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Miotto MB, Balchan B, Combe L. Safe Administration of Medication in School: Policy Statement. Pediatrics 2024; 153:e2024066839. [PMID: 38804057 DOI: 10.1542/peds.2024-066839] [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: 03/27/2024] [Revised: 03/27/2024] [Accepted: 03/28/2024] [Indexed: 05/29/2024] Open
Abstract
Many youth with acute and chronic health conditions require medication to be administered during the school day. This policy statement offers guidance to school physicians, community prescribers, school nurses, other school health professionals, and groups providing oversight to school health activities and ensures patient safety and equity lenses are applied to administration of medications during school and for school-related activities. The American Academy of Pediatrics supports a robust collaborative model that allows all those involved in student health, including the student and family, to communicate, participate in effective medication management, inform delegated medication responsibilities, and promote safe medication storage and administration. School medication administration protocols are developed to help prevent medication administration errors specific to potential risks in the school setting and are responsive to the maturing students' evolving understanding of their health needs, growing autonomy, and responsibility. All protocols involving school nurses, unlicensed assistive personnel, and prescribers must be consistent with state and federal regulations on scope of practice, student privacy laws, and professional nursing organization guidelines. Consistent policies and messaging on safety of the patient and the entire school community enable school health teams to ensure equitable treatment of students prescribed therapeutic agents newly regulated by the US Food and Drug Administration, over-the-counter medications, or products that are currently not regulated by the US Food and Drug Administration.
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Affiliation(s)
- Mary Beth Miotto
- Department of Pediatrics, UMass Chan School of Medicine, Worcester, Massachusetts, and Mattapan Community Health Center, Boston, Massachusetts
| | | | - Laurie Combe
- Independent School Nursing and School Health Consulting Practice, Spring, Texas
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2
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Sahli J, Grossoehme D, Friebert S. Experience With Medical Marijuana in a Pediatric Palliative Care Clinic: Case Report. J Pain Symptom Manage 2024; 67:e361-e365. [PMID: 38278190 DOI: 10.1016/j.jpainsymman.2024.01.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Revised: 01/16/2024] [Accepted: 01/18/2024] [Indexed: 01/28/2024]
Abstract
Children receiving palliative care have life-limiting or life-threatening conditions, which include symptoms ranging from unpleasant to intolerable suffering. We describe three diverse cases of medical marijuana within ambulatory pediatric palliative care, highlighting use for spasticity, refractory seizures, and cancer-related symptoms. Included are caregiver perspectives of their child's experience with medical marijuana. This population has high potential for positive effects from medical marijuana therapy, particularly for maximizing quality of life.
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Affiliation(s)
- Jenna Sahli
- Haslinger Family Pediatric Palliative Care Center (J.S., D.G., S.F.), Akron Children's Hospital, Akron, OH, USA
| | - Daniel Grossoehme
- Haslinger Family Pediatric Palliative Care Center (J.S., D.G., S.F.), Akron Children's Hospital, Akron, OH, USA; Rebecca D. Considine Research Institute (D.G., S.F.), Akron Children's Hospital, Akron, OH, USA.
| | - Sarah Friebert
- Haslinger Family Pediatric Palliative Care Center (J.S., D.G., S.F.), Akron Children's Hospital, Akron, OH, USA; Rebecca D. Considine Research Institute (D.G., S.F.), Akron Children's Hospital, Akron, OH, USA
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3
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Tagsold D, Toni I, Trollmann R, Woelfle J, Gravou-Apostolatou C. The Use of Cannabinoids in Pediatric Palliative Care-A Retrospective Single-Center Analysis. CHILDREN (BASEL, SWITZERLAND) 2024; 11:234. [PMID: 38397346 PMCID: PMC10887187 DOI: 10.3390/children11020234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/21/2024] [Revised: 02/05/2024] [Accepted: 02/09/2024] [Indexed: 02/25/2024]
Abstract
This data analysis aimed to systematically analyze a pediatric patient population with a life-limiting disease who were administered cannabinoids. It was a retrospective single-center analysis of patients under supervision of the specialized outpatient pediatric palliative care (SOPPC) team at the Department of Pediatrics and Adolescent Medicine of the Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU). Thirty-one patients with a primary diagnosis of neuropediatric, oncologic, metabolic, and cardiologic categories were included. The indications we identified were spasticity, pain, restlessness, anxiety, loss of appetite, epilepsy, and paresis. Certain aspects of quality of life were improved for 20 of 31 patients (64.5%). For nine patients (29%), no improvement was detected. No conclusions could be drawn for two patients (6.5%). Adverse events were reported for six of the thirty-one patients (19.4%). These were graded as mild, including symptoms such as restlessness, nausea, and behavioral issues. We detected no clinically relevant interactions with other medications. We collected fundamental data on the use of cannabinoids by pediatric palliative patients. Cannabinoids are now frequently administered in pediatric palliative care. They seem to be safe to use and should be considered an add-on therapy for other drug regimens.
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Affiliation(s)
| | | | | | | | - Chara Gravou-Apostolatou
- Department of Pediatrics and Adolescent Medicine, Friedrich-Alexander-Universität Erlangen-Nürnberg, 91054 Erlangen, Germany; (D.T.)
