Cannabis-related hospitalizations: unexpected serious events identified through hospital databases

Cannabis and children: risk mitigation strategies for edibles

In the era of (re)legalisation of medicinal and recreational cannabis, accidental and intentional exposure to edibles, cannabis-infused food products, has increased substantially. However, there is particular concern regarding younger age groups. Most concerning is the increase in hospitalisations. According to a study by Myran et al. (1), provinces in Canada, where the sale of edibles is permitted, saw an increase in paediatric poisonings due to unintentional consumption of edibles. Similar trends have been observed in "legalised states" in the US, such as Colorado (2). The impact of using cannabis at an early age, but particularly the impact of accidental exposure to high THC quantities, may have negative mental or physical health outcomes. Whilst regulatory restrictions vary significantly from one legalised region to another, it is difficult to identify a best practice. The aim of this study is to identify and discuss new and existing risk mitigation strategies to give guidance to policymakers. Furthermore, practical aspects, such as compliance (e.g. audits by authorities), are discussed. It is noted that edibles have been around much longer than recent political attempts to regulate them.

Cannabis use disorder, suicide attempts, and self-harm among adolescents: A national inpatient study across the United States

BACKGROUND

Suicide is among the top three causes of adolescent mortality. There is a scarcity of research examining cannabis use and suicidal behavior in adolescents.

OBJECTIVES

To determine the association between cannabis use disorder (CUD) and suicide attempt/self-harm in a hospitalized sample of adolescents.

METHODS

We conducted a cross-sectional observation study using data from the Nationwide Inpatient Sample collected over four years from January 1, 2016, through December 31, 2019. We included adolescents aged 10-19 hospitalized during the above period (N = 807,105). The primary outcome was suicide attempt/self-harm and the main predictor was CUD. The International Classification of Diseases Tenth Revision (ICD 10) diagnostic codes was used to identify a diagnosis of CUD, suicide attempt/self-harm, and other diagnoses included in the analyses. Adolescents diagnosed with CUD (n = 53,751) were compared to adolescents without CUD (n = 753,354). Univariate and multivariate logistic regressions were conducted to determine the association between CUD and suicide attempts/self-harm.

RESULTS

807,105 adolescent hospitalizations were analyzed, of which 6.9% had CUD. Adolescents with CUD were more likely to be older (17 years vs. 15 years), female (52% vs. 48%), have depression (44% vs. 17%), anxiety (32% vs. 13%), an eating disorder (1.9% vs. 1.2%), ADHD (16.3% vs. 9.1%), Conduct Disorder (4.1% vs. 1.3%), Alcohol Use Disorder (11.9% vs. 0.8%), Nicotine Use Disorder (31.1% vs. 4.1%), Cocaine Use Disorder (5.4% vs. 0.2%), Stimulant Use Disorder (0.8% vs. 0.4%) and report suicide attempts/self-harm (2.8% vs. 0.9%) [all ps<0.001]. After adjusting for potential confounders, CUD was associated with a higher risk of suicide attempts/self-harm (OR = 1.4, 95% CI 1.3-1.6, p <0.001). Post-hoc analyses showed the presence of depression moderated the association between CUD and suicide attempts/self-harm in that adolescents with CUD and depression had 2.4 times the odds of suicide attempt/self-harm compared to those with CUD but no depression after controlling for potential confounders (p<0.001).

CONCLUSIONS

Our study provides evidence for the association between CUD and suicide risk among hospitalized adolescents and underscores the importance of recognizing and addressing co-occurring mental and substance use disorders along with CUD to mitigate suicide risk. Identifying high-risk adolescents in inpatient settings provides an opportunity for intervention.

Should oncologists trust cannabinoids?

Cannabis enjoyed a "golden age" as a medicinal product in the late 19th, early 20th century, but the increased risk of overdose and abuse led to its criminalization. However, the 21st century have witnessed a resurgence of interest and a large body of literature regarding the benefits of cannabinoids have emerged. As legalization and decriminalization have spread around the world, cancer patients are increasingly interested in the potential utility of cannabinoids. Although eager to discuss cannabis use with their oncologist, patients often find them to be reluctant, mainly because clinicians are still not convinced by the existing evidence-based data to guide their treatment plans. Physicians should prescribe cannabis only if a careful explanation can be provided and follow up response evaluation ensured, making it mandatory for them to be up to date with the positive and also negative aspects of the cannabis in the case of cancer patients. Consequently, this article aims to bring some clarifications to clinicians regarding the sometimes-confusing various nomenclature under which this plant is mentioned, current legislation and the existing evidence (both preclinical and clinical) for the utility of cannabinoids in cancer patients, for either palliation of the associated symptoms or even the potential antitumor effects that cannabinoids may have.

A Case Report of Cannabis Abuse: A Surprising Etiology of Elevated Troponin

Cannabis is the most commonly used additive drug after alcohol and tobacco. There has been literature proving the relationship between cannabis use and elevated troponin from myocardial infarction, with many mechanisms explaining them. However, limited data are available on elevated troponin due to cannabis-induced high myocardial oxygen demand due to vasospasm. We present a case of a 21-year-old female presenting with chest pain after cannabis abuse. She exhibited a steep rise in troponin with a normal electrocardiogram (EKG). She refused a coronary angiogram, but a bedside echocardiogram showed no wall motion abnormality. Therefore, the dramatic rise of troponin levels with the chest pain and the resolution of the symptoms were most likely explained by demand ischemia via the mechanism of reversible vasospasm.

Can cannabis kill? Characteristics of deaths following cannabis use in England (1998-2020)

BACKGROUND

Cannabis is the most widely used illegal drug but is rarely considered a causal factor in death.

AIMS

This study aimed to understand trends in deaths in England where cannabinoids were detected at post-mortem, and to evaluate the clinical utility of post-mortem cannabinoid concentrations in coronial investigations.

METHODS

Deaths with cannabinoid detections reported to the National Programme on Substance Abuse Deaths (NPSAD) were extracted and analysed.

RESULTS

From 1998 to 2011, on average 7% of all cases reported to NPSAD had a cannabinoid detected (n = 110 deaths per year), rising to 18% in 2020 (n = 350). Death following cannabis use alone was rare (4% of cases, n = 136/3455). Traumatic injury was the prevalent underlying cause in these cases (62%, n = 84/136), with cannabis toxicity cited in a single case. Polydrug use was evident in most cases (96%, n = 3319/3455), with acute drug toxicity the prevalent underlying cause (74%, n = 2458/3319). Cardiac complications were the most cited physiological underlying cause of death (4%, n = 144/3455). The median average Δ9-tetrahydrocannabinol post-mortem blood concentrations were several magnitudes lower than previously reported median blood concentrations in living users (cannabis alone: 4.3 µg/L; cannabis in combination with other drugs: 3.5 µg/L).

