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Accepted: 01/26/2024] [Indexed: 03/22/2024] Open
Abstract
Importance Young children are ingesting illicit drugs at increased rates, but it is unknown what the associated child protection system (CPS) responses are when a child tests positive. Objective To document the child protection system involvement and the characteristics of children who test positive for illicit substances. Design, Setting, and Participants This retrospective cross-sectional study linked medical discharge and child protection system administrative data. The setting was Rady Children's Hospital San Diego, a free-standing pediatric hospital in California. Participants included all emergency department and inpatient medical encounters involving children aged 12 years or younger with a positive urine drug test between 2016 and 2021. Statistical analysis was performed from February 2023 to January 2024. Exposure Drug type, including amphetamines, barbiturates, benzodiazepines, cannabis, cocaine, fentanyl, opiates, and phencyclidine. Main Measures and Outcomes CPS responses associated with the medical encounter including reports, substantiations, case openings, and out-of-home placements. Results A total of 511 emergency department and inpatient medical encounters involving children had a positive drug test (262 [51.3%] were female; 309 [60.5%] were age 6 years or younger; fewer than 10 [<3.0%] were American Indian or Alaska Native; 252 [49.3%] were Hispanic [any race], 20 [3.9%] were non-Hispanic Asian, 56 [11.0%] were non-Hispanic Black, 143 [28.0%] were non-Hispanic White, 36 [7.0%] had other or unknown race and ethnicity; 233 [43.6%] had a CPS report prior to the medical encounter). Following the positive screen, 244 (47.7%) were reported to child protection, and 61 (11.9%) were placed out-of-home within 30 days. Mean (SD) quarterly counts of encounters with positive drug tests doubled after the COVID-19 pandemic onset (32.9 [9.8]) compared with prior to the pandemic onset (16.5 [4.7]); for encounters positive for cannabis, mean (SD) quarterly counts were 3 times as high after the pandemic onset than prior (16.6 [4.7] vs 5.7 [2.9]). Encounters for children under age 1 were significantly more likely to have associated child protection reports (relative risk [RR], 2.91 [95% CI, 2.21-3.83]) and child protection case openings (RR, 1.71 [95% CI, 1.07-2.72]) than encounters involving older children. Conclusions and Relevance In this cross-sectional study of emergency department and inpatient medical encounters, less than half of children with positive urine drug screens were reported to CPS; out-of-home placements were uncommon. With increased encounters for positive drug tests, it is unclear what services these children and families are receiving.
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Affiliation(s)
- Rebecca Rebbe
- University of North Carolina at Chapel Hill School of Social Work, Chapel Hill
| | - Denise Malicki
- University of California, San Diego
- Rady Children’s Hospital, San Diego, California
- Chadwick Center for Children and Families, San Diego, California
| | - Nadia Siddiqi
- Nova Southeastern University, Fort Lauderdale, Florida
| | - Jeannie S. Huang
- University of California, San Diego
- Rady Children’s Hospital, San Diego, California
| | | | - Natalie Laub
- University of California, San Diego
- Rady Children’s Hospital, San Diego, California
- Chadwick Center for Children and Families, San Diego, California
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Abstract
Little is understood about the unintended consequences of cannabis liberalization on children. Subsequently, this scoping review aimed to map and identify evidence related to acute cannabis intoxication in children. We searched three medical literature databases from inception until October 2019. We identified 4644 information sources and included 158 which were mapped by topic area relating to 1) public health implications and considerations; 2) clinical management; and 3) experiences and information needs of HCPs and families. Public health implications were addressed by 129 (82%) and often reported an increased incidence of acute pediatric cannabis intoxications. Clinical information was reported in 116 (73%) and included information on signs and symptoms (n = 106, 92%), clinical management processes (n = 60, 52%), and treatment recommendations (n = 42, 36%). Few sources addressed the experiences or information needs of either HCPs (n = 5, <1%) treating children for acute cannabis intoxication or families (n = 1, <1%) seeking care. Increasing incidence of acute cannabis intoxications concurrent with liberalization of cannabis legislation is clear, however, evidence around clinical management is limited. Additionally, further research exploring HCPs and families experiences and information needs around cannabis intoxication is warranted.
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Affiliation(s)
- Lindsay A Gaudet
- Department of Pediatrics, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Kaitlin Hogue
- Department of Pediatric Emergency Medicine, Max Rady College of Medicine, Winnipeg, University of Manitoba, MB, Canada
| | - Shannon D Scott
- Faculty of Nursing, University of Alberta, Edmonton, AB, Canada
| | - Lisa Hartling
- Department of Pediatrics, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Sarah A Elliott
- Department of Pediatrics, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, AB, Canada
- Cochrane Child Health, Department of Pediatrics, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, AB, Canada
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8
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Dupont AS, Walsh PS. Do young children with known cannabis intoxication benefit from further neurological-based testing or imaging? Am J Emerg Med 2024; 75:119-121. [PMID: 37944295 DOI: 10.1016/j.ajem.2023.10.047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Revised: 10/19/2023] [Accepted: 10/30/2023] [Indexed: 11/12/2023] Open
Abstract
BACKGROUND Recent work has demonstrated that children with unintentional cannabis ingestions often undergo extensive ancillary testing such as head imaging or lumbar puncture. To better understand the yield of these tests, our objective was to describe the frequency of additional significant diagnoses in children with cannabis ingestion. METHODS We performed a retrospective cross-sectional study of the Pediatric Health Information System (PHIS) database, including ED encounters from January 2016 to April 2023 with a diagnosis indicating cannabis exposure in children <6 years of age. We assessed the frequency of co-diagnoses that would be found on head imaging, lumbar puncture, or toxicology testing. RESULTS We included 4132 ED encounters for cannabis ingestion from 47 hospitals. Of these, 1243 (30%) received head imaging and 130 (3.1%) underwent lumbar puncture. There were 23 children (0.6%) with diagnosis of skull fracture or intracranial hemorrhage, 4 (<0.1%) with intracranial neoplasm, and 0 (0%) with a diagnosis for meningitis or intracranial abscess. Presence of discharge diagnosis for other drugs was also uncommon. The most frequent drug ingestion co-diagnoses were cocaine in 43 (1.0%) and opioids in 22 (0.5%) encounters. CONCLUSION In children with cannabis intoxication, high rates of head imaging and lumbar puncture are likely driven by the signs of altered mental status at presentation. These data suggest that if cannabis ingestion is considered early and identified quickly with testing, neuroimaging, particularly that with ionizing radiation, may be low yield.
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Affiliation(s)
- Amanda S Dupont
- Department of Pediatrics, Section of Pediatric Emergency Medicine, Medical College of Wisconsin, Milwaukee, WI, United States of America
| | - Patrick S Walsh
- Department of Pediatrics, Section of Pediatric Emergency Medicine, Medical College of Wisconsin, Milwaukee, WI, United States of America.
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Allaf S, Lim JS, Buckley NA, Cairns R. The impact of cannabis legalization and decriminalization on acute poisoning: A systematic review. Addiction 2023; 118:2252-2274. [PMID: 37496145 PMCID: PMC10952774 DOI: 10.1111/add.16280] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2023] [Accepted: 05/25/2023] [Indexed: 07/28/2023]
Abstract
BACKGROUND AND AIMS Many countries have recently legalized medicinal and recreational cannabis. With increasing use and access come the potential for harms. We aimed to examine the effect of cannabis legalization/decriminalization on acute poisoning. METHODS A systematic review and meta-analysis registered with PROSPERO (CRD42022323437). We searched Embase, Medline, Scopus and Cochrane Central Register of Controlled Trials from inception to March 2022. No restrictions on language, age or geography were applied. Abstracts from three main clinical toxicology conferences were hand-searched. Included studies had to report on poisonings before and after changes in cannabis legislation, including legalization and decriminalization of medicinal and recreational cannabis. Where possible, relative risk (RR) of poisoning after legalization (versus before) was calculated and pooled. Risk of bias was assessed with ROBINS-I. RESULTS Of the 1065 articles retrieved, 30 met inclusion criteria (including 10 conference abstracts). Studies used data from the United States, Canada and Thailand. Studies examined legalization of medicinal cannabis (n = 14) and decriminalization or legalization of recreational cannabis (n = 21). Common data sources included poisons centre records (n = 18) and hospital presentations/admissions (n = 15, individual studies could report multiple intervention types and multiple data sources). Most studies (n = 19) investigated paediatric poisoning. Most (n = 24) reported an increase in poisonings; however, the magnitude varied greatly. Twenty studies were included in quantitative analysis, with RRs ranging from 0.81 to 29.00. Our pooled estimate indicated an increase in poisoning after legalization [RR = 3.56, 95% confidence interval (CI) = 2.43-5.20], which was greater in studies that focused on paediatric patients (RR = 4.31, 95% CI = 2.30-8.07). CONCLUSIONS Most studies on the effect of medicinal or recreational cannabis legalization/decriminalization on acute poisoning reported a rise in cannabis poisoning after legalization/decriminalization. Most evidence is from US legalization, despite legalization and decriminalization in many countries.