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4
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Finn K, Bakewell BK. Cannabis education: how providers and patients can engage in discussion. Int J Legal Med 2023; 137:1439-1440. [PMID: 37344584 DOI: 10.1007/s00414-023-03041-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Accepted: 06/07/2023] [Indexed: 06/23/2023]
Affiliation(s)
- Kenneth Finn
- Springs Rehabilitation, P.C., 2955 Professional Place, Suite 201, Colorado Springs, CO, 80904, USA.
- International Academy on the Science and Impact of Cannabis, Leesburg, VA, USA.
| | - Brock K Bakewell
- Rocky Vista University College of Osteopathic Medicine, Ivins, UT, USA
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5
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Motamedi S, Amleshi RS, Javar BA, Shams P, Kohlmeier KA, Shabani M. Cannabis during pregnancy: A way to transfer an impairment to later life. Birth Defects Res 2023; 115:1327-1344. [PMID: 37318343 DOI: 10.1002/bdr2.2207] [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: 12/09/2022] [Revised: 05/11/2023] [Accepted: 05/20/2023] [Indexed: 06/16/2023]
Abstract
Epidemiological studies examining the influence of cannabis across the lifespan show that exposure to cannabis during gestation or during the perinatal period is associated with later-life mental health issues that manifest during childhood, adolescence, and adulthood. The risk of later-life negative outcomes following early exposure is particularly high in persons who have specific genetic variants, implying that cannabis usage interacts with genetics to heighten mental health risks. Prenatal and perinatal exposure to psychoactive components has been shown in animal research to be associated with long-term effects on neural systems relevant to psychiatric and substance use disorders. The long-term molecular, epigenetic, electrophysiological, and behavioral consequences of prenatal and perinatal exposure to cannabis are discussed in this article. Animal and human studies, as well as in vivo neuroimaging methods, are used to provide insights into the changes induced in the brain by cannabis. Here, based on the literature from both animal models and humans, it can be concluded that prenatal cannabis exposure alters the developmental route of several neuronal regions with correlated functional consequences evidenced as changes in social behavior and executive functions throughout life.
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Affiliation(s)
- Sina Motamedi
- Neuroscience Research Center, Neuropharmacology Institute, Kerman University of Medical Sciences, Kerman, Iran
| | - Reza Saboori Amleshi
- Neuroscience Research Center, Neuropharmacology Institute, Kerman University of Medical Sciences, Kerman, Iran
| | - Behnoush Akbari Javar
- Neuroscience Research Center, Neuropharmacology Institute, Kerman University of Medical Sciences, Kerman, Iran
- Health Foresight and Innovation Research Center, Institute for Futures Studies in Health, Kerman University of Medical Sciences, Kerman, Iran
| | - Parisa Shams
- Neuroscience Research Center, Neuropharmacology Institute, Kerman University of Medical Sciences, Kerman, Iran
- Department of Anatomical Sciences, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Kristi A Kohlmeier
- Department of Drug Design and Pharmacology, Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Mohammad Shabani
- Neuroscience Research Center, Neuropharmacology Institute, Kerman University of Medical Sciences, Kerman, Iran
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6
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Krebs NF, Belfort MB, Meier PP, Mennella JA, O'Connor DL, Taylor SN, Raiten DJ. Infant factors that impact the ecology of human milk secretion and composition-a report from "Breastmilk Ecology: Genesis of Infant Nutrition (BEGIN)" Working Group 3. Am J Clin Nutr 2023; 117 Suppl 1:S43-S60. [PMID: 37173060 PMCID: PMC10356564 DOI: 10.1016/j.ajcnut.2023.01.021] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Revised: 12/08/2022] [Accepted: 01/03/2023] [Indexed: 05/15/2023] Open
Abstract
Infants drive many lactation processes and contribute to the changing composition of human milk through multiple mechanisms. This review addresses the major topics of milk removal; chemosensory ecology for the parent-infant dyad; the infant's inputs into the composition of the human milk microbiome; and the impact of disruptions in gestation on the ecology of fetal and infant phenotypes, milk composition, and lactation. Milk removal, which is essential for adequate infant intake and continued milk synthesis through multiple hormonal and autocrine/paracrine mechanisms, should be effective, efficient, and comfortable for both the lactating parent and the infant. All 3 components should be included in the evaluation of milk removal. Breastmilk "bridges" flavor experiences in utero with postweaning foods, and the flavors become familiar and preferred. Infants can detect flavor changes in human milk resulting from parental lifestyle choices, including recreational drug use, and early experiences with the sensory properties of these recreational drugs impact subsequent behavioral responses. Interactions between the infant's own developing microbiome, that of the milk, and the multiple environmental factors that are drivers-both modifiable and nonmodifiable-in the microbial ecology of human milk are explored. Disruptions in gestation, especially preterm birth and fetal growth restriction or excess, impact the milk composition and lactation processes such as the timing of secretory activation, adequacy of milk volume and milk removal, and duration of lactation. Research gaps are identified in each of these areas. To assure a sustained and robust breastfeeding ecology, these myriad infant inputs must be systematically considered.