CONCLUSIONS

Risk of death due to cannabis toxicity is negligible. However, cannabis can prove fatal in circumstances with risk of traumatic physical injury, or in individuals with cardiac pathophysiologies. These indirect harms need careful consideration and further study to better elucidate the role cannabis plays in drug-related mortality. Furthermore, the relevance of cannabinoid quantifications in determining cause of death in coronial investigations is limited.

The Impact of Cannabis Packaging Characteristics on Perceptions and Intentions

INTRODUCTION

As cannabis increasingly becomes a consumer product in the U.S., its product packaging has become critically important to regulators. This study examined the influence of recreational cannabis packaging characteristics.

METHODS

Five online between-subjects experiments were conducted in April 2021, and data were analyzed in May 2021-July 2021. Experiments randomized participants to view different (1) types of cannabis, (2) visual displays of tetrahydrocannabinol content, (3) cannabis packages designed around brand personality research, (4) health warnings, and (5) health claims. Outcomes included cognitive, affective, and behavioral responses.

RESULTS

A total of 841 adults from the U.S. (49% male, 50% young adults, 44% White, 17% Hispanic) were included in the study. Edible gummies were perceived as healthier (β=0.32, 95% CI=0.03, 0.62), less grown up (β= -0.58, 95% CI= -0.86, -0.28), and more socially acceptable to consume (β=0.30, 95% CI=0.01, 0.59) than cannabis concentrate in a medical dropper. Participants also had more interest in trying edible gummies (β=1.33, 95% CI=1.04, 1.62) and trying a free sample (β=1.30, 95% CI=1.01, 1.60) than trying cannabis concentrate. Cannabis packages with a helps-you-relax health claim elicited more happy (β=0.34, 95% CI=0.04, 0.64) and good (β=0.37, 95% CI=0.07, 0.67) feelings than cannabis packages without this claim. Minimal effects were found for visual displays of tetrahydrocannabinol content and health warnings.

CONCLUSIONS

Edibles are a unique type of cannabis that should be given special consideration under state laws, and lawmakers should consider limiting and governing the use of both implicit and explicit health claims on recreational cannabis packages when implementing laws.

Rates and correlates of cannabis-associated psychotic symptoms in over 230,000 people who use cannabis

Cannabis, a widely used psychoactive substance, can trigger acute cannabis-associated psychotic symptoms (CAPS) in people who use cannabis (PWUC). To assess rates and correlates of CAPS requiring emergency medical treatment, we analyzed data from an international sample of PWUC (n = 233,475). We found that 0.47% (95%CI 0.42; 0.52) PWUC reported lifetime occurrence of CAPS, defined as the occurrence of hallucinations and/or paranoia requiring emergency medical treatment following the use of cannabis. A range of factors correlated with risk of CAPS in the last year: higher rates were observed in young individuals [risk ratio (RR) 2.66, compared to older PWUC] and those residing in Denmark (RR 3.01, compared to PWUC from other countries). Furthermore, risk was elevated in those using predominantly high-potency resin (RR 2.11, compared to PWUC using herbal cannabis), those mixing cannabis with tobacco (RR 2.15, compared to PWUC not mixing with tobacco) and those with a diagnosis of psychosis (RR 14.01), bipolar (RR 4.30), anxiety (RR 2.92) and depression (RR 2.68), compared to individuals without a mental health diagnosis. Taken together, acute self-limiting psychotic symptoms in the context of cannabis use may occur in about 1 in 200 PWUC's lifetime. Some individuals could be particularly sensitive to the adverse psychological effects of cannabis, such as young individuals or those with pre-existing mental health vulnerabilities. In light of the movements towards legalization of recreational cannabis, more research should focus on the potential harms related to cannabis use, to educate PWUC and the public about risks related to its use.

Prevalence of Cannabis Use and Factors Related to Hospitalizations in the United States: A Population-Based Study Using National Inpatient Sample Between 2012 and 2018

Introduction: Cannabis use has been associated with adverse outcomes among adults and adolescents. As more states legalize or consider legalization, it is imperative to understand cannabis-related hospitalizations among the US population. This study is aimed at understanding the prevalence of cannabis-related hospitalizations using a nationally representative sample.

Methods: Using the National Inpatient Sample (NIS) available through the Healthcare Cost and Utilization Project (HCUP), we included all hospitalizations that met the inclusion criteria of documented history of cannabis use and those with any cannabis diagnosis as the reason for hospitalization between 2012 and 2014, and 2016 and 2018 using listwise deletion methods. Cannabis use was identified based on International Classification of Disease (ICD 9 & 10) codes (304.3X, 305.2X) (F12.XXX) for 2012-2014 and 2016-2018, respectively. We included both primary and secondary diagnoses among hospitalized patients. We further analyzed the relationship between cannabis-related diagnoses, race and ethnicity cases, household income, region, age group, rural-urban demographics, and sex.

Results: A weighted total of 2,099,665 and 1,023,325 patients with a history of cannabis use were identified for the period of 2012-2014 and 2016-2018, respectively. The primary reason for presentation among a majority of patients was related to mental health, alcohol, HIV, trauma, burns, and toxic effects of drugs for all included years. The rate of the presentation was highest among individuals 12-24-years-old (351, 846) and 25-34-years-old (255 and 563) per 10,000 presentations between 2012-2014 and 2016-2018, respectively. The highest rate of increase by race and ethnicity was observed among Native Americans (227 and 457), Black (287 and 468), and others (125 and 214) during 2012-2014 and 2016-2018, respectively. The highest observations were in the East North Central, West North Central, Mountain, and Pacific Regions of the United States. The highest presentation rates were observed among males with no insurance coverage and populations in the lowest income quartiles.

Conclusion: Cannabis-related hospitalization increased significantly over the years, and presentations are not isolated to areas with cannabis legalization. The high presentation rate among individuals with mental and alcohol necessitates the development of strategies to educate and mitigate potential causes of hospitalization among all age groups and races or ethnicity.

Early Onset Cardiovascular Disease from Cocaine, Amphetamines, Alcohol, and Marijuana

Cardiovascular disease (CVD), a disease typically associated with aging and the definitive leading cause of death worldwide, now threatens the young and middle-aged populations. Recreational abuse of alcohol, marijuana, cocaine and amphetamine-type stimulants has been an escalating public health problem for decades, but now use of these substances has become a significant contributor to early onset CVD. While this remains a global phenomenon, the epicenter of substance abuse is rooted in North America where it has been exacerbated by the COVID-19 pandemic. For the first time in history, the United States (US) crossed 100,000 overdose-related deaths in a calendar year. Sadly, Canada's recreational drug abuse problem closely mirrors that of the US. This is indicative of the larger public health crisis unfolding, as we now know that these substances are cardiotoxic and are contributing to the rising levels of premature chronic CVD, including hypertension, arrhythmias, heart failure, stroke, myocardial infarction, arterial dissection, sudden cardiac death and early mortality.

What Do We Know About Medical Cannabis in Neurological Disorders and What Are the Next Steps?