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Affiliation(s)
- Sara Allaf
- Faculty of Medicine and Health, School of PharmacyThe University of SydneySydneyNSWAustralia
| | - Jessy S. Lim
- Faculty of Medicine and Health, School of PharmacyThe University of SydneySydneyNSWAustralia
| | - Nicholas A. Buckley
- New South Wales Poisons Information CentreThe Children’s Hospital at WestmeadSydneyNSWAustralia
- Faculty of Medicine and Health, School of Medical Sciences, Biomedical Informatics and Digital HealthThe University of SydneySydneyNSWAustralia
| | - Rose Cairns
- Faculty of Medicine and Health, School of PharmacyThe University of SydneySydneyNSWAustralia
- New South Wales Poisons Information CentreThe Children’s Hospital at WestmeadSydneyNSWAustralia
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Hall W, Stjepanović D, Dawson D, Leung J. The implementation and public health impacts of cannabis legalization in Canada: a systematic review. Addiction 2023; 118:2062-2072. [PMID: 37380613 PMCID: PMC10953418 DOI: 10.1111/add.16274] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Accepted: 05/15/2023] [Indexed: 06/30/2023]
Abstract
AIMS We provide a narrative summary of research on changes in cannabis arrests, cannabis products and prices, cannabis use and cannabis-related harm since legalization. METHODS We systematically searched for research on the impacts of cannabis legalization in Canada in PubMed, Embase, Statistics Canada and government websites and Google Scholar, published between 2006 and 2021. RESULTS Cannabis legalization in Canada has been followed by substantial reductions in cannabis-related arrests and cannabis prices. It has also increased adults' access to a diverse range of cannabis products, including edibles and extracts. The prevalence of cannabis use among young adults has increased, but there have been no marked increases or decreases in use among high school students or changes in the prevalence of daily or near-daily use. Legalization has been associated with increased adult hospital attendances for psychiatric distress and vomiting, unintentional ingestion of edible cannabis products by children and hospitalizations for cannabis use disorders in adults. There is conflicting evidence on whether cannabis-impaired driving has increased since legalization. There is suggestive evidence that presentations to emergency departments with psychoses and cannabis use disorders may have increased since legalization. CONCLUSIONS Legalization of cannabis in Canada appears to have reduced cannabis arrests and increased access to a variety of more potent cannabis products at lower prices. Since 2019, recent cannabis use in Canada has modestly increased among adults but not among adolescents. There is evidence of increased acute adverse effects of cannabis among adults and children.
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Affiliation(s)
- Wayne Hall
- National Centre for Youth Substance Use ResearchThe University of QueenslandBrisbaneAustralia
| | - Daniel Stjepanović
- National Centre for Youth Substance Use ResearchThe University of QueenslandBrisbaneAustralia
| | - Danielle Dawson
- National Centre for Youth Substance Use ResearchThe University of QueenslandBrisbaneAustralia
| | - Janni Leung
- National Centre for Youth Substance Use ResearchThe University of QueenslandBrisbaneAustralia
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Toce MS, Dorney K, D'Ambrosi G, Monuteaux MC, Paydar-Darian N, Raghavan VR, Bourgeois FT, Hudgins J. Resource utilization among children presenting with cannabis poisonings in the emergency department. Am J Emerg Med 2023; 73:171-175. [PMID: 37696075 DOI: 10.1016/j.ajem.2023.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Revised: 09/01/2023] [Accepted: 09/02/2023] [Indexed: 09/13/2023] Open
Abstract
BACKGROUND Exploratory pediatric cannabis poisonings are increasing. The aim of this study is to provide a national assessment of the frequency and trends of diagnostic testing and procedures in the evaluation of pediatric exploratory cannabis poisonings. METHODS This is a retrospective cross-sectional study of the Pediatric Health Information Systems database involving all cases of cannabis poisoning for children age 0-10 years between 1/2016 and 12/2021. Cannabis poisoning trends were assessed using a negative binomial regression model. A new variable named "ancillary testing" was created to isolate testing that would not confirm the diagnosis of cannabis poisoning or be used to exclude co-ingestion of acetaminophen or aspirin. Ancillary testing was assessed with regression analyses, with ancillary testing as the outcomes and year as the predictor, to assess trends over time. RESULTS A total of 2001 cannabis exposures among 1999 children were included. Cannabis exposures per 100,000 ED visits increased 68.7% (95% CI, 50.3, 89.3) annually. There was a median of 4 (IQR 2.0, 6.0) diagnostic tests performed per encounter. 64.5% of encounters received blood tests, 28.8% received a CT scan, and 2.4% received a lumbar puncture. Compared to White individuals, Black individuals were more likely to receive ancillary testing (OR 1.52 [95% CI, 1.23, 1.89]). Compared to those 2-6 years, those <2 years were more likely to receive ancillary testing (OR 1.55 [95% CI, 1.19, 2.02). We found no significant annual change in the odds of receiving ancillary testing (OR 1.04 [95% CI, 0.97, 1.12]). CONCLUSIONS We found no change in the proportion of encounters associated with ancillary testing, despite increases in exploratory cannabis poisonings over the study period. Given the increasing rate of pediatric cannabis poisonings, emergency providers should consider this diagnosis early in the evaluation of a pediatric patient with acute change in mental status. While earlier use of urine drug screening may reduce ancillary testing and invasive procedures, even a positive urine drug screen does not rule out alternative pathologies and should not replace a thoughtful evaluation.
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Affiliation(s)
- Michael S Toce
- Division of Emergency Medicine, Boston Children's Hospital, Boston, MA, United States of America; Harvard Medical Toxicology Program, Boston Children's Hospital, Boston, MA, United States of America; Department of Pediatrics, Harvard Medical School, Boston, MA, United States of America.