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Affiliation(s)
- Nancy F Krebs
- Section of Nutrition, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA.
| | - Mandy B Belfort
- Department of Pediatric Newborn Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Paula P Meier
- Department of Pediatrics, Rush University Medical Center, Chicago, IL, USA
| | | | - Deborah L O'Connor
- Department of Nutritional Sciences, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada; The Hospital for Sick Children, Toronto, ON, Canada
| | - Sarah N Taylor
- Division of Neonatology, Department of Pediatrics, Yale School of Medicine, New Haven, CT, USA
| | - Daniel J Raiten
- Pediatric Growth and Nutrition Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, USA
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7
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Reece AS, Hulse GK. State Trends of Cannabis Liberalization as a Causal Driver of Increasing Testicular Cancer Rates across the USA. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph191912759. [PMID: 36232059 PMCID: PMC9565972 DOI: 10.3390/ijerph191912759] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Revised: 09/18/2022] [Accepted: 09/30/2022] [Indexed: 05/16/2023]
Abstract
BACKGROUND The cause of the worldwide doubling-tripling of testicular cancer rates (TCRs) in recent decades is unknown. Previous cohort studies associated cannabis use with TCR including dose-response relationships but the contribution of cannabis to TCRs at the population level is unknown. This relationship was tested by analyzing annual trends across US states and formally assessed causality. Four US datasets were linked at state level: age-adjusted TCRs from Centers for Disease Control Surveillance Epidemiology and End Results database; drug use data from annual National Survey of Drug Use and Health including 74.1% response rate; ethnicity and median household income data from the US Census Bureau; and cannabinoid concentration data from Drug Enforcement Agency reports. Data was processed in R in spatiotemporal and causal inference protocols. RESULTS Cannabis-use quintile scatterplot-time and boxplots closely paralleled those for TCRs. The highest cannabis-use quintile had a higher TCR than others (3.44 ± 0.05 vs. 2.91 ± 0.2, mean ± S.E.M., t = 10.68, p = 1.29 × 10-22). A dose-response relationship was seen between TCR and Δ9-tetrahydrocannabinol (THC), cannabinol, cannabigerol, and cannabichromene (6.75 × 10-9 < p < 1.83 × 10-142). In a multivariate inverse probability-weighted interactive regression including race and ethnic cannabis exposure (ECE), ECE was significantly related to TCR (β-estimate = 0.89 (95%C.I. 0.36, 2.67), p < 2.2 × 10-16). In an additive geospatiotemporal model controlling for other drugs, cannabis alone was significant (β-estimate = 0.19 (0.10, 0.28), p = 3.4 × 10-5). In a full geospatial model including drugs, income and ethnicity cannabinoid exposure was significant (cannabigerol: β-estimate = 1.39 (0.024, 2.53), p = 0.0017); a pattern repeated at two spatial and two temporal lags (cannabigerol: β-estimate = 0.71 (0.05, 1.37), p = 0.0.0350; THC: β-estimate = 23.60 (11.92, 35.29), p = 7.5 × 10-5). 40/41 e-Values > 1.25 ranged up to 1.4 × 1063 and 10 > 1000 fitting causal relationship criteria. Cannabis liberalization was associated with higher TCRs (ChiSqu. = 312.2, p = 2.64 × 10-11). Rates of TC in cannabis-legal states were elevated (3.36 ± 0.09 vs. 3.01 ± 0.03, t = 4.69, p = 4.86 × 10-5). CONCLUSIONS Cannabis use is closely and causally associated with TCRs across both time and space and higher in States with liberal cannabis legislation. Strong dose-response effects were demonstrated for THC, cannabigerol, cannabinol, cannabichromene and cannabidiol. Cannabinoid genotoxicity replicates all major steps to testicular carcinogenesis including whole-genome doubling, chromosomal arm excision, generalized DNA demethylation and chromosomal translocations thereby accelerating the pathway to testicular carcinogenesis by several decades.
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Affiliation(s)
- Albert Stuart Reece
- Division of Psychiatry, University of Western Australia, Crawley, WA 6009, Australia
- School of Medical and Health Sciences, Edith Cowan University, Joondalup, WA 6027, Australia
- Correspondence: ; Tel.: +61-7-3844-4000; Fax: +61-7-3844-4015
| | - Gary Kenneth Hulse
- Division of Psychiatry, University of Western Australia, Crawley, WA 6009, Australia
- School of Medical and Health Sciences, Edith Cowan University, Joondalup, WA 6027, Australia
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8
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Scott C, Neira Agonh D, Lehmann C. Antibacterial Effects of Phytocannabinoids. Life (Basel) 2022; 12:1394. [PMID: 36143430 PMCID: PMC9505641 DOI: 10.3390/life12091394] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Revised: 09/02/2022] [Accepted: 09/05/2022] [Indexed: 11/16/2022] Open
Abstract
Antibiotics are used as the first line of treatment for bacterial infections. However, antibiotic resistance poses a significant threat to the future of antibiotics, resulting in increased medical costs, hospital stays, and mortality. New resistance mechanisms are emerging and spreading globally, impeding the success of antibiotics in treating common infectious diseases. Recently, phytocannabinoids have been shown to possess antimicrobial activity on both Gram-negative and Gram-positive bacteria. The therapeutic use of phytocannabinoids presents a unique mechanism of action to overcome existing antibiotic resistance. Future research must be carried out on phytocannabinoids as potential therapeutic agents used as novel treatments against resistant strains of microbes.