Medical use of cannabis has been receiving growing attention over the last few decades in modern medicine. As we know that the endocannabinoid system is largely involved in neurological disorders, we focused on the scientific rationale of medical cannabis in three neurological disorders: amyotrophic lateral sclerosis, Parkinson’s disease, and Alzheimer’s disease through pharmacological plausibility, clinical studies, and patients’ view. Clinical studies (randomized controlled trials, open-label studies, cohorts, and case reports) exploring medical cannabis in these disorders show different results depending on the methods and outcomes. Some show benefits on motor symptoms and others on non-motor symptoms and quality of life. Concerning patients’ view, several web surveys were collected, highlighting the real use of cannabis to relieve symptoms of neurological disorders, mostly outside a medical pathway. This anarchic use keeps questioning particularly in terms of risks: consumption of street cannabis, drug–drug interactions with usual medical treatment, consideration of medical history, and adverse reactions (psychiatric, respiratory, cardiovascular disorders, etc.), underlining the importance of a medical supervision. To date, most scientific data support the therapeutic potential of cannabis in neurological disorders. As far as patients and patients’ associations are calling for it, there is an urgent need to manage clinical studies to provide stronger evidence and secure medical cannabis use.

Trends and Socioeconomic Health Outcomes of Cannabis Use Among Patients With Gastroparesis: A United States Nationwide Inpatient Sample Analysis

BACKGROUND

Although cannabis may worsen nausea and vomiting for patients with gastroparesis, it may also be an effective treatment for gastroparesis-related abdominal pain. Given conflicting data and a lack of current epidemiological evidence, we aimed to investigate the association of cannabis use on relevant clinical outcomes among hospitalized patients with gastroparesis.

MATERIALS AND METHODS

Patients with a diagnosis of gastroparesis were reviewed from the National Inpatient Sample (NIS) database between 2008 and 2014. Gastroparesis was identified by International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes with patients classified based on a diagnosis of cannabis use disorder. Demographics, comorbidities, socioeconomic status, and outcomes were compared between cohorts using χ2 and analysis of variance. Logistic regression was then performed and annual trends also evaluated.

RESULTS

A total of 1,473,363 patients with gastroparesis were analyzed [n=33,085 (2.25%) of patients with concomitant cannabis use disorder]. Patients with gastroparesis and cannabis use disorder were more likely to be younger and male gender compared with nonusers (36.7±18.8 vs. 51.9±16.8; P<0.001 and 52.9% vs. 33.5%; P<0.001, respectively). Race/ethnicity was different between groups (P<0.001). Cannabis users had a lower median household income and were more likely to have Medicaid payor status (all P<0.001). Controlling for confounders, length of stay, and mortality were significantly decreased for patients with gastroparesis and cannabis use (all P<0.001).

CONCLUSION

While patients with gastroparesis and cannabis use disorder were younger, with a lower socioeconomic status, and disproportionately affected by psychiatric diagnoses, these patients had better hospitalization outcomes, including decreased length of stay and improved in-hospital mortality.

Why Do Marijuana and Synthetic Cannabimimetics Induce Acute Myocardial Infarction in Healthy Young People?

The use of cannabis preparations has steadily increased. Although cannabis was traditionally assumed to only have mild vegetative side effects, it has become evident in recent years that severe cardiovascular complications can occur. Cannabis use has recently even been added to the risk factors for myocardial infarction. This review is dedicated to pathogenetic factors contributing to cannabis-related myocardial infarction. Tachycardia is highly important in this respect, and we provide evidence that activation of CB₁ receptors in brain regions important for cardiovascular regulation and of presynaptic CB₁ receptors on sympathetic and/or parasympathetic nerve fibers are involved. The prototypical factors for myocardial infarction, i.e., thrombus formation and coronary constriction, have also been considered, but there is little evidence that they play a decisive role. On the other hand, an increase in the formation of carboxyhemoglobin, impaired mitochondrial respiration, cardiotoxic reactions and tachyarrhythmias associated with the increased sympathetic tone are factors possibly intensifying myocardial infarction. A particularly important factor is that cannabis use is frequently accompanied by tobacco smoking. In conclusion, additional research is warranted to decipher the mechanisms involved, since cannabis use is being legalized increasingly and Δ⁹-tetrahydrocannabinol and its synthetic analogue nabilone are indicated for the treatment of various disease states.

Relationship Between Marijuana Use and Hospitalization for Acute Coronary Syndrome

Background: Recreational marijuana use is rising, especially among young adults. The cardiovascular (CVD) effect of marijuana remains mostly unknown.

Methods: This is a retrospective study of 14,490 patients admitted to our hospital between 2012 and 2014 who had urine toxicology done for various reasons. Patients with a primary diagnosis of acute coronary syndrome (ACS) were queried in both the marijuana-positive group (n = 59) and the marijuana-negative group (n = 195). The risks of having ACS were compared in both groups.

Results: There was no difference in the risk of having ACS between the two groups in the population < 54 years of age (OR: 0.90, 95% CI: 0.67-1.20, p = 0.48). However, there was a significant difference in the risk of having ACS in the 18-36 age group (OR: 2.84, 95% CI: 1.14-7.07, p = 0.01). Multivariate analysis performed to adjust for the potential confounding effects of smoking and cocaine use showed that marijuana use (OR: 0.93, 95% CI: 0.68-1.25, p = 0.65) did not increase the likelihood of ACS for patients ≤ 54 years or for those in the 37-54 age group (OR: 1.11, 95% CI: 0.79-1.53, p = 0.50). However, among the 18-36 age bracket, marijuana use was independently associated with a higher risk of ACS (OR: 5.24, 95% CI: 1.84-16.93, p = 0.002).

Conclusion: In younger patients (age 18-36 years), marijuana use is independently associated with a five-fold higher risk of ACS.

High-intensity cannabis use and hospitalization: a prospective cohort study of street-involved youth in Vancouver, Canada

BACKGROUND

There is concern that cannabis use negatively affects vulnerable groups such as youth; however, the relationship between cannabis use and health care utilization has not been well characterized in this population. We longitudinally evaluated the association between daily cannabis use and hospitalization among a prospective cohort of street-involved youth.

METHODS

Data were collected from the At-Risk Youth Study (ARYS) in Vancouver, Canada, from September 2005 to May 2015. Participants were interviewed semi-annually and multivariable generalized estimating equation (GEE) logistic regression was used to examine the relationship between daily cannabis use and hospitalization.

RESULTS

A total of 1216 participants (31.2% female) were included in this analysis, and 373 (30.7%) individuals reported hospitalization at some point during the study period. In a multivariable GEE analysis, daily cannabis use was not significantly associated with hospitalization (Adjusted Odds Ratio [AOR] = 1.17, 95% Confidence interval [CI] = 0.84, 1.65). We did observe a significant interaction between daily cannabis use and sex (AOR = 0.51, 95% CI = 0.34, 0.77), whereby cannabis use was associated with a decreased odds of hospitalization among males (AOR = 0.60, 95% CI = 0.47, 0.78), yet was not significantly associated with hospitalization among females (AOR = 1.19, 95% CI = 0.84, 1.67).