| | - Kate Dorney
- Division of Emergency Medicine, Boston Children's Hospital, Boston, MA, United States of America; Department of Pediatrics, Harvard Medical School, Boston, MA, United States of America
| | - Gabrielle D'Ambrosi
- Division of Emergency Medicine, Boston Children's Hospital, Boston, MA, United States of America; Department of Pediatrics, Harvard Medical School, Boston, MA, United States of America
| | - Michael C Monuteaux
- Division of Emergency Medicine, Boston Children's Hospital, Boston, MA, United States of America; Department of Pediatrics, Harvard Medical School, Boston, MA, United States of America
| | - Niloufar Paydar-Darian
- Division of Emergency Medicine, Boston Children's Hospital, Boston, MA, United States of America; Department of Pediatrics, Harvard Medical School, Boston, MA, United States of America
| | - Vidya R Raghavan
- Division of Emergency Medicine, Boston Children's Hospital, Boston, MA, United States of America; Department of Pediatrics, Harvard Medical School, Boston, MA, United States of America
| | - Florence T Bourgeois
- Division of Emergency Medicine, Boston Children's Hospital, Boston, MA, United States of America; Department of Pediatrics, Harvard Medical School, Boston, MA, United States of America; Computational Health Informatics Program (CHIP), Boston Children's Hospital, Boston, MA, United States of America
| | - Joel Hudgins
- Division of Emergency Medicine, Boston Children's Hospital, Boston, MA, United States of America; Department of Pediatrics, Harvard Medical School, Boston, MA, United States of America
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Varin M, Champagne A, Venugopal J, Li L, McFaull SR, Thompson W, Toigo S, Graham E, Lowe AM. Trends in cannabis-related emergency department visits and hospitalizations among children aged 0-11 years in Canada from 2015 to 2021: spotlight on cannabis edibles. BMC Public Health 2023; 23:2067. [PMID: 37872564 PMCID: PMC10591397 DOI: 10.1186/s12889-023-16987-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Accepted: 10/13/2023] [Indexed: 10/25/2023] Open
Abstract
BACKGROUND Cannabis poisonings among children are of public health concern. Existing evidence from the US and from four provinces in Canada (Quebec, Ontario, Alberta, British Columbia) indicate an increase in pediatric cannabis-related poisonings since the legalization of cannabis. This study evaluates trends in cannabis-related poisoning pediatric emergency department (ED) visits and hospitalizations in Canada and addresses a gap in literature by describing trends and context around cannabis edible-related poisoning cases using data from a Canadian sentinel surveillance system. METHODS Mixed-methods using data from two administrative data sources and one injury/poisoning sentinel surveillance system to estimate age-specific rates of cannabis-related poisonings ED visits (Ontario and Alberta), edible-related events (sentinel surveillance Canada), and hospitalizations (Canada with the exception of Quebec) among children between the ages of 0 to 11 from 2015/2016 to 2021. Annual absolute changes were calculated to quantify the magnitude of change between each age-specific rate. Joinpoint regression was used for trend analysis. A thematic analysis was completed to gain a better understanding of cannabis edible-related poisoning cases in the ED. RESULTS The pediatric age-specific rates for cannabis-related poisoning ED visits (average annual percent change (AAPC) Ontario: 98.2%, 95% CI: 79.1, 119.2; AAPC Alberta: 57.4%, 95% CI: 36.7, 81.2), hospitalizations (AAPC: 63.4%, 95% CI: 42.0, 87.9) and cannabis edible-related events (AAPC: 122.8%, 95% CI: 64.0, 202.6) increased significantly from 2015 to 2021. Almost half of all pediatric edible-related events involved gummy edible products (48.8%, n = 143). Based on the thematic analysis, 88% cannabis edible-related events were attributed to inadvertent ingestion due to access to such products or lack of safe storage practices. CONCLUSION Age-specific rates of cannabis-related poisoning ED visits (Ontario and Alberta) and hospitalizations (Canada with the exception of Quebec) have increased since cannabis legalization, with the largest increase in rates occurring from 2019 to 2020. A similar increase in the rate of cannabis edible-related cases from sentinel surveillance data underscores the importance of monitoring this outcome. Public health messaging and national public health promotion strategies targeted towards raising awareness on the risks associated with consuming illegal cannabis and safe storage of cannabis could help mitigate cannabis poisonings among children.
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Affiliation(s)
| | | | | | - Le Li
- Public Health Agency of Canada, Ottawa, ON, Canada
| | | | | | | | - Eva Graham
- Public Health Agency of Canada, Ottawa, ON, Canada
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13
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Pepin LC, Simon MW, Banerji S, Leonard J, Hoyte CO, Wang GS. Toxic Tetrahydrocannabinol (THC) Dose in Pediatric Cannabis Edible Ingestions. Pediatrics 2023; 152:e2023061374. [PMID: 37635689 DOI: 10.1542/peds.2023-061374] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/22/2023] [Indexed: 08/29/2023] Open
Abstract
OBJECTIVE The study characterizes cannabis toxicity in relation to tetrahydrocannabinol (THC) dose in pediatric edible cannabis ingestions. METHODS This is a retrospective review of children aged <6 years presenting with edible cannabis ingestions of known THC dose within a pediatric hospital network (January 1, 2015-October 25, 2022). Cannabis toxicity was characterized as severe if patients exhibited severe cardiovascular (bradycardia, tachycardia/hypotension requiring vasopressors or intravenous fluids, other dysrhythmias), respiratory (respiratory failure, apnea, requiring oxygen supplementation), or neurologic (seizure, myoclonus, unresponsiveness, responsiveness to painful stimulation only, requiring intubation or sedation) effects. Cannabis toxicity was characterized as prolonged if patients required >6 hours to reach baseline. The relationship between THC dose and severe and prolonged toxicity was explored using multivariable logistic regression and receiver operator characteristic curve analyses. RESULTS Eighty patients met inclusion. The median age was 2.9 years. The median THC ingestion was 2.1 mg/kg. Severe and prolonged toxicity was present in 46% and 74%, respectively. THC dose was a significant predictor of severe (adjusted odds ratio 2.9, 95% confidence interval: 1.8-4.7) and prolonged toxicity (adjusted odds ratio 3.2, 95% confidence interval: 1.6-6.5), whereas age and sex were not. Area under the curve was 92.9% for severe and 87.3% for prolonged toxicity. THC ingestions of ≥1.7 mg/kg can predict severe (sensitivity 97.3%) and prolonged toxicity (sensitivity 75.4%). CONCLUSIONS The THC dose of edible cannabis correlates to the degree of toxicity in children <6 years old. The threshold of 1.7 mg/kg of THC may guide medical management and preventive regulations.
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Affiliation(s)
- Lesley C Pepin
- Rocky Mountain Poison & Drug Safety, Denver Health and Hospital Authority, Denver, Colorado
| | - Mark W Simon
- Rocky Mountain Poison & Drug Safety, Denver Health and Hospital Authority, Denver, Colorado
| | - Shireen Banerji
- Rocky Mountain Poison & Drug Safety, Denver Health and Hospital Authority, Denver, Colorado
| | - Jan Leonard
- Department of Pediatrics, Section of Emergency Medicine, University of Colorado, Aurora, Colorado
| | - Christopher O Hoyte
- Rocky Mountain Poison & Drug Safety, Denver Health and Hospital Authority, Denver, Colorado
- Department of Emergency Medicine, University of Colorado Hospital, Aurora, Colorado
| | - George S Wang
- Rocky Mountain Poison & Drug Safety, Denver Health and Hospital Authority, Denver, Colorado
- University of Colorado Anschutz Medical Campus, Children's Hospital Colorado, Aurora, Colorado
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14
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Chang H, Yu JY, Lee GH, Heo S, Lee SU, Hwang SY, Yoon H, Cha WC, Shin TG, Sim MS, Jo IJ, Kim T. Clinical support system for triage based on federated learning for the Korea triage and acuity scale. Heliyon 2023; 9:e19210. [PMID: 37654468 PMCID: PMC10465866 DOI: 10.1016/j.heliyon.2023.e19210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Revised: 08/11/2023] [Accepted: 08/16/2023] [Indexed: 09/02/2023] Open
Abstract
Background and aims This study developed a clinical support system based on federated learning to predict the need for a revised Korea Triage Acuity Scale (KTAS) to facilitate triage. Methods This was a retrospective study that used data from 11,952,887 patients in the Korean National Emergency Department Information System (NEDIS) from 2016 to 2018 for model development. Separate cohorts were created based on the emergency medical center level in the NEDIS: regional emergency medical center (REMC), local emergency medical center (LEMC), and local emergency medical institution (LEMI). External and temporal validation used data from emergency department (ED) of the study site from 2019 to 2021. Patient features obtained during the triage process and the initial KTAS scores were used to develop the prediction model. Federated learning was used to rectify the disparity in data quality between EDs. The patient's demographic information, vital signs in triage, mental status, arrival information, and initial KTAS were included in the input feature. Results 3,626,154 patients' visits were included in the regional emergency medical center cohort; 8,278,081 patients' visits were included in the local emergency medical center cohort; and 48,652 patients' visits were included in the local emergency medical institution cohort. The study site cohort, which is used for external and temporal validation, included 135,780 patients visits. Among the patients in the REMC and study site cohorts, KTAS level 3 patients accounted for the highest proportion at 42.4% and 45.1%, respectively, whereas in the LEMC and LEMI cohorts, KTAS level 4 patients accounted for the highest proportion. The area under the receiver operating characteristic curve for the prediction model was 0.786, 0.750, and 0.770 in the external and temporal validation. Patients with revised KTAS scores had a higher admission rate and ED mortality rate than those with unaltered KTAS scores. Conclusions This novel system might accurately predict the likelihood of KTAS acuity revision and support clinician-based triage.