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Affiliation(s)
- Cassidy Scott
- Department of Pharmacology, Dalhousie University, Halifax, NS B3H 4R2, Canada
| | - Daniel Neira Agonh
- Department of Anesthesia, Pain Management and Perioperative Medicine, Dalhousie University, Halifax, NS B3H 4R2, Canada
| | - Christian Lehmann
- Department of Pharmacology, Dalhousie University, Halifax, NS B3H 4R2, Canada
- Department of Anesthesia, Pain Management and Perioperative Medicine, Dalhousie University, Halifax, NS B3H 4R2, Canada
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9
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Stoner MJ, Dietrich A, Lam SH, Wall JJ, Sulton C, Rose E. Marijuana use in children: An update focusing on pediatric tetrahydrocannabinol and cannabidiol use. J Am Coll Emerg Physicians Open 2022; 3:e12770. [PMID: 35813522 PMCID: PMC9255894 DOI: 10.1002/emp2.12770] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Revised: 05/20/2022] [Accepted: 05/31/2022] [Indexed: 11/08/2022] Open
Affiliation(s)
- Michael J. Stoner
- Department of Pediatrics Division of Emergency Medicine Nationwide Children's Hospital The Ohio State University College of Medicine Columbus Ohio USA
| | - Ann Dietrich
- Department of Pediatrics and Emergency Medicine Prisma University of South Carolina College of Medicine Columbia South Carolina USA
| | | | - Jessica J. Wall
- Department of Pediatrics and Emergency Medicine University of Washington School of Medicine Seattle Washington USA
| | - Carmen Sulton
- Department of Pediatrics and Emergency Medicine Children's Healthcare of Atlanta at Eagleton Emory University School of Medicine Atlanta Georgia USA
| | - Emily Rose
- Department of Clinical Medicine Emergency Medicine (Educational Scholar) Department of Emergency Medicine Los Angeles County & USC Medical Center Keck School of Medicine of the University of Southern California Los Angeles California USA
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10
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Deitche AL, Burda AM. Management of Toxicological Emergencies in the School Setting: An Overview for School Nurses Part 2. NASN Sch Nurse 2022; 37:250-256. [PMID: 35633054 DOI: 10.1177/1942602x221100213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
School nurses may encounter a variety of poisoning and overdose scenarios in the school setting. Youth have an increased risk for harm due to factors associated with substance use, self-harm, and exposure to more toxic ingestants. Poison Control Centers are uniquely qualified to assist the public and health professionals, including school nurses, with poisoning and overdose incidents and are available 24 hours per day. This article is Part 2 of a series of three articles and focuses on poisonings related to substances of abuse and addiction or as a result of social media challenges. Information includes expected clinical effects, potential for serious injury, and a reasonable approach to manage these exposures for the following substances of potential harm: alcohol, caffeine, dextromethorphan, inhalants, marijuana, tobacco, and nicotine replacement therapy. Part 3 of the series will discuss potential environmental hazards specific to the school setting.
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Affiliation(s)
- Amy L Deitche
- Certified Specialist in Poison Information, Illinois Poison Center (Illinois Health and Hospital Association), Chicago, IL
| | - Anthony M Burda
- Clinical Toxicologist, Illinois Poison Center (Illinois Health and Hospital Association), Chicago, IL
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11
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Harvey T, Gomez R, Wolk B, Ozcan A. Varied Presentations of Pediatric Patients With Positive Cannabinoid Tests. Cureus 2022; 14:e23493. [PMID: 35345813 PMCID: PMC8956361 DOI: 10.7759/cureus.23493] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/25/2022] [Indexed: 11/22/2022] Open
Abstract
Background: Cannabis (marijuana) is one of the most abused drugs worldwide. The increasing availability of cannabis has been associated with increased emergency department (ED) visits. There is a wide range of presentations documented in the recent literature, and the full scope of symptoms in young children is not fully known. Objective: The primary objectives were to gather information regarding the characteristics in the presentation of the children with positive cannabinoid urine drug screen (UDS) results in the ED and to determine if there are certain common presentations with cannabinoid ingestion or inhalation. Design/methods: This study was a descriptive retrospective chart review from March 2013 to June 2020 of pediatric patients <18 years old with positive UDS for cannabinoids. Data collected included age, gender, chief complaint, history, review of systems, vital signs, physical exam findings, laboratory studies, imaging findings, and disposition. Four hundred and twenty-two charts were included in the study. Analysis was done using Stata 13 (College Station, TX). Results: The data showed that there was a significant increase in the number of pediatric patients with a positive UDS after cannabis legalization. Using cases from November 2013 to November 2019 showed 71% of cases presented after legalization on November 8, 2016 (Z=7.72, p<.01). The majority of cases were patients between the ages of 15 and 17 (78%). 43% (n=182) of patients presented with chief complaints of suicidal ideation. The other most common chief complaints were vomiting (8%, n=33), nausea (5%, n=22), trauma (5%, n=21), and altered mental status (AMS) (5%, n=20). The most common vital sign abnormalities included tachycardia (27%, n=115) and hypertension (18%, n=74). Forty-two percent of patients had tests ordered during their visit with 7% undergoing head computerized tomography. On the UDS, 28% of patients were positive for at least one other drug with amphetamine being the most common (13%, n=55). Conclusion: Our data showed a significant increase in the number of cases since the legalization of cannabis in 2016, supporting the need for ED physicians to become more familiar with cannabis intoxication and its complications. The presentations of these patients can vary greatly. Common presentations include suicidal ideation, nausea/vomiting, AMS, and trauma with vital sign abnormalities including tachycardia and hypertension. Physicians should continue to consider cannabis use when evaluating these pediatric complaints. It may decrease the number of tests ordered in this patient population.