CONCLUSIONS

The finding that daily cannabis use was not associated with hospitalization among street-involved youth is encouraging given the high rates of cannabis use in this population and the expansion of cannabis legalization and regulation. Future studies, however, are warranted to monitor possible changes in the consequences of cannabis use as cannabis legalization and regulation increase internationally.

Stroke and cannabis use in patients with no cardiovascular risk factors: a systematic review of case reports

INTRODUCTION

Cannabis and its synthetic analogues are currently the most widely consumed illicit substances worldwide. Multiple alterations have been linked to its use, including cerebrovascular disease (CVD) or stroke, whose association with the substance has been based mainly on the hypothesis of transient vasoconstriction, which explains a large proportion of the cases reported. However, epidemiological studies have not performed an individual analysis of patients without other cardiovascular risk factors, which may limit the estimation of the risk of stroke associated with cannabis use alone.

DEVELOPMENT

A systematic literature review was conducted through Medline, EBSCOhost, EMBASE, Lilacs, and Scielo to gather case reports published before 13 May 2016 presenting patients with a diagnosis of CVD or transient ischaemic attack, a history of cannabinoid use, and no other cardiovascular risk factors. Key words such as stroke, cerebrovascular disease, cannabis, and marijuana, among others, were used. A total of 18 case reports were selected from the 566 references found.

CONCLUSIONS

There is a wide variety of reports of stroke associated with cannabis use in patients with no other risk factors. Noteworthy findings were presentation at young age and a strong temporal association, which place cannabis use as a potential risk factor for this population in line with the epidemiological and pathophysiological studies in this area.

Cannabis and Cannabis Edibles: A Review

Cannabis is an excellent natural source of fiber and various bioactive cannabinoids. So far, at least 120 cannabinoids have been identified, and more novel cannabinoids are gradually being unveiled by detailed cannabis studies. However, cannabinoids in both natural and isolated forms are especially vulnerable to oxygen, heat, and light. Therefore, a diversity of cannabinoids is associated with their chemical instability to a large extent. The research status of structural conversion of cannabinoids is introduced. On the other hand, the use of drug-type cannabis and the phytocannabinoids thereof has been rapidly popularized and plays an indispensable role in both medical therapy and daily recreation. The recent legalization of edible cannabis further extends its application into the food industry. The varieties of legal edible cannabis products in the current commercial market are relatively monotonous due to rigorous restrictions under the framework of Cannabis Regulations and infancy of novel developments. Meanwhile, patents/studies related to the safety and quality assurance systems of cannabis edibles are still rare and need to be developed. Furthermore, along with cannabinoids, many phytochemicals such as flavonoids, lignans, terpenoids, and polysaccharides exist in the cannabis matrix, and these may exhibit prebiotic/probiotic properties and improve the composition of the gut microbiome. During metabolism and excretion, the bioactive phytochemicals of cannabis, mostly the cannabinoids, may be structurally modified during enterohepatic detoxification and gut fermentation. However, the potential adverse effects of both acute and chronic exposure to cannabinoids and their vulnerable groups have been clearly recognized. Therefore, a comprehensive understanding of the chemistry, metabolism, toxicity, commercialization, and regulations regarding cannabinoid edibles is reviewed and updated in this contribution.

Reevaluating America's Latest Pharmaceutical Trend: The Cardiovascular Risk of Cannabis

For the first time in the history of the modern era smoking tobacco is not the most popular inhaled product. After a flurry of legislature, cannabis has come to the forefront of both medicinal and recreational drug use. A confluence of evidence suggests, however, that marijuana consumption may confer a particularly worrisome cardiovascular risk profile. While combustible forms still contain many of the same harmful chemicals found in tobacco such as aromatic amines, polycyclic aromatic hydrocarbons (PAHs), and nitric oxide, some in even greater concentrations than tobacco, edible preparations have been evidenced to cause more cardiovascular-related emergency department visits. Importantly, this body of evidence suggests that cannabis use may be placing a younger, healthier population at risk of suffering major cardiovascular accidents particularly in the moments immediately following consumption. With males in their 30's apparently bearing the brunt of this burden, cannabis consumption has been associated with an increase in ischemic stroke-a blockage in the cerebral or cerebellar vasculature-and almost a fivefold increase in myocardial infarction. THC containing compounds have also been linked to vascular complications ranging from mild plaques to total arterial occlusion resulting in claudication, rest pain, ischemic ulceration and gangrene-recently termed cannabis arteritis. While this research remains in a nascent stage, marijuana consumption seems to be predisposing a youthful, traditionally low health risk cohort to a variety of major adverse cardiovascular events.

Cardiac Ischemia Associated With Marijuana Use in an Adolescent

With the increasing use of marijuana globally, including in pediatric populations, healthcare providers see more adverse health effects associated with this substance. This report details a case presentation of cardiac ischemia in an adolescent male associated with marijuana use. The patient presented with palpitations and chest pain shortly after consuming marijuana. Clinical workup demonstrated anterior ST-segment elevations and troponin elevation with no inflammatory marker elevation or findings of myocarditis on MRI. Extensive drug screening was only positive for marijuana, with a synthetic THC panel negative. These findings resolved after close observation and the patient was discharged in good clinical condition. This case shows a concerning presentation of marijuana-associated cardiac ischemia in an otherwise healthy adolescent, illustrating a potentially severe health concern with an increasingly common substance and demonstrating the need for pediatric centers to have a high index of suspicion for cardiac causes of chest pain when marijuana ingestion is involved even when there are no prior medical or cardiac risk factors.

The cardiovascular health of prisoners who use cannabis: An exploratory study among hospitalised prisoners

OBJECTIVE

It is essential that health professionals who practice medicine in prison rely on accurate knowledge about their patients to provide them with adapted care. The use of cannabis can influence the health status of prisoners, but data are lacking regarding the potentially related adverse health consequences. The objective of this descriptive study was to describe the cardiovascular outcomes related to cannabis use in prisoners from several detention centres hospitalised in a French hospital.

METHODS

In France, prisoners who require a longer than 48-hour hospitalisation are admitted in specific secured polyvalent units called inter-regional secured hospital units (ISHU). Hospitalisations in the ISHU of Toulouse University Hospital between 2012 and 2016 for cardiovascular disorders potentially related to the use of cannabis were extracted from the French hospital database and analysed using a previously validated methodology. Included patients were those hospitalised for an inaugural cardiovascular event or deterioration of a preexisting cardiovascular illness who declared having used cannabis while imprisoned.

RESULTS

Overall, 31 cardiovascular outcomes were identified in cannabis-using hospitalised prisoners among 411 hospitalisations for cardiovascular disorders (all men, mean age 43±SD years old). All used cannabis (daily: 56%) and tobacco (more than 15 PY: 83.3%), 5 used cocaine, and none used alcohol. The most frequent were coronaropathy (n=13), followed by obliterating arteriopathy of the lower limb (OALL, n=7), arrhythmic cardiomyopathy (n=4), venous thrombosis (n=3), infectious cardiopathy (n=2), and ischemic stroke (n=2).