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Affiliation(s)
- Hansol Chang
- Department of Emergency Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 115 Irwon-ro Gangnam-gu, Seoul, 06355, South Korea
- Department of Digital Health, Samsung Advanced Institute for Health Science & Technology (SAIHST), Sungkyunkwan University, 115 Irwon-ro Gangnam-gu, Seoul, 06355, South Korea
| | - Jae Yong Yu
- Department of Biomedical System Informatics, Yonsei University College of Medicine, Seoul, South Korea
| | - Geun Hyeong Lee
- Department of Digital Health, Samsung Advanced Institute for Health Science & Technology (SAIHST), Sungkyunkwan University, 115 Irwon-ro Gangnam-gu, Seoul, 06355, South Korea
- Department of Intelligent Precision Healthcare Convergence, Sungkyunkwan University, Suwon 16419, South Korea
| | - Sejin Heo
- Department of Emergency Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 115 Irwon-ro Gangnam-gu, Seoul, 06355, South Korea
- Department of Digital Health, Samsung Advanced Institute for Health Science & Technology (SAIHST), Sungkyunkwan University, 115 Irwon-ro Gangnam-gu, Seoul, 06355, South Korea
| | - Se Uk Lee
- Department of Emergency Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 115 Irwon-ro Gangnam-gu, Seoul, 06355, South Korea
| | - Sung Yeon Hwang
- Department of Emergency Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 115 Irwon-ro Gangnam-gu, Seoul, 06355, South Korea
| | - Hee Yoon
- Department of Emergency Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 115 Irwon-ro Gangnam-gu, Seoul, 06355, South Korea
| | - Won Chul Cha
- Department of Emergency Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 115 Irwon-ro Gangnam-gu, Seoul, 06355, South Korea
- Department of Digital Health, Samsung Advanced Institute for Health Science & Technology (SAIHST), Sungkyunkwan University, 115 Irwon-ro Gangnam-gu, Seoul, 06355, South Korea
- Digital Innovation Center, Samsung Medical Center, Seoul, Korea. 81 Irwon-ro Gangnam-gu, Seoul 06351, South Korea
| | - Tae Gun Shin
- Department of Emergency Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 115 Irwon-ro Gangnam-gu, Seoul, 06355, South Korea
| | - Min Seob Sim
- Department of Emergency Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 115 Irwon-ro Gangnam-gu, Seoul, 06355, South Korea
| | - Ik Joon Jo
- Department of Emergency Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 115 Irwon-ro Gangnam-gu, Seoul, 06355, South Korea
| | - Taerim Kim
- Department of Emergency Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 115 Irwon-ro Gangnam-gu, Seoul, 06355, South Korea
- Department of Digital Health, Samsung Advanced Institute for Health Science & Technology (SAIHST), Sungkyunkwan University, 115 Irwon-ro Gangnam-gu, Seoul, 06355, South Korea
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15
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Cohen N, Mathew M, Brent J, Wax P, Davis AL, Obilom C, Burns MM, Canning J, Baumgartner K, Koons AL, Wiegand TJ, Judge B, Hoyte C, Chenoweth JA, Froberg B, Farrar H, Carey JL, Hendrickson RG, Hodgman M, Caravati EM, Christian MR, Wolk BJ, Seifert SA, Bentur Y, Levine M, Farrugia LA, Vearrier D, Minns AB, Kennedy JM, Kirschner RI, Aldy K, Schuh S, Campleman S, Li S, Myran DT, Feng L, Freedman SB, Finkelstein Y. Severe outcomes following pediatric cannabis intoxication: a prospective cohort study of an international toxicology surveillance registry. Clin Toxicol (Phila) 2023; 61:591-598. [PMID: 37603042 DOI: 10.1080/15563650.2023.2238121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2023] [Revised: 07/09/2023] [Accepted: 07/13/2023] [Indexed: 08/22/2023]
Abstract
INTRODUCTION An increasing number of jurisdictions have legalized recreational cannabis for adult use. The subsequent availability and marketing of recreational cannabis has led to a parallel increase in rates and severity of pediatric cannabis intoxications. We explored predictors of severe outcomes in pediatric patients who presented to the emergency department with cannabis intoxication. METHODS In this prospective cohort study, we collected data on all pediatric patients (<18 years) who presented with cannabis intoxication from August 2017 through June 2020 to participating sites in the Toxicology Investigators Consortium. In cases that involved polysubstance exposure, patients were included if cannabis was a significant contributing agent. The primary outcome was a composite severe outcome endpoint, defined as an intensive care unit admission or in-hospital death. Covariates included relevant sociodemographic and exposure characteristics. RESULTS One hundred and thirty-eight pediatric patients (54% males, median age 14.0 years, interquartile range 3.7-16.0) presented to a participating emergency department with cannabis intoxication. Fifty-two patients (38%) were admitted to an intensive care unit, including one patient who died. In the multivariable logistic regression analysis, polysubstance ingestion (adjusted odds ratio = 16.3; 95% confidence interval: 4.6-58.3; P < 0.001)) and cannabis edibles ingestion (adjusted odds ratio = 5.5; 95% confidence interval: 1.9-15.9; P = 0.001) were strong independent predictors of severe outcome. In an age-stratified regression analysis, in children older than >10 years, only polysubstance abuse remained an independent predictor for the severe outcome (adjusted odds ratio 37.1; 95% confidence interval: 6.2-221.2; P < 0.001). As all children 10 years and younger ingested edibles, a dedicated multivariable analysis could not be performed (unadjusted odds ratio 3.3; 95% confidence interval: 1.6-6.7). CONCLUSIONS Severe outcomes occurred for different reasons and were largely associated with the patient's age. Young children, all of whom were exposed to edibles, were at higher risk of severe outcomes. Teenagers with severe outcomes were frequently involved in polysubstance exposure, while psychosocial factors may have played a role.
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Affiliation(s)
- Neta Cohen
- Division of Emergency Medicine, The Hospital for Sick Children, Toronto, Canada
- Department of Pediatrics, University of Toronto, Toronto, Canada
| | - Mathew Mathew
- Division of Emergency Medicine, The Hospital for Sick Children, Toronto, Canada
- Department of Pediatrics, University of Toronto, Toronto, Canada
| | - Jeffrey Brent
- Departments of Medicine and Emergency Medicine, University of Colorado School of Medicine, Aurora, CO, USA
- Toxicology Associates, Littleton, USA
| | - Paul Wax
- Department of Emergency Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
- American College of Medical Toxicology, Phoenix, AZ, USA
| | - Adrienne L Davis
- Division of Emergency Medicine, The Hospital for Sick Children, Toronto, Canada
- Department of Pediatrics, University of Toronto, Toronto, Canada
| | - Cherie Obilom
- Department of Emergency Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | | | - Joshua Canning
- Department of Medical Toxicology, Banner - University Medical Center, Phoenix, AZ, USA
| | - Kevin Baumgartner
- Department of Emergency Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Andrew L Koons
- Department of Emergency Medicine, Lehigh Valley Health Network, USF Morsani College of Medicine, Allentown, PA, USA
| | - Timothy J Wiegand
- Department of Emergency Medicine, University of Rochester Medical Center, Rochester, NY, USA
| | - Bryan Judge
- Department of Emergency Medicine, Michigan State University College of Human Medicine, Grand Rapids, MI, USA
| | - Christopher Hoyte
- Rocky Mountain Poison and Drug Center, Denver Health, Denver, CO, USA
| | - James A Chenoweth
- Department of Emergency Medicine, University of California at Davis, Sacramento, CA, USA
| | - Blake Froberg
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Henry Farrar
- Arkansas Children's Hospital, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | | | | | - Michael Hodgman
- Department of Emergency Medicine, Upstate Medical University, Syracuse, NY, USA
| | - E Martin Caravati
- Department of Emergency Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
| | | | - Brian J Wolk
- Loma Linda University School of Medicine, Loma Linda, CA, USA
| | - Steven A Seifert
- Department of Emergency Medicine, University of New Mexico, Albuquerque, NM, USA
| | - Yedidia Bentur
- Rambam Health Care Campus, Technion-Israel Institute of Technology, Haifa, Israel
| | - Michael Levine
- Department of Emergency Medicine, University of California at Los Angeles, Los Angeles, CA, USA
| | - Lynn A Farrugia
- UF Health Shands Hospital, University of Florida College of Medicine, Gainesville, FL, USA
| | - David Vearrier
- Department of Emergency Medicine, University of Mississippi Medical Center, Jackson, MS, USA
| | - Alicia B Minns
- Department of Emergency Medicine, University of California San Diego, San Diego, CA, USA
| | - Joseph M Kennedy
- Department of Emergency Medicine, University of Vermont Medical Center, Burlington, VT, USA
| | | | - Kim Aldy
- Department of Emergency Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
- American College of Medical Toxicology, Phoenix, AZ, USA
| | - Suzanne Schuh
- Division of Emergency Medicine, The Hospital for Sick Children, Toronto, Canada
- Department of Pediatrics, University of Toronto, Toronto, Canada
| | | | - Shao Li
- American College of Medical Toxicology, Phoenix, AZ, USA
| | | | - Lisa Feng
- Department of Pediatrics, University of Toronto, Toronto, Canada
| | - Stephen B Freedman
- Departments of Pediatrics and Emergency Medicine, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Yaron Finkelstein
- Division of Emergency Medicine, The Hospital for Sick Children, Toronto, Canada
- Department of Pediatrics, University of Toronto, Toronto, Canada
- Division of Clinical Pharmacology and Toxicology, Department of Paediatrics, The Hospital for Sick Children, Toronto, Canada
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16
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Claudet I, Bréhin C. Unintentional cannabis pediatric intoxications: Where do we stand?: Pediatric cannabis intoxication. Arch Pediatr 2023; 30:257-259. [PMID: 37286423 DOI: 10.1016/j.arcped.2023.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Revised: 04/25/2023] [Accepted: 05/21/2023] [Indexed: 06/09/2023]
Affiliation(s)
- Isabelle Claudet
- Pediatric Emergency Department, Children's Hospital, CHU Toulouse, France; UMR 1295, Inserm, Paul Sabatier University, UPS, Toulouse III, France.