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12
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Linhares RE, Zacharin M. Behavioural changes in an adolescent boy: Not always as it seems. J Paediatr Child Health 2022; 58:191-193. [PMID: 33733480 DOI: 10.1111/jpc.15446] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Revised: 01/06/2021] [Accepted: 03/01/2021] [Indexed: 11/28/2022]
Affiliation(s)
- Rafaela E Linhares
- Department of Pediatric Endocrinology, Children's Institute, University of Sao Paulo, São Paulo, Brazil
| | - Margaret Zacharin
- Department of Pediatric Endocrinology, Royal Children's Hospital and Murdoch Children's Research Institute, Melbourne, Victoria, Australia
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13
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Treves N, Mor N, Allegaert K, Bassalov H, Berkovitch M, Stolar OE, Matok I. Efficacy and safety of medical cannabinoids in children: a systematic review and meta-analysis. Sci Rep 2021; 11:23462. [PMID: 34873203 PMCID: PMC8648720 DOI: 10.1038/s41598-021-02770-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Accepted: 11/09/2021] [Indexed: 01/06/2023] Open
Abstract
Despite the increased use of medical cannabinoids, the efficacy and safety of the treatment among children remain uncertain. The objective was to study the efficacy and safety of medical cannabinoids in children. The search included studies through 11-May-2020. Selection criteria included studies evaluating efficacy and safety outcomes of medical cannabinoids (tetrahydrocannabinol, cannabidiol and other cannabis derivatives) versus control in children, independently assessed by two reviewers. Eight studies were included, all of which are randomized controlled trials. Cannabidiol is associated with 50% reduction in seizures rate (Relative Risk (RR) = 1.69, 95% CI [1.20-2.36]) and caregiver global impression of change (Median Estimated difference = (- 1), 95%CI [- 1.39-(- 0.60)]) in Dravet syndrome, compared to placebo. While cannabidiol was associated with a reduction in reported seizure events (RR = 0.59, 95% CI [0.36-0.97]), no association was found in products contained also tetrahydrocannabinol (RR = 1.35, 95% CI [0.46-4.03]). Higher dose of cannabidiol was associated with decreased appetite (RR = 2.40, 95% CI [1.39-4.15]). A qualitative assessment suggests that medical cannabinoids might be associated with adverse mental events. In conclusion, cannabidiol is associated with clinical improvement in Dravet syndrome. However, cannabidiol is also associated with decreased appetite. Adverse mental events were reported as well, however, more research should be performed to assess well this outcome.
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Affiliation(s)
- Nir Treves
- Division of Clinical Pharmacy, School of Pharmacy, Faculty of Medicine, The Hebrew University of Jerusalem, Jerusalem, Israel
| | - Noa Mor
- Division of Clinical Pharmacy, School of Pharmacy, Faculty of Medicine, The Hebrew University of Jerusalem, Jerusalem, Israel
| | - Karel Allegaert
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
- Department of Hospital Pharmacy, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | | | - Matitiahu Berkovitch
- Clinical Pharmacology Unit, Shamir Medical Center (Assaf Harofeh), Zerifin, Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Orit E Stolar
- The Autism Center, Alut, Shamir Medical Center (Assaf Harofeh), Zerifin, Israel
| | - Ilan Matok
- Department of Clinical Pharmacy, Institute for Drug Research, School of Pharmacy and the David R. Bloom Center of Pharmacy, Faculty of Medicine, The Hebrew University of Jerusalem, Jerusalem, Israel.