CONCLUSION

This description of serious cardiovascular outcomes in prisoners who use cannabis provides insights into the clinical features possibly observed in this vulnerable population The findings indicate that 7.5% of hospitalizations of prisoners for cardiovascular disorders are potentially linked to cannabis used in prison.

[Substance use among young people: From medicine to illicit substances]

This paper aims to present the main information presented at the 9th meeting about addictovigilance in 2016 by three healthcare professionals and addiction experts on the issue of substance use in young people. The results of surveys conducted in general population and of specific addictovigilance investigations, bring information on consumption data and use patterns in this population of 11-25years of age. The provision of care, mainly constituted by the Young consumers' consultations, has to adapt to diversified practices, ranging from experiment to substance use disorders, which vary over time and often hidden.

Shifting the Paradigm on Cannabis Safety

The global movement toward legalization of cannabis is resulting in an ever-increasing public perception that cannabis is safe. Cannabis is not the first drug to be available for nonmedical use, nor is it the first to have such an unfounded safety profile. The safety of long-term exposure to phytocannabinoids is misunderstood by, and under reported to, the general public. There is evidence to suggest that long-term use of recreational cannabis may be associated with an increased risk of undesirable side effects. This evidence warrants both appropriate caution from the general public and investment in further research by government and industry sectors that are profiting from the sale of these potent psychoactive agents. There is no doubt that these compounds have medical potential. However, in addition to the medical potential, we must also remain aware of the adverse health effects that are becoming synonymous with recreational cannabis use. This perspective highlights the privileged role that cannabis has as a perceived “safe drug” in society and summarizes some concerning side effects that are becoming associated with regular nonprescribed cannabis use.

Assessing the public health impact of cannabis legalization in Canada: core outcome indicators towards an 'index' for monitoring and evaluation

The legalization of non-medical cannabis use and supply is impending in Canada. This constitutes a major policy change with the declared objective of improving public health outcomes, which requires rigorous monitoring and evaluation. While numerous different aspects associated with legalization will be examined, a focused perspective is required for effective policy evaluation purposes. To these ends, we have identified a set of 10 core indicators associated with cannabis-related risk/harm outcomes-based on current best evidence-that are expected to measure the primary impacts of legalization on public health outcomes. We briefly review these indicators, and their respective data availability in Canada. As ideally an integrated outcome assessment of cannabis legalization's impact on public health will be available, we further propose options to merge the individual indicators into an integrated, weighted 'index', considering their expected relative impact for public health. One possible approach to undertake this is 'multi-criteria decision analysis' as a method to weight the relative indicator impact on public health; alternative approaches are proposed. The integrated 'public health index' for cannabis legalization will allow for scientifically comprehensive, while focused, monitoring and evaluation of the effects of legalization in Canada for the benefits of science and evidence-based policy alike.

Assessing the public health impacts of legalizing recreational cannabis use: the US experience

The sale of cannabis for adult recreational use has been made legal in nine US states since 2012, and nationally in Uruguay in 2013 and Canada in 2018. We review US research on the effects of legalization on cannabis use among adults and adolescents and on cannabis-related harms; the impact of legalizing adult recreational use on cannabis price, availability, potency and use; and regulatory policies that may increase or limit adverse effects of legalization. The legalization of recreational cannabis use in the US has substantially reduced the price of cannabis, increased its potency, and made cannabis more available to adult users. It appears to have increased the frequency of cannabis use among adults, but not so far among youth. It has also increased emergency department attendances and hospitalizations for some cannabis-related harms. The relatively modest effects on cannabis use to date probably reflect restrictions on the number and locations of retail cannabis outlets and the constraints on commercialization under a continued federal prohibition of cannabis. Future evaluations of legalization should monitor: cannabis sales volumes, prices and content of tetrahydrocannabinol; prevalence and frequency of cannabis use among adolescents and adults in household and high school surveys; car crash fatalities and injuries involving drivers who are cannabis-impaired; emergency department presentations related to cannabis; the demand for treatment of cannabis use disorders; and the prevalence of regular cannabis use among vulnerable young people in mental health services, schools and the criminal justice system. Governments that propose to legalize and regulate cannabis use need to fund research to monitor the impacts of these policy changes on public health, and take advantage of this research to develop ways of regulating can-nabis use that minimize adverse effects on public health.

Cohort study of medical cannabis authorisation and healthcare utilisation in 2014-2017 in Ontario, Canada

BACKGROUND

The impact of medical cannabis on healthcare utilisation between 2014 and 2017 in Ontario, Canada. With cannabis legalisation in Canada and some states in the USA, high-quality longitudinal cohort research studies are of urgent need to assess the impact of cannabis use on healthcare utilisation.

METHODS

A matched cohort study of 9925 medical cannabis authorised adult patients (inhaled (smoked or vaporised) or orally consumed (oils)) at specialised cannabis clinics, and inclusion of 17 732 controls (not authorised) between 24 April 2014 and 31 March 2017 from Ontario, Canada. Interrupted time series and multivariate Poisson regression analyses were conducted. Medical cannabis impact on healthcare utilisation was measured over 6 months: all-cause physician visits, all-cause hospitalisation, ambulatory care sensitive conditions (ACSC)-related hospitalisations, all-cause emergency department (ED) visits and ACSC-related ED visits.

RESULTS

For medical cannabis patients compared with controls, there was an initial (within the first month) increase in physician visits (additional 4330 visits per 10 000 patients). However, a numerical reduction was noted over the 6-month follow-up, and no statistical difference was observed (p=0.126). Likewise, in hospitalisations and ACSC ED visits, there was an initial increase (44 per 10 000 people, p<0.05) but no statistical difference after follow-up (p=0.34). Conversely, no initial increase in all-cause ED visits was observed with a slight decrease (19 visits per 10 000 patients, p=0.014) in follow-up.

CONCLUSIONS

An initial increase (within first month) in healthcare utilisation may be expected among medical cannabis users that appears to wane over time. Proactive follow-up of patients using medical cannabis is warranted to minimise initial risks to patients and actively assess potential benefits/harms of ongoing use.

Harmful Effects of Smoking Cannabis: A Cerebrovascular and Neurological Perspective

Apart from being used as a medicine, cannabis or marijuana is the most widely abused recreational drug all over the world. The legalization and decriminalization of cannabis in Canada and various states of USA may be the underlying reason of the widespread popularity of it among young population. Various studies have reported about the relationship between cannabis use and different detrimental effects like cardiovascular, cerebrovascular, and neurological complications among different age groups. Specifically, the young population is getting adversely affected by this, harmful yet, readily accessible recreational drug. Although the mechanism behind cannabis mediated neurological and cerebrovascular complications has not been elucidated yet, the results of these studies have confirmed the association of these diseases with cannabis. Given the lack of comprehensive study relating these harmful complications with cannabis use, the aim of this narrative literature review article is to evaluate and summarize current studies on cannabis consumption and cerebrovascular/neurological diseases along with the leading toxicological mechanisms.