| | - Camille Bréhin
- Pediatric Emergency Department, Children's Hospital, CHU Toulouse, France; UMR 1416, Inserm, IRSD, Toulouse, France
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17
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Kourgiantakis T, Lee E, Kosar AKT, Tait C, Lau CKY, McNeil S, Craig S, Ashcroft R, Williams CC, Goldstein AL, Chandrasekera U, Sur D, Henderson JL. Youth cannabis use in Canada post-legalization: service providers' perceptions, practices, and recommendations. Subst Abuse Treat Prev Policy 2023; 18:36. [PMID: 37349741 PMCID: PMC10288694 DOI: 10.1186/s13011-023-00550-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Accepted: 06/16/2023] [Indexed: 06/24/2023] Open
Abstract
BACKGROUND In 2018, Canada legalized recreational cannabis use with the purpose of protecting youth and restricting access. However, concerns have been raised that this objective has not been met as rates of cannabis use among youth aged 16-24 have not declined. Youth cannabis use is associated with various adverse effects including psychosis, anxiety, depression, suicidality, respiratory distress, cannabinoid hyperemesis syndrome, and intoxications. Service providers play a crucial role in addressing youth cannabis use. This study aimed to understand Ontario service providers' perceptions, practices, and recommendations on youth cannabis use. METHODS This mixed method study included a survey and two focus groups. The survey was distributed to mental health service providers serving youth aged 16-24 across Ontario who were given the option to participate in a focus group. The survey included closed and open-ended questions regarding perceptions, practices, and recommendations, while the focus groups explored these categories in greater depth. Descriptive statistics were used to analyze close-ended questions and interpretative content analysis was applied for open-ended questions. Focus group data were analyzed using thematic analysis. RESULTS The survey was completed by 160 service providers and 12 participated in two focus groups. Regarding perceptions, 60% of survey participants agreed with legalization, 26% had a strong understanding of medical versus recreational cannabis, 84% believed that cannabis has physical and mental health risks, and 49% perceived stigmatization. Less than half of the survey participants reported screening or assessing cannabis use, 16% stated they are highly familiar with treating cannabis use, and 67% reported that they rarely work with families. Subthemes identified in the focus groups under perceptions included normalization and stigmatization, harms for youth, and stigma, racism, and discrimination. Subthemes under practice included cannabis not being the primary focus, challenges with screening, assessment, and intervention, and referral to specialized services. Both the survey and focus group participants recommended increasing public education, enhancing service provider training, improving regulation and policies, reducing stigma and minimization, improving service access, and providing more culturally responsive services. CONCLUSION Youth cannabis use in Canada remains a significant public health concern, necessitating a more comprehensive plan to protect Ontario youth and reduce associated harms.
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Affiliation(s)
- Toula Kourgiantakis
- Factor-Inwentash Faculty of Social Work, University of Toronto, 246 Bloor Street West, Toronto, ON, M5S 1V4, Canada.
| | - Eunjung Lee
- Factor-Inwentash Faculty of Social Work, University of Toronto, 246 Bloor Street West, Toronto, ON, M5S 1V4, Canada
| | - A Kumsal Tekirdag Kosar
- Factor-Inwentash Faculty of Social Work, University of Toronto, 246 Bloor Street West, Toronto, ON, M5S 1V4, Canada
| | - Christine Tait
- Factor-Inwentash Faculty of Social Work, University of Toronto, 246 Bloor Street West, Toronto, ON, M5S 1V4, Canada
| | - Carrie K Y Lau
- Factor-Inwentash Faculty of Social Work, University of Toronto, 246 Bloor Street West, Toronto, ON, M5S 1V4, Canada
| | - Sandra McNeil
- Factor-Inwentash Faculty of Social Work, University of Toronto, 246 Bloor Street West, Toronto, ON, M5S 1V4, Canada
| | - Shelley Craig
- Factor-Inwentash Faculty of Social Work, University of Toronto, 246 Bloor Street West, Toronto, ON, M5S 1V4, Canada
| | - Rachelle Ashcroft
- Factor-Inwentash Faculty of Social Work, University of Toronto, 246 Bloor Street West, Toronto, ON, M5S 1V4, Canada
| | - Charmaine C Williams
- Factor-Inwentash Faculty of Social Work, University of Toronto, 246 Bloor Street West, Toronto, ON, M5S 1V4, Canada
| | - Abby L Goldstein
- Department of Applied Psychology and Human Development, Ontario Institute for Studies in Education, Toronto, ON, Canada
| | - Uppala Chandrasekera
- Factor-Inwentash Faculty of Social Work, University of Toronto, 246 Bloor Street West, Toronto, ON, M5S 1V4, Canada
| | - Deepy Sur
- Ontario Association of Social Workers (OASW), Toronto, ON, Canada
| | - J L Henderson
- Margaret and Wallace McCain Centre for Child, Youth and Family Mental Health, Department of Psychiatry, Centre for Addiction and Mental Health (CAMH), University of Toronto, Toronto, ON, Canada
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18
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Lorenzo M, Beno S. Evolving threat of pediatric ingestions: a discussion of cannabis and button batteries and their implications for children. Curr Opin Pediatr 2023; 35:316-323. [PMID: 36876321 DOI: 10.1097/mop.0000000000001238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/07/2023]
Abstract
PURPOSE OF REVIEW Pediatric button battery and cannabis ingestions are rising in incidence and have the potential for significant harm. This review will focus on the clinical presentation and complications of these two common inadvertent ingestions in children, as well as recent regulatory efforts and advocacy opportunities. RECENT FINDINGS The rising incidence of cannabis toxicity in children has corresponded with its legalization across several countries in the last decade. Inadvertent pediatric cannabis intoxication is most commonly due to the ingestion of edible forms discovered by children in their own home. The clinical presentation can be nonspecific, therefore clinicians should have a low threshold for including it on their differential diagnosis. Button battery ingestions are also increasing in incidence. While many children are asymptomatic at presentation, button battery ingestions can quickly cause esophageal injury and lead to several serious and potentially life-threatening complications. Prompt recognition and removal of esophageal button batteries is essential for reducing harm. SUMMARY Cannabis and button battery ingestions are important for physicians who take care of children to recognize and manage appropriately. Given their rising incidence, there are many opportunities for policy improvements and advocacy efforts to make a difference in preventing these ingestions altogether.