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14
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Morean ME, Davis DR, Kong G, Bold KW, Camenga DR, Suttiratana S, Lee J, Rajeshkumar L, Krishnan-Sarin S. Demographic and substance use-related differences among high school adolescents who vape cannabis versus use other cannabis modalities. Drug Alcohol Depend 2021; 228:109104. [PMID: 34607191 PMCID: PMC8595758 DOI: 10.1016/j.drugalcdep.2021.109104] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Revised: 09/07/2021] [Accepted: 09/22/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Vaping is the second most common modality of using cannabis following smoking. We examined differences in demographics and substance use behaviors between adolescent cannabis vapers and those exclusively using other cannabis modalities. METHODS In 2019, 4875 students from six Connecticut high schools completed school-wide, online surveys. Past-month cannabis users (n = 931; 52.8% female, 16.38(1.27) years old, 44.9% non-Hispanic White) reported on cannabis modalities used (e.g., combustible, vaporizable, edible) and were classified as cannabis vapers or non-vapers. Cannabis vapers reported on device type used to vape cannabis: a cannabis-specific device or modified/hacked e-cigarette. Unadjusted and adjusted relationships were examined to identify demographic and substance-related differences between cannabis vapers and non-vapers. RESULTS 56.3% of past-month cannabis users reported vaping cannabis. Cannabis vapers reported using both cannabis-specific vaporizers (91.9%) and modifying/hacking e-cigarettes (23.7%). Cannabis vapers, relative to other cannabis users, were more likely to be male, White, initiate cannabis use at a younger age; endorse past-month use of all cannabis modalities, alcohol, and e-cigarettes; and report smoking and dabbing cannabis more frequently; consuming more drinks per drinking day; and using e-cigarettes at a younger age and more frequently. CONCLUSIONS Relative to other cannabis modalities, vaping was associated with increased use of several cannabis products and other substances. Adolescent past-month cannabis users reported modifying e-cigarettes to vape cannabis. Findings suggest that regulations should be implemented to prevent e-cigarettes from being modifiable for use with cannabis and highlight the importance of assessing different cannabis use modalities, as vaping was associated with distinct substance-related risks.
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Affiliation(s)
- Meghan E. Morean
- Yale School of Medicine, Dept. of Psychiatry, 34 Park Street, New Haven, CT, 06519, USA,Corresponding author:
| | - Danielle R. Davis
- Yale School of Medicine, Dept. of Psychiatry, 34 Park Street, New Haven, CT, 06519, USA
| | - Grace Kong
- Yale School of Medicine, Dept. of Psychiatry, 34 Park Street, New Haven, CT 06519, USA.
| | - Krysten W. Bold
- Yale School of Medicine, Dept. of Psychiatry, 34 Park Street, New Haven, CT, 06519, USA
| | - Deepa R. Camenga
- Yale School of Medicine, Dept. of Emergency Medicine, 464 Congress Avenue (Suite 260), New Haven, CT, 06519, USA
| | - Sakinah Suttiratana
- Yale School of Public Health, Dept. of Chronic Disease Epidemiology, 60 College Street, New Haven, CT 06520, USA.
| | - Juhan Lee
- Yale School of Medicine, Dept. of Psychiatry, 34 Park Street, New Haven, CT 06519, USA.
| | - Lavanya Rajeshkumar
- Yale School of Medicine, Dept. of Psychiatry, 34 Park Street, New Haven, CT 06519, USA.
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15
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Kaczor EE, Mathews B, LaBarge K, Chapman BP, Carreiro S. Cannabis Product Ingestions in Pediatric Patients: Ranges of Exposure, Effects, and Outcomes. J Med Toxicol 2021; 17:386-396. [PMID: 34117620 PMCID: PMC8455762 DOI: 10.1007/s13181-021-00849-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Revised: 05/17/2021] [Accepted: 05/17/2021] [Indexed: 10/21/2022] Open
Abstract
INTRODUCTION Pediatric exposures to cannabis edibles have been associated with serious adverse effects, such as respiratory depression. Yet, their incidence and relationship to exposure characteristics are not well defined. We attempt to describe the temporal, demographic, and clinical characteristics of pediatric patients with edible cannabis exposures and examine the relationship between these characteristics and two clinical outcomes: need for respiratory support and hospital admission. METHODS A retrospective chart review was conducted at a single, tertiary care academic medical center covering a 28-month period. Inclusion criteria were: evaluation in the ED, age <18 years at the time of presentation, and physician documented exposure to edible cannabis. Exclusion criteria were: known or suspected co-ingestion of other substances. RESULTS Thirty-two cases of edible cannabis ingestions were identified. Age <10 years was associated with bradypnea, hypertension, hospital admission, and respiratory support. Use of respiratory support was significantly associated with the presence of lethargy, bradypnea, hypercarbia, seizure, and hypertension. There was a five-fold increase in the number of pediatric edible cannabis exposures after recreational cannabis dispensaries opened in Massachusetts. Five patients (16%) required respiratory support and eleven (34%) required hospital admission. CONCLUSIONS There was a low incidence of need for respiratory support in our population, but hospital admission was more common. Severe symptoms (including lethargy and respiratory depression), need for respiratory support and hospital admission were more frequent in younger children. Exposures occurred with increasing frequency over time. Larger studies are needed to explore the relationship between THC dosage, age, and incidence of adverse outcomes.