Social and public health implications of the legalisation of recreational cannabis: A literature review

BACKGROUND

After many years of legal struggles for the legalisation of recreational use of cannabis, the Constitutional Court of South Africa ruled in favour of the applicants in September 2018. Although the ruling issued caution regarding the social challenges accompanying this legalisation, it did not address how the country would deal with the societal consequences of this ruling.

AIM

The aim of this article was to discuss the social and public health implications of the legalisation of recreational cannabis on South Africa.

METHODS

Literature review on the social, health and legal impacts of legalisation of cannabis, considering experiences of other countries that have legalised cannabis.

RESULTS

The legalisation brings a range of significant negative consequences, which include an expected increase in the number of users and the subsequent undesirable effects on the physical, mental and social health of communities.

CONCLUSION

In terms of financial, infrastructural and human resources, South Africa cannot afford the consequences of the legalisation of recreational cannabis. Poor communities, children and the youth will carry the brunt of the scourge of cannabis use.

[Safety signal detection by the French Addictovigilance Network: Innovative methods of investigation, examples and usefulness for public health]

The French Addictovigilance Network aims to monitor all psychoactive substances with abuse potential including prescription drugs and other legal and illegal substances such as new psychoactive substances (NPS) and its consequences in humans. Created in 1990 through a network of regional addictovigilance centres covering the entire country, these pharmacologists with expertise in addictovigilance have developed interface with different partners (physicians, toxicologists, network of community pharmacies, addictology care centers…) and implemented several original tools of pharmacosurveillance (such as DRAMES [death related to the abuse of medicines] in strong collaboration with toxicologists or such OPPIDUM [observation of illegal products and misuse of psychotropic medications]), complementary to the spontaneous reporting. A such multidimensional approach including proactive surveillance by these tools and also among several heterogenous data sources (such as data from hospitals or claims database) is able to detect early addictovigilance signals and warnings as illustrated with three following examples: cannabis use and acute serious cardiovascular disorders, new synthetic opioids (ocfentanil, carfentanil) and severe opiate overdose or deaths, the diverted use of psychoactive drugs (codeine analgesics or sedative H1 antihistamines called purple drank) by adolescents and young adults. The choice of a broad strategy and the multifaceted system implemented by the French Addictovigilance Network using elements of pharmacology (fundamental, clinical, pharmacoepidemiology) expertise is an innovative method to detect early addictovigilance signals, and to describe its characteristics in order to increase awareness of psychoactive substances by patients, users and health professionals.

Acute cannabis toxicity

Objective: We describe the clinical effects of, and products associated with, acute exposures to cannabis during the early legalization period of recreational cannabis in Oregon and Alaska. Methods: This was an observational study of Oregon/Alaska Poison Center data between 4 December 2015 and 15 April 2017. A standardized data collection instrument was created for this study that captured information about cannabis product description, route of exposure, intentional vs unintentional exposure, product dose, product manufacture source, product ownership source, initial vital signs, clinical signs and symptoms, and subject disposition. Subjects were included if the Poison Center received a call about an acute exposure to cannabis from the subject, subject's family member or friend, or healthcare worker participating in the subject's care. Subjects were excluded if there was no evident exposure, the exposure was chronic, there were co-ingestants, or the subject was non-human (e.g. pet). Results: Two hundred fifty three individuals were acutely exposed to cannabis (median age 20 years; range 8 months - 96 years; 54.2% males): 71 (28.1%) children (<12 years), 42 (16.6%) adolescents (12-17 years), and 140 (55.3%) adults (≥18 years). Children were most likely to unintentionally (98.6%) ingest (97.2%) homemade (35.2%) edibles (64.8%) belonging to a family member (73.2%) and experience sedation (52.1%). Adults were most likely to intentionally (88.6%) ingest (66.4%) retail (40.0%) edibles (48.6%) and experience neuroexcitation (47.1%). Adolescents' exposures had similarities to both adult and children; they were most likely to intentionally (81.0%) ingest (50.0%) homemade (23.8%) edibles (45.2%) belonging to a friend (47.3%) and to experience either neuroexcitation (42.9%) or sedation (40.5%). Among all ages, tachycardia and neuroexcitation were more likely following inhalation exposures compared to ingestions. Eight subjects were admitted to an intensive care unit, including three patients who were intubated; one subject died. Edibles were the most common products to cause symptoms in all age groups, while concentrated products were more likely to lead to intubation, especially when ingested. Children in particular had a higher likelihood of intensive care unit admission and intubation following exposure to concentrated products. Conclusions: Neurotoxicity is common after acute cannabis exposures. Children experienced unintentional exposures, particularly within the home and occasionally with major adverse outcomes. Concentrated products such as resins and liquid concentrates were associated with greater toxicity than other cannabis products. These findings may help guide other states during the early retail cannabis legalization period.

[Identification of abuse/dependence cases by the French addictovigilance network (FAN): A pilot study of the addictovigilance center and the psychotherapeutic center of Nancy (France)]

OBJECTIVES

France is the only European country with a dedicated addictovigilance network (French addictovigilance network [FAN]). However, the reporting of cases of abuse/dependence is insufficient. In an attempt to overcome this under-reporting, data from the medical information systems program (PMSI) is regularly used to identify cases. Since addictions are frequently associated with psychiatric comorbidities, a pilot study was conducted for the first time in a psychiatric hospital. It aims, through a PMSI request, to identify the sociodemographic characteristics and psychiatric diagnoses of patients consuming psychoactive substances (PAS) and the PAS types consumed.

METHODS

This is a retrospective observational study conducted over a nine-month period at the psychotherapeutic center of Nancy (CPN). The codes used for the PMSI request are those of the international classification of diseases, tenth revision (ICD-10), codes F10 to F19 that characterize mental and behavioral disorders associated with the use of PAS. Cases presenting the four criteria necessary for an addictovigilance notification: (1) identified notifier, (2) identified patient, (3) known consumed product (s) and (4) presence of an effect related to the abuse/dependence of PAS; were retained and analyzed.

RESULTS

On an initial number of 252 cases, 82 cases of abuse/dependence were retained. The selected sample is predominantly male (67%). Cannabis (29%) and heroin (15%) are the most common illicit PAS. Regarding drugs, the consumption of benzodiazepines, a predominantly female phenomenon, is observed in 34% of subjects. Sixty-four per cent of the subjects were diagnosed "disorders related to the use of PAS", 14% as neurotic disorders, 9% as schizophrenia and 5% as of the mood disorders.

CONCLUSION

This study identified a significant number of potentially reportable cases to the French Addictovigilance Network and demonstrated the interest of investigating cases of abuse/dependence in a psychiatric hospital.