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Affiliation(s)
- Melissa Lorenzo
- Division of Pediatric Emergency Medicine, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
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19
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Raffa BJ, Schilling S, Henry MK, Ritter V, Bennett CE, Huang JS, Laub N. Ingestion of Illicit Substances by Young Children Before and During the COVID-19 Pandemic. JAMA Netw Open 2023; 6:e239549. [PMID: 37083660 PMCID: PMC10122182 DOI: 10.1001/jamanetworkopen.2023.9549] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/22/2023] Open
Abstract
Importance Information about the trend in illicit substance ingestions among young children during the pandemic is limited. Objectives To assess immediate and sustained changes in overall illicit substance ingestion rates among children younger than 6 years before and during the COVID-19 pandemic and to examine changes by substance type (amphetamines, benzodiazepines, cannabis, cocaine, ethanol, and opioids) while controlling for differing statewide medicinal and recreational cannabis legalization policies. Design, Setting, and Participants Retrospective cross-sectional study using an interrupted time series at 46 tertiary care children's hospitals within the Pediatric Health Information System (PHIS). Participants were children younger than 6 years who presented to a PHIS hospital for an illicit substance(s) ingestion between January 1, 2017, and December 31, 2021. Data were analyzed in February 2023. Exposure Absence or presence of the COVID-19 pandemic. Main Outcome(s) and Measure(s) The primary outcome was the monthly rate of encounters for illicit substance ingestions among children younger than 6 years defined by International Statistical Classification of Diseases, Tenth Revision, Clinical Modification diagnosis code(s) for poisoning by amphetamines, benzodiazepines, cannabis, cocaine, ethanol, and opioids. The secondary outcomes were the monthly rate of encounters for individual substances. Results Among 7659 children presenting with ingestions, the mean (SD) age was 2.2 (1.3) years and 5825 (76.0%) were Medicaid insured/self-pay. There was a 25.6% (95% CI, 13.2%-39.4%) immediate increase in overall ingestions at the onset of the pandemic compared with the prepandemic period, which was attributed to cannabis, opioid, and ethanol ingestions. There was a 1.8% (95% CI, 1.1%-2.4%) sustained monthly relative increase compared with prepandemic trends in overall ingestions which was due to opioids. There was no association between medicinal or recreational cannabis legalization and the rate of cannabis ingestion encounters. Conclusions and Relevance In this study of illicit substance ingestions in young children before and during the COVID-19 pandemic, there was an immediate and sustained increase in illicit substance ingestions during the pandemic. Additional studies are needed to contextualize these findings in the setting of pandemic-related stress and to identify interventions to prevent ingestions in face of such stress, such as improved parental mental health and substance treatment services, accessible childcare, and increased substance storage education.
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Affiliation(s)
- Brittany J Raffa
- Division of General Pediatrics and Adolescent Medicine, Department of Pediatrics, University of North Carolina at Chapel Hill
- The Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill
| | - Samantha Schilling
- Division of General Pediatrics and Adolescent Medicine, Department of Pediatrics, University of North Carolina at Chapel Hill
| | - M Katherine Henry
- Safe Place: Center for Child Protection and Health, Division of General Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
- Clinical Futures, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Victor Ritter
- Division of General Pediatrics and Adolescent Medicine, Department of Pediatrics, University of North Carolina at Chapel Hill
| | - Colleen E Bennett
- Safe Place: Center for Child Protection and Health, Division of General Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Jeannie S Huang
- Department of Pediatrics, University of California San Diego
| | - Natalie Laub
- Division of Child Abuse Pediatrics, Department of Pediatrics, University of California at San Diego
- Department of Pediatrics, University of California San Diego
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20
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Assanangkornchai S, Kalayasiri R, Ratta-Apha W, Tanaree A. Effects of cannabis legalization on the use of cannabis and other substances. Curr Opin Psychiatry 2023:00001504-990000000-00062. [PMID: 37185310 DOI: 10.1097/yco.0000000000000868] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/17/2023]
Abstract
PURPOSE OF REVIEW As more jurisdictions legalize cannabis for non-medical use, the evidence on how legalization policies affect cannabis use and the use of other substances remains inconclusive and contradictory. This review aims to summarize recent research findings on the impact of recreational cannabis legalization (RCL) on cannabis and other substance use among different population groups, such as youth and adults. RECENT FINDINGS Recent literature reports mixed findings regarding changes in the prevalence of cannabis use after the adoption of RCL. Most studies found no significant association between RCL and changes in cannabis use among youth in European countries, Uruguay, the US, and Canada. However, some studies have reported increases in cannabis use among youth and adults in the US and Canada, although these increases seem to predate RCL. Additionally, there has been a marked increase in unintentional pediatric ingestion of cannabis edibles postlegalization, and an association between RCL and increased alcohol, vaping, and e-cigarette use among adolescents and young adults. SUMMARY Overall, the effects of cannabis legalization on cannabis use appear to be mixed. Further monitoring and evaluation research is needed to provide longer-term evidence and a more comprehensive understanding of the effects of RCL.
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Affiliation(s)
- Sawitri Assanangkornchai
- Department of Epidemiology, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, 90110
| | - Rasmon Kalayasiri
- Department of Psychiatry, Faculty of Medicine, Chulalongkorn University
| | - Woraphat Ratta-Apha
- Department of Psychiatry, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok
| | - Athip Tanaree
- Srithanya Psychiatric Hospital, Nonthaburi, Thailand
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21
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Myran DT, Imtiaz S, Konikoff L, Douglas L, Elton-Marshall T. Changes in health harms due to cannabis following legalisation of non-medical cannabis in Canada in context of cannabis commercialisation: A scoping review. Drug Alcohol Rev 2023; 42:277-298. [PMID: 36165188 DOI: 10.1111/dar.13546] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Revised: 08/18/2022] [Accepted: 08/23/2022] [Indexed: 02/03/2023]
Abstract
ISSUE On 17 October 2018, Canada legalised non-medical cannabis. Critically, the cannabis market in Canada has changed considerably since legalisation. In this scoping review, we identified available evidence on changes in cannabis-related health harms following legalisation and contextualised findings based on legal market indicators. APPROACH Electronic searches were conducted to identify studies that compared changes in cannabis-related health harms pre- and post-legalisation. We contextualised each study by the mean per capita legal cannabis stores and sales during the study period and compared study means to per capita stores and sales on October 2021-3 years following legalisation. IMPLICATIONS AND CONCLUSIONS Some measures of cannabis harms have increased since legalisation but studies to date have captured periods of relatively low market maturity. Longer-term monitoring of health harms as the market continues to expand is indicated.
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Affiliation(s)
- Daniel T Myran
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
- Department of Family Medicine, University of Ottawa, Ottawa, Canada
| | - Sameer Imtiaz
- Institute for Mental Health Policy Research, Centre for Addiction and Mental Health, Toronto, Canada
| | - Lauren Konikoff
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Laura Douglas
- Institute for Mental Health Policy Research, Centre for Addiction and Mental Health, Toronto, Canada
| | - Tara Elton-Marshall
- School of Epidemiology and Public Health, Faculty of Medicine, University of Ottawa, Ottawa, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
- Department of Epidemiology and Biostatistics, Western University, London, Canada
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22
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Tweet MS, Nemanich A, Wahl M. Pediatric Edible Cannabis Exposures and Acute Toxicity: 2017-2021. Pediatrics 2023; 151:190427. [PMID: 36594224 DOI: 10.1542/peds.2022-057761] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/08/2022] [Indexed: 01/04/2023] Open
Abstract
OBJECTIVES This study evaluates trends in pediatric cannabis edible ingestions in children younger than age 6 years with regard to toxicity, medical outcome, and health care utilization for the years 2017-2021. METHODS We performed retrospective analysis of the National Poison Data System data for pediatric exposures to edible cannabis products in children <6 years from 2017 to 2021. Data were analyzed quantitatively with a focus on incidence, common clinical effects, medical outcomes, health care utilization, and changes in acute toxicity between the pre-COVID years (2017-2019) to the COVID years (2020-2021). RESULTS There were 7043 exposures reported during 2017-2021. In 2017, there were 207 reported cases, and in 2021 there were 3054 cases, an increase of 1375.0%. Most exposures (97.7%) occurred in a residential setting. Seventy percent of cases followed to a known outcome were reported to have central nervous system depression. Of all reported cases, 22.7% of patients were admitted to the hospital. There was a significant increase in both ICU and non-ICU admissions, whereas the number of patients treated and released decreased when comparing the pre-COVID years (2017-2019) to the COVID years (2020-2021) (P < .05). Major and moderate effects also significantly increased during the prepandemic years compared with the 2 years during the pandemic (P < .05). CONCLUSIONS There has been a consistent increase in pediatric edible cannabis exposures over the past 5 years, with the potential for significant toxicity. It is important for providers to be aware of this in their practice and it presents an important opportunity for education and prevention.