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Affiliation(s)
- Eric E Kaczor
- Division of Medical Toxicology, Department of Emergency Medicine, University of Massachusetts Medical School, 55 Lake Avenue North, Worcester, MA, 01655, USA.
| | - Bonnie Mathews
- Division of Emergency Medicine, Department of Pediatrics, University of Massachusetts Medical School, Worcester, MA, USA
| | - Kara LaBarge
- Division of Medical Toxicology, Department of Emergency Medicine, University of Massachusetts Medical School, 55 Lake Avenue North, Worcester, MA, 01655, USA
| | - Brittany P Chapman
- Division of Medical Toxicology, Department of Emergency Medicine, University of Massachusetts Medical School, 55 Lake Avenue North, Worcester, MA, 01655, USA
| | - Stephanie Carreiro
- Division of Medical Toxicology, Department of Emergency Medicine, University of Massachusetts Medical School, 55 Lake Avenue North, Worcester, MA, 01655, USA
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16
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Reece AS, Hulse GK. Cannabinoid exposure as a major driver of pediatric acute lymphoid Leukaemia rates across the USA: combined geospatial, multiple imputation and causal inference study. BMC Cancer 2021; 21:984. [PMID: 34479489 PMCID: PMC8414697 DOI: 10.1186/s12885-021-08598-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Accepted: 07/07/2021] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Acute lymphoid leukaemia (ALL) is the commonest childhood cancer whose incidence is rising in many nations. In the USA, between 1975 and 2016, ALL rates (ALLRs) rose 93.51% from 1.91 to 3.70/100,000 < 20 years. ALL is more common in Caucasian-Americans than amongst minorities. The cause of both the rise and the ethnic differential is unclear, however, prenatal cannabis exposure was previously linked with elevated childhood leukaemia rates. We investigated epidemiologically if cannabis use impacted nationally on ALLRs, its ethnic effects, and if the relationship was causal. METHODS State data on overall, and ethnic ALLR from the Surveillance Epidemiology and End Results databank of the Centre for Disease Control (CDC) and National Cancer Institute (NCI) were combined with drug (cigarettes, alcoholism, cannabis, analgesics, cocaine) use data from the National Survey of Drug Use and Health; 74.1% response rate. Income and ethnicity data was from the US Census bureau. Cannabinoid concentration was from the Drug Enforcement Agency Data. Data was analyzed in R by robust and spatiotemporal regression. RESULTS In bivariate analyses a dose-response relationship was demonstrated between ALLR and Alcohol Use Disorder (AUD), cocaine and cannabis exposure, with the effect of cannabis being strongest (β-estimate = 3.33(95%C.I. 1.97, 4.68), P = 1.92 × 10- 6). A strong effect of cannabis use quintile on ALLR was noted (Chi.Sq. = 613.79, P = 3.04 × 10- 70). In inverse probability weighted robust regression adjusted for other substances, income and ethnicity, cannabis was independently significant (β-estimate = 4.75(0.48, 9.02), P = 0.0389). In a spatiotemporal model adjusted for all drugs, income, and ethnicity, cannabigerol exposure was significant (β-estimate = 0.26(0.01, 0.52), P = 0.0444), an effect increased by spatial lagging (THC: β-estimate = 0.47(0.12, 0.82), P = 0.0083). After missing data imputation ethnic cannabis exposure was significant (β-estimate = 0.64(0.55, 0.72), P = 3.1 × 10- 40). 33/35 minimum e-Values ranged from 1.25 to 3.94 × 1036 indicative of a causal relationship. Relaxation of cannabis legal paradigms had higher ALLR (Chi.Squ.Trend = 775.12, P = 2.14 × 10- 112). Cannabis legal states had higher ALLR (2.395 ± 0.039 v. 2.127 ± 0.008 / 100,000, P = 5.05 × 10- 10). CONCLUSIONS Data show that ALLR is associated with cannabis consumption across space-time, is associated with the cannabinoids, THC, cannabigerol, cannabinol, cannabichromene, and cannabidiol, contributes to ethnic differentials, demonstrates prominent quintile effects, satisfies criteria for causality and is exacerbated by cannabis legalization.
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Affiliation(s)
- Albert Stuart Reece
- Division of Psychiatry, University of Western Australia, Crawley, Western Australia, 6009, Australia. .,School of Medical and Health Sciences, Edith Cowan University, Joondalup, Western Australia, 6027, Australia.
| | - Gary Kenneth Hulse
- Division of Psychiatry, University of Western Australia, Crawley, Western Australia, 6009, Australia.,School of Medical and Health Sciences, Edith Cowan University, Joondalup, Western Australia, 6027, Australia
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17
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Brown JD, Rivera Rivera KJ, Hernandez LYC, Doenges MR, Auchey I, Pham T, Goodin AJ. Natural and Synthetic Cannabinoids: Pharmacology, Uses, Adverse Drug Events, and Drug Interactions. J Clin Pharmacol 2021; 61 Suppl 2:S37-S52. [PMID: 34396558 DOI: 10.1002/jcph.1871] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Accepted: 04/01/2021] [Indexed: 01/15/2023]
Abstract
The purpose of this narrative review is to describe the current use environment of both natural and synthetic cannabinoids while providing context for cannabinoid chemistry and pharmacology. In addition to a long history of recreational and nonmedical use, natural cannabinoids are increasingly used as prescription products, through medical cannabis programs, and as consumer health products. Despite anecdotal safety evidence, cannabis and cannabinoids are pharmacologically complex and pose risks for adverse drug events and drug-drug interactions. Synthetic cannabinoids, particularly agonists of cannabinoid receptors, are more potent than natural cannabinoids and can lead to more severe reactions and medical emergencies. This review provides a summary of approved uses and an overview of mechanisms of action for adverse drug events with natural and synthetic cannabinoids. Clinical considerations for special populations that may be at heightened risk for drug-drug interactions and adverse drug events while using natural or synthetic cannabinoids are examined, and recommendations are provided.