Ischaemic cardiomyopathy and embolic stroke in a young adult with suspected synthetic cannabinoid use

The incidence of cardiovascular disease is increasing in young adults. We are reporting a case of acute stroke in a young patient with severe ischaemic cardiomyopathy in the absence of traditional risk factors. After ruling out atherosclerotic disease, his presentation was attributed to synthetic cannabinoid use. We then discussed the typical barriers in early diagnosis and limitations of laboratory testing in this condition. Due to the increase in abuse of these synthetic drugs among young adults, there is a need for high clinical suspicion which can help with early recognition and improve morbidity and mortality associated with these chemicals.

Cardiovascular Complications of Marijuana and Related Substances: A Review

The recreational use of cannabis has sharply increased in recent years in parallel with its legalization and decriminalization in several countries. Commonly, the traditional cannabis has been replaced by potent synthetic cannabinoids and cannabimimetics in various forms. Despite overwhelming public perception of the safety of these substances, an increasing number of serious cardiovascular adverse events have been reported in temporal relation to recreational cannabis use. These have included sudden cardiac death, vascular (coronary, cerebral and peripheral) events, arrhythmias and stress cardiomyopathy among others. Many of the victims of these events are relatively young men with few if any cardiovascular risk factors. However, there are reasons to believe that older individuals and those with risk factors for or established cardiovascular disease are at even higher danger of such events following exposure to cannabis. The pathophysiological basis of these events is not fully understood and likely encompasses a complex interaction between the active ingredients (particularly the major cannabinoid, Δ9-tetrahydrocannabinol), and the endo-cannabinoid system, autonomic nervous system, as well as other receptor and non-receptor mediated pathways. Other complicating factors include opposing physiologic effects of other cannabinoids (predominantly cannabidiol), presence of regulatory proteins that act as metabolizing enzymes, binding molecules, or ligands, as well as functional polymorphisms of target receptors. Tolerance to the effects of cannabis may also develop on repeated exposures at least in part due to receptor downregulation or desensitization. Moreover, effects of cannabis may be enhanced or altered by concomitant use of other illicit drugs or medications used for treatment of established cardiovascular diseases. Regardless of these considerations, it is expected that the current cannabis epidemic would add significantly to the universal burden of cardiovascular diseases.

Identification and initial management of intoxication by alcohol and other drugs in the pediatric emergency room

OBJECTIVE

To review the screening, diagnosis, evaluation, and treatment of intoxication by alcohol and other drugs in children and adolescents in the emergency scenario.

DATA SOURCE

This was a narrative literature review.

DATA SUMMARY

The detection of this problem in the emergency room can be a challenge, especially when its assessment is not standardized. The intentional and episodic use of large amounts of psychoactive substances by adolescents is a usual occurrence, and unintentional intoxication is more common in children younger than 12 years. The clinical picture in adolescents and children differs from that in adults and some particularities are important in the emergency scenario. After management of the acute condition, interventions targeting the adolescent at risk may be effective.

CONCLUSION

The diagnosis and treatment of intoxication by alcohol and other drugs in adolescents and children in the emergency scenario requires a systematic evaluation of the use of these drugs. There are few specific treatments for intoxication, and the management comprehends support measures and management of related clinical complications.

Cannabis use among patients at a comprehensive cancer center in a state with legalized medicinal and recreational use

BACKGROUND

Cannabis is purported to alleviate symptoms related to cancer treatment, although the patterns of use among cancer patients are not well known. This study was designed to determine the prevalence and methods of use among cancer patients, the perceived benefits, and the sources of information in a state with legalized cannabis.

METHODS

A cross‐sectional, anonymous survey of adult cancer patients was performed at a National Cancer Institute–designated cancer center in Washington State. Random urine samples for tetrahydrocannabinol provided survey validation.

RESULTS

Nine hundred twenty‐six of 2737 eligible patients (34%) completed the survey, and the median age was 58 years (interquartile range [IQR], 46‐66 years). Most had a strong interest in learning about cannabis during treatment (6 on a 1‐10 scale; IQR, 3‐10) and wanted information from cancer providers (677 of 911 [74%]). Previous use was common (607 of 926 [66%]); 24% (222 of 926) used cannabis in the last year, and 21% (192 of 926) used cannabis in the last month. Random urine samples found similar percentages of users who reported weekly use (27 of 193 [14%] vs 164 of 926 [18%]). Active users inhaled (153 of 220 [70%]) or consumed edibles (154 of 220 [70%]); 89 (40%) used both modalities. Cannabis was used primarily for physical (165 of 219 [75%]) and neuropsychiatric symptoms (139 of 219 [63%]). Legalization significantly increased the likelihood of use in more than half of the respondents.

CONCLUSIONS

This study of cancer patients in a state with legalized cannabis found high rates of active use across broad subgroups, and legalization was reported to be important in patients' decision to use. Cancer patients desire but are not receiving information about cannabis use during their treatment from oncology providers. Cancer 2017;123:4488‐97. © 2017 The Authors. Cancer published by Wiley Periodicals, Inc. on behalf of American Cancer Society. This is an open access article under the terms of the Creative Commons Attribution‐NonCommercial‐NoDerivs License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non‐commercial and no modifications or adaptations are made.

Cannabis use is common among patients receiving treatment at a large cancer center in a state with legalized recreational and medical cannabis. Active use is reported across broad demographic and diagnostic cancer subgroups, and legalization is reported to be important in patients' decision to use.

The association of cannabis use on inpatient psychiatric hospital outcomes

BACKGROUND

The associations between cannabis use and psychosis are well documented in numerous studies. There is a need to evaluate the impact of cannabis use on inpatient psychiatric utilization and outcomes.

OBJECTIVES

To evaluate the impact of cannabis use on psychiatric hospital outcomes.

METHODS

This study was conducted between April 20, 2015 and October 20, 2015. All patients (n = 120) admitted to Denver Health with psychotic symptoms were administered a urine toxicology screening testing for the presence of 11-nor-9-carboxy-Δ⁹-tetrahydrocannabinol (THC-COOH, the active metabolite of cannabis). Patients with positive tests were compared to those with negative tests on several measures, including length of stay, presence or lack of 30-day readmission, Brief Psychotic Rating Scale (BPRS) score, and use of antipsychotics and/or sedatives/anxiolytics.

RESULTS

There were 120 patients. Twenty nine were women and 91 were men. Patients testing positive for THC-COOH had a shorter length of stay compared to patients testing negative for THC-COOH, after adjusting for age, prior psychiatric admissions, history of a psychotic-spectrum disorder, and comorbid additional substance use (p = 0.02). There were no differences in 30-day readmissions, 30-day post-discharge presentation to the Denver Health psychiatric emergency department, BPRS scores, and medication administration.

CONCLUSION

Patients presenting with psychotic symptoms and cannabis use require shorter inpatient psychiatric hospitalizations. This study is the first to quantify this observation and highlights the need for future clinical decision-making tools that would ideally correlate cannabis use with the degree of potential need for expensive and scarce mental health resources, such as psychiatric hospitalization.

Cannabis-induced bullous lung disease leading to pneumothorax: Case report and literature review

RATIONALE

Marijuana use has been increasing in the United States among college students and young adults. Marijuana use has been associated with bullous lung disease which can lead to pneumothorax. There are other recreational drugs like methylphenidate, cocaine and heroin which have been associated with pneumothorax.