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Affiliation(s)
- Marit S Tweet
- Department of Emergency Medicine, Southern Illinois University School of Medicine, Springfield, Illinois.,Illinois Poison Center, Chicago, Illinois
| | - Antonia Nemanich
- Illinois Poison Center, Chicago, Illinois.,Department of Emergency Medicine, Rush University Medical Center, Chicago, Illinois
| | - Michael Wahl
- Illinois Poison Center, Chicago, Illinois.,Division of Emergency Medicine, NorthShore University HealthSystem, Evanston, Illinois
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23
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Myran DT, Tanuseputro P, Auger N, Konikoff L, Talarico R, Finkelstein Y. Pediatric Hospitalizations for Unintentional Cannabis Poisonings and All-Cause Poisonings Associated With Edible Cannabis Product Legalization and Sales in Canada. JAMA HEALTH FORUM 2023; 4:e225041. [PMID: 36637814 PMCID: PMC9857209 DOI: 10.1001/jamahealthforum.2022.5041] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
Importance Canada legalized cannabis in October 2018 but initially prohibited the sale of edibles (eg, prepackaged candies). Starting in January 2020, some provinces permitted the sale of commercial cannabis edibles. The association of legalizing cannabis edibles with unintentional pediatric poisonings is uncertain. Objective To evaluate changes in proportions of all-cause hospitalizations for poisoning due to cannabis in children during 3 legalization policy periods in Canada's 4 most populous provinces (including 3.4 million children aged 0-9 years). Design, Setting, and Participants This repeated cross-sectional study included all hospitalizations in children aged 0 to 9 years in Ontario, Alberta, British Columbia, and Quebec between January 1, 2015, and September 30, 2021. Exposures Prelegalization (January 2015 to September 2018); period 1, in which dried flower only was legalized in all provinces (October 2018 to December 2019); and period 2, in which edibles were legalized in 3 provinces (exposed provinces) and restricted in 1 province (control province) (January 2020 to September 2021). Main Outcomes and Measures The primary outcome was the proportion of hospitalizations due to cannabis poisoning out of all-cause poisoning hospitalizations. Data analysis was performed using descriptive statistics and Poisson regression models. Results During the 7-year study period, there were 581 pediatric hospitalizations for cannabis poisoning (313 [53.9%] boys; 268 [46.1%] girls; mean [SD] age, 3.6 [2.5] years) and 4406 hospitalizations for all-cause poisonings. Of all-cause poisoning hospitalizations, the rate per 1000 due to cannabis poisoning before legalization was 57.42 in the exposed provinces and 38.50 in the control province. During period 1, the rate per 1000 poisoning hospitalizations increased to 149.71 in the exposed provinces (incidence rate ratio [IRR], 2.55; 95% CI, 1.88-3.46) and to 117.52 in the control province (IRR, 3.05; 95% CI, 1.82-5.11). During period 2, the rate per 1000 poisoning hospitalizations due to cannabis more than doubled to 318.04 in the exposed provinces (IRR, 2.16; 95% CI, 1.68-2.80) but remained similar at 137.93 in the control province (IRR, 1.18; 95% CI, 0.71-1.97). Conclusions and Relevance This cross-sectional study found that following cannabis legalization, provinces that permitted edible cannabis sales experienced much larger increases in hospitalizations for unintentional pediatric poisonings than the province that prohibited cannabis edibles. In provinces with legal edibles, approximately one-third of pediatric hospitalizations for poisonings were due to cannabis. These findings suggest that restricting the sale of legal commercial edibles may be key to preventing pediatric poisonings after recreational cannabis legalization.
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Affiliation(s)
- Daniel T. Myran
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada,Department of Family Medicine, University of Ottawa, Ottawa, Ontario, Canada,ICES uOttawa, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Peter Tanuseputro
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada,Department of Family Medicine, University of Ottawa, Ottawa, Ontario, Canada,ICES uOttawa, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada,Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada,Bruyere Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Nathalie Auger
- University of Montreal Hospital Centre, Montreal, Quebec, Canada,Institut national de santé publique du Quebec, Montreal, Quebec, Canada,Department of Social and Preventive Medicine, School of Public Health, University of Montreal, Montreal, Quebec, Canada,Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Quebec, Canada
| | - Lauren Konikoff
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Robert Talarico
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada,ICES uOttawa, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Yaron Finkelstein
- Divisions of Pediatric Emergency Medicine and Clinical Pharmacology and Toxicology, Hospital for Sick Children, Toronto, Ontario, Canada,Departments of Paediatrics and Pharmacology and Toxicology, University of Toronto, Toronto, Ontario, Canada
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24
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Athanassiou M, Dumais A, Zouaoui I, Potvin S. The clouded debate: A systematic review of comparative longitudinal studies examining the impact of recreational cannabis legalization on key public health outcomes. Front Psychiatry 2023; 13:1060656. [PMID: 36713920 PMCID: PMC9874703 DOI: 10.3389/fpsyt.2022.1060656] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Accepted: 12/20/2022] [Indexed: 01/27/2023] Open
Abstract
Background Ineffective cannabis regulatory frameworks such as prohibition have sparked interest in alternative solutions to reduce individual and societal harms. While it has been suggested that the recreational legalization process has yielded early successes, the relatively recent implementation of the novel policies has provided a modest time frame for a truly thorough establishment and assessment of key population-level indicators. The following systematic review focuses on identifying the downstream public health sequelae of cannabis legalization policies, including parameters such as cannabis consumption rates, hospitalization rates, vehicular accidents and fatalities, criminal activity, and suicidal behaviors, as well as other substance use trends. Methods An exhaustive search of the MEDLINE and Google Scholar databases were performed to identify high-quality (1) longitudinal studies, which (2) compared key public health outcomes between regions which had and had not implemented recreational cannabis legalization (RML) policies, (3) using distinct databases and/or time frames. Thirty-two original research articles were retained for review. Results Adult past-month cannabis consumption (26+ years) seems to have significantly increased following RML, whereas young adult (18-26 years) and adolescent (12-17 years) populations do not show a significant rise in past-month cannabis use. RML shows preliminary trends in increasing service use (such as hospitalizations, emergency department visits, or poisonings) or vehicular traffic fatalities. Preliminary evidence suggests that RML is related to potential increases in serious/violent crimes, and heterogeneous effects on suicidal behaviors. While the research does not illustrate that RML is linked to changing consumptions patterns of cigarette, stimulant, or opioid use, alcohol use may be on the rise, and opioid prescribing patterns are shown to be significantly correlated with RML. Conclusion The current data supports the notion that RML is correlated with altered cannabis consumption in adults, potentially increased criminal activity, and a decline in opioid quantities and prescriptions provided to patients. Future work should address additional knowledge gaps for vulnerable populations, such as individuals with mental health problems or persons consuming cannabis frequently/at higher THC doses. The effects of varying legalization models should also be evaluated for their potentially differing impacts on population-level outcomes.
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Affiliation(s)
- Maria Athanassiou
- Centre de recherche de l'Institut Universitaire en Santé Mentale de Montréal, Montreal, QC, Canada
- Department of Psychiatry and Addiction, Faculty of Medicine, University of Montreal, Montreal, QC, Canada
| | - Alexandre Dumais
- Centre de recherche de l'Institut Universitaire en Santé Mentale de Montréal, Montreal, QC, Canada
- Department of Psychiatry and Addiction, Faculty of Medicine, University of Montreal, Montreal, QC, Canada
- Philippe-Pinel National Institute of Legal Psychiatry, Montreal, QC, Canada
| | - Inès Zouaoui
- Centre de recherche de l'Institut Universitaire en Santé Mentale de Montréal, Montreal, QC, Canada
- Department of Psychiatry and Addiction, Faculty of Medicine, University of Montreal, Montreal, QC, Canada
| | - Stéphane Potvin
- Centre de recherche de l'Institut Universitaire en Santé Mentale de Montréal, Montreal, QC, Canada
- Department of Psychiatry and Addiction, Faculty of Medicine, University of Montreal, Montreal, QC, Canada
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25
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Blumenberg A. A cross-sectional assessment of package labels aimed at children of edible and leaf cannabis discarded in New York City. TOXICOLOGY COMMUNICATIONS 2022. [DOI: 10.1080/24734306.2022.2106397] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022] Open
Affiliation(s)
- Adam Blumenberg
- Department of Emergency Medicine, Columbia University Medical Center, New York City, NY, USA
- Poison Center of Oregon Alaska, and Guam, Portland, OR, USA
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26
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Boury H, Hall W, Fischer B. Developments and Changes in Primary Public Health Outcome Indicators Associated with the Legalization of Non-Medical Cannabis Use and Supply in Canada (2018): A Comprehensive Overview. Int J Ment Health Addict 2022:1-15. [PMID: 36589471 PMCID: PMC9794107 DOI: 10.1007/s11469-022-00986-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/05/2022] [Indexed: 12/28/2022] Open
Abstract
Canada legalized non-medical cannabis use and supply for adults in 2018. We examined developments and changes associated with the legalization policy reform on key indicators for public health, namely cannabis (including frequent/problematic) use prevalence, cannabis-related hospitalizations, cannabis-impaired driving, and cannabis sourcing. We identified peer-reviewed and "grey" study data that featured population-level or other quasi-representative samples and comparable outcome data for pre- and post-legalization periods, including possible trends of changes over time. Cannabis use has increased in select population groups, with use modes shifting away from smoking. Evidence on cannabis-related hospitalizations (e.g., for mental health) is mixed. The prevalence of cannabis-impaired driving appears to be generally steady but THC exposure among crash-involved drivers may have increased. Increasing proportions of users obtain cannabis products from legal sources but some-especially regular-users continue to use illicit sources. Overall, data suggest a mixed and inconclusive picture on cannabis legalization's impacts on essential public health indicators, including select extensions in trends from pre-legalization.
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Affiliation(s)
- Himani Boury
- Faculty of Health Sciences, Centre for Applied Research in Mental Health and Addiction, Simon Fraser University, Suite 2400, 515 W. Hastings Street, Vancouver, BC V6B 5K3 Canada
- School of Public Health, Queens University, Kingston, Canada
| | - Wayne Hall
- Faculty of Health and Behavioural Sciences, National Centre for Youth Substance Use Research, University of Queensland, 17 Upland Road, St Lucia, Australia
| | - Benedikt Fischer
- Faculty of Health Sciences, Centre for Applied Research in Mental Health and Addiction, Simon Fraser University, Suite 2400, 515 W. Hastings Street, Vancouver, BC V6B 5K3 Canada
- School of Population Health, University of Auckland, 85 Park Road, Auckland, New Zealand
- Department of Psychiatry, Federal University of Sao Paulo, R. Sena Madureira, São Paulo, 1500 Brazil
- Department of Psychiatry, University of Toronto, 250 College Street, Toronto, ON M5S2S1 Canada
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27
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Donnelly J, Young M, Marshall B, Hecht ML, Saldutti E. Public Health Implications of Cannabis Legalization: An Exploration of Adolescent Use and Evidence-Based Interventions. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19063336. [PMID: 35329023 PMCID: PMC8950733 DOI: 10.3390/ijerph19063336] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Revised: 03/04/2022] [Accepted: 03/08/2022] [Indexed: 11/16/2022]
Abstract
This article examines the relaxation of state marijuana laws, changes in adolescent use of marijuana, and implications for drug education. Under federal law, use of marijuana remains illegal. In spite of this federal legislation, as of 1 June 2021, 36 states, four territories and the District of Columbia have enacted medical marijuana laws. There are 17 states, two territories and the District of Columbia that have also passed recreational marijuana laws. One of the concerns regarding the enactment of legislation that has increased access to marijuana is the possibility of increased adolescent use of marijuana. While there are documented benefits of marijuana use for certain medical conditions, we know that marijuana use by young people can interfere with brain development, so increased marijuana use by adolescents raises legitimate health concerns. A review of results from national survey data, including CDC’s YRBS, Monitoring the Future, and the National Household Survey on Drug Use, allows us to document changes in marijuana use over time. Increased legal access to marijuana also has implications for educational programming. A “Reefer Madness” type educational approach no longer works (if it ever did). We explore various strategies, including prevention programs for education about marijuana, and make recommendations for health educators.
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Affiliation(s)
- Joseph Donnelly
- Department of Public Health, Montclair State University, Upper Montclair, NJ 07043, USA;
- Correspondence:
| | - Michael Young
- Center for Evidence-Based Programming, South Padre Island, TX 78597, USA;
| | - Brenda Marshall
- Department of Nursing, William Paterson University, Wayne, NJ 07470, USA;
| | | | - Elena Saldutti
- Department of Public Health, Montclair State University, Upper Montclair, NJ 07043, USA;
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28
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Ventresca M, Elliott C. Cannabis edibles packaging: Communicative objects in a growing market. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2022; 103:103645. [PMID: 35276401 DOI: 10.1016/j.drugpo.2022.103645] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2021] [Revised: 02/25/2022] [Accepted: 02/26/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND Cannabis edibles were legalized for recreational use across Canada in October 2019. The Canadian Cannabis Act requires legally produced edibles to be sold in plain single-color packages with limited branded elements and prominent health warning labels, serving size and nutritional information, and product ingredients including amounts of cannabis compounds. Little research, however, assesses what consumers think of standardized packaging, and how product packaging influences perceptions of cannabis edibles. METHODS Eight focus groups with young adults (ages 18-24; n = 57) were conducted in November 2018. Participants were recruited from a Canadian university, and asked to assess sample images of cannabis packaging approved by Health Canada. They then discussed the information they would like to see on packages. Focus group discussions were transcribed and analyzed using a descriptive, qualitative approach following methods of process evaluation and inductive coding. RESULTS Discussions generally pertained to four main themes: dosage and consumption recommendations; food and nutritional information; concerns for children; and health warning labels. Participants suggested improvements for cannabis packaging, including standardized THC units, non-numerical consumption instructions, and unit-dose packaging. Instead of recommending packaging that deters consumption, participants requested packaging features that promote safe consumption by adults while also protecting children. Findings reveal how packages function as communicative objects that convey meanings about safety and risk, yet these meanings may not resonate with Canadian young adults' perceptions of cannabis as relatively safe. CONCLUSIONS While the packaging regulated for use in Canada may be assumed, due to its plain, standardized format, to communicate "little", we highlight tensions in the meanings of such packaging to young adults-especially around competing ideas related to safety and risk.
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Affiliation(s)
- Matt Ventresca
- Department of Communication, Media, and Film, University of Calgary, Canada
| | - Charlene Elliott
- Department of Communication, Media, and Film, University of Calgary, Canada.
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29
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Wilson S, Rhee SH. Causal effects of cannabis legalization on parents, parenting, and children: A systematic review. Prev Med 2022; 156:106956. [PMID: 35074421 PMCID: PMC9021885 DOI: 10.1016/j.ypmed.2022.106956] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Revised: 12/26/2021] [Accepted: 01/15/2022] [Indexed: 11/29/2022]
Abstract
Medical and recreational cannabis legalization lead to increased cannabis use among adults. There is concern that legalization has negative implications for minors via effects on parents. We conducted a systematic review of studies examining legalization in the United States. Web of Science, PsycInfo, and PubMed were searched through May 2021, studies examining effects of legalization on maternal cannabis and other substance use during pregnancy and postpartum, perinatal outcomes, parental cannabis and other substance use and attitudes, parenting, and child outcomes were identified, and two independent reviewers extracted information on study designs, samples, and outcomes, and assessed classification of evidence and risk of bias. Forty-one studies met inclusion criteria; only 6 (15%) used the most causally informative study design (difference in differences). It is likely legalization increases maternal cannabis use during pregnancy and postpartum, parental cannabis use, and approval of adult cannabis use. Legalization may increase some adverse perinatal outcomes, though findings were inconsistent. It is likely legalization increases unintentional pediatric cannabis exposure. There is insufficient evidence for effects of legalization on child abuse and neglect, and there have been no studies examining effects of legalization on other aspects of parenting or on child adjustment. There is a critical lack of causally informative epidemiological studies examining effects of legalization on parenting and young children. Additional causally informative research is needed. Studies of parental cannabis use in a legal context are particularly needed. Commonsense guidelines must recognize the shifting national landscape around legalization while seeking to minimize potential harm to minors.
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Affiliation(s)
- Sylia Wilson
- Institute of Child Development, University of Minnesota, USA.
| | - Soo Hyun Rhee
- Department of Psychology and Neuroscience, University of Colorado Boulder, USA.
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30
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Lunn SE, Smitherman G. Comment on "pediatric cannabis intoxication trends in the pre and post-legalization era". Clin Toxicol (Phila) 2021; 60:544-545. [PMID: 34499001 DOI: 10.1080/15563650.2021.1975735] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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