PATIENT CONCERNS

We present a case of a 30-year-old man with spontaneous pneumothorax associated with marijuana use. The patient had no medical conditions and presented to the emergency room with chest pain. The physical examination revealed decreased breath sound on the right side of the chest.

DIAGNOSES

Bed side ultrasound of chest showed stratosphere sign, absent lung sliding; consistent with right-sided pneumothorax.

INTERVENTIONS AND OUTCOMES

The patient underwent placement of a chest tube. Computed tomography chest scans performed on day two also showed bullous lung disease in the right lung. Serial x-rays of the chest showed re-expansion of the lung.

LESSONS

Despite the beneficial effects of Marijuana there are deleterious effects which are emphasized here. This case highlights the need for further studies to establish the relationship between marijuana use and lung diseases in the absence of nicotine use.

Strokes are possible complications of cannabinoids use

It is critically important to identify all factors that may play a role in the recent increase of the incidence of stroke among the young population. Considering the worldwide use of cannabinoids (cannabis and synthetic cannabinoids), the recent legalization of their consumption in some countries, and their supposed involvement in cardiovascular events, we evaluated their role in the occurrence of neurovascular complications among the young. Ninety-eight patients were described in the literature as having a cannabinoids-related stroke (85 after cannabis use and 13 after synthetic cannabinoids). The distribution by type of stroke was as follows: 4 patients with an undetermined type of stroke, 85 with an ischemic stroke and/or a transient ischemic attack, and 9 with a hemorrhagic stroke. The mean age of patients was 32.3±11.8years (range 15-63), and the majority of them were male with a sex ratio of 3.7:1. Cannabis was often smoked with tobacco in 66% of cases. Most of the patients with cannabinoids-related strokes were chronic cannabis users in 81% of cases, and for 18% of them, there was a recent increase of the amount of cannabis consumption during the days before the occurrence of stroke. Even if the prognosis of stroke was globally favorable in 46% of cases, with no or few sequelae, 5 patients died after the neurovascular event. One striking element reported in the majority of the reports was a temporal relationship between cannabinoids use, whether natural or synthetic, and the occurrence of stroke. However, a temporal correlation does not mean causation, and other factors may be involved. Cannabis may be considered as a risk factor of stroke until research shows evidence of an underlying mechanism that, alone or in association with others, contributes to the development of stroke. As of today, reversible cerebral vasoconstriction triggered by cannabinoids use may be a convincing mechanism of stroke in 27% of cases. Indeed, despite the widespread use of cannabinoids, the low frequency of neurovascular complications after their use may be due to a genetic predisposition to their neurovascular toxicity in some individuals. Further studies should focus on this point. More importantly however, this low frequency may be underestimated because the drug consumption may not be systematically researched, neither by questioning nor by laboratory screening. Besides this vascular role of cannabinoids in the occurrence of stroke, a cellular effect of cannabis on brain mitochondria was recently suggested in an experimental study. One of the mechanisms involved in young cannabis users with stroke may be the generation of reactive oxygen species leading to an oxidative stress, which is a known mechanism in stroke in humans. It is useful to inform the young population about the real potential risk of using cannabinoids. We suggest to systematically ask all young adults with stroke about their drug consumption including cannabinoids, to screen urine for cannabis or to include a specific diagnostic test to detect synthetic cannabinoids, and to obtain non-invasive intracranial arterial investigations (i.e. CT-angiography or cerebral MRA) in order to search for cerebral vasoconstriction. However, several questions remained unresolved and further research is still needed to assess the pathophysiological mechanisms involved in young cannabinoids users with stroke. This article is part of a Special Issue entitled "Cannabinoids and Epilepsy".

[Cannabis-induced disorders]

Use and misuse of cannabis and marihuana are frequent. About 5% of the adult population are current users but only 1.2% are dependent. The medical use of cannabis is controversial but there is some evidence for improvement of chronic pain and spasticity. The somatic toxicity of cannabis is well proven but limited and psychiatric disorders induced by cannabis are of more relevance, e.g. cognitive disorders, amotivational syndrome, psychoses and delusional disorders as well as physical and psychological dependence. The withdrawal symptoms are usually mild and do not require pharmacological interventions. To date there is no established pharmacotherapy for relapse prevention. Psychosocial interventions include psychoeducation, behavioral therapy and motivational enhancement. The CANDIS protocol is the best established German intervention among abstinence-oriented therapies.

Identifying Life-Threatening Admissions for Drug Dependence or Abuse (ILIADDA): Derivation and Validation of a Model

Given that drug abuse and dependence are common reasons for hospitalization, we aimed to derive and validate a model allowing early identification of life-threatening hospital admissions for drug dependence or abuse. Using the French National Hospital Discharge Data Base, we extracted 66,101 acute inpatient stays for substance abuse, dependence, mental disorders or poisoning associated with medicines or illicit drugs intake, recorded between January 1st, 2009 and December 31st, 2014. We split our study cohort at the center level to create a derivation cohort and a validation cohort. We developed a multivariate logistic model including patient's age, sex, entrance mode and diagnosis as predictors of a composite primary outcome of in-hospital death or ICU admission. A total of 2,747 (4.2%) patients died or were admitted to ICU. The risk of death or ICU admission was mainly associated with the consumption of opioids, followed by cocaine and other narcotics. Particularly, methadone poisoning was associated with a substantial risk (OR: 35.70, 95% CI [26.94-47.32], P < 0.001). In the validation cohort, our model achieved good predictive properties in terms of calibration and discrimination (c-statistic: 0.847). This allows an accurate identification of life-threatening admissions in drug users to support an early and appropriate management.

Marijuana Use and Cardiovascular Disease

Marijuana is currently the most used illicit substance in the world. With the current trend of decriminalization and legalization of marijuana in the US, physicians in the US will encounter more patients using marijuana recreationally over a diverse range of ages and health states. Therefore, it is relevant to review marijuana's effects on human cardiovascular physiology and disease. Compared with placebo, marijuana cigarettes cause increases in heart rate, supine systolic and diastolic blood pressures, and forearm blood flow via increased sympathetic nervous system activity. These actions increase myocardial oxygen demand to a degree that they can decrease the time to exercise-induced angina in patients with a history of stable angina. In addition, marijuana has been associated with triggering myocardial infarctions (MIs) in young male patients. Smoking marijuana has been shown to increase the risk of MI onset by a factor of 4.8 for the 60 minutes after marijuana consumption, and to increase the annual risk of MI in the daily cannabis user from 1.5% to 3% per year. Human and animal models suggest that this effect may be due to coronary arterial vasospasm. However, longitudinal studies have indicated that marijuana use may not have a significant effect on long-term mortality. While further research is required to definitively determine the impact of marijuana on cardiovascular disease, it is reasonable to recommend against recreational marijuana use, especially in individuals with a history of coronary artery disorders.