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Affiliation(s)
- Joshua D Brown
- Center for Drug Evaluation & Safety, University of Florida, Gainesville, Florida, USA.,Consortium for Medical Marijuana Clinical Outcomes Research, University of Florida, Gainesville, Florida, USA.,Department of Pharmaceutical Outcomes & Policy, University of Florida College of Pharmacy, Gainesville, Florida, USA
| | | | | | - Matthew R Doenges
- University of Florida College of Pharmacy, Gainesville, Florida, USA
| | - India Auchey
- University of Florida College of Pharmacy, Gainesville, Florida, USA
| | - Thanh Pham
- University of Florida College of Pharmacy, Gainesville, Florida, USA
| | - Amie J Goodin
- Center for Drug Evaluation & Safety, University of Florida, Gainesville, Florida, USA.,Consortium for Medical Marijuana Clinical Outcomes Research, University of Florida, Gainesville, Florida, USA.,Department of Pharmaceutical Outcomes & Policy, University of Florida College of Pharmacy, Gainesville, Florida, USA
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18
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Reece AS, Hulse GK. Causal inference multiple imputation investigation of the impact of cannabinoids and other substances on ethnic differentials in US testicular cancer incidence. BMC Pharmacol Toxicol 2021; 22:40. [PMID: 34246312 PMCID: PMC8272900 DOI: 10.1186/s40360-021-00505-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2020] [Accepted: 05/14/2021] [Indexed: 11/29/2022] Open
Abstract
Background Ethnic differences in testicular cancer rates (TCRs) are recognized internationally. Cannabis is a known risk factor for testicular cancer (TC) in multiple studies with dose-response effects demonstrated, however the interaction between ancestral and environmental mutagenic effects has not been characterized. We examined the effects of this presumed gene-environment interaction across US states. Methods State based TCR was downloaded from the Surveillance Epidemiology and End Results (SEER) website via SEERStat. Drug use data for cigarettes, alcohol use disorder, analgesics, cannabis and cocaine was taken from the National Survey of Drug Use and Health a nationally representative study conducted annually by the Substance Abuse and Mental Health Services Administration (SAMHSA) with a 74.1% response rate. Cannabinoid concentrations derived from Drug Enforcement Agency publications. Median household income and ethnicity data (Caucasian-American, African-American, Hispanic-American, Asian-American, American-Indian-Alaska-Native-American, Native-Hawaiian-Pacific-Islander-American) was from the US Census Bureau. Data were processed in R using instrumental regression, causal inference and multiple imputation. Results 1975–2017 TCR rose 41% in African-Americans and 78.1% in Caucasian-Americans; 2003–2017 TCR rose 36.1% in Hispanic-Americans and 102.9% in Asian-Pacific-Islander-Americans. Ethnicity-based scatterplot-time and boxplots for cannabis use and TCR closely mirrored each other. At inverse probability-weighted interactive robust regression including drugs, income and ethnicity, ethnic THC exposure was the most significant factor and was independently significant (β-estimate = 4.72 (2.04, 7.41), P = 0.0018). In a similar model THC, and cannabigerol were also significant (both β-estimate = 13.87 (6.33, 21.41), P = 0.0017). In additive instrumental models the interaction of ethnic THC exposure with Asian-American, Hispanic-American, and Native-Hawaiian-Pacific-Islander-American ethnicities was significant (β-estimate = − 0.63 (− 0.74, − 0.52), P = 3.6 × 10− 29, β-estimate = − 0.25 (− 0.32, − 0.18), P = 4.2 × 10− 13, β-estimate = − 0.19 (− 0.25, − 0.13), P = 3.4 × 10− 9). After multiple imputation, ethnic THC exposure became more significant (β-estimate = 0.68 (0.62, 0.74), P = 1.80 × 10− 92). 25/33 e-Values > 1.25 ranging up to 1.07 × 105. Liberalization of cannabis laws was linked with higher TCR’s in Caucasian-Americans (β-estimate = 0.09 (0.06, 0.12), P = 6.5 × 10− 10) and African-Americans (β-estimate = 0.22 (0.12, 0.32), P = 4.4 × 10− 5) and when dichotomized to illegal v. others (t = 6.195, P = 1.18 × 10− 9 and t = 4.50, P = 3.33 × 10− 5). Conclusion Cannabis is shown to be a TC risk factor for all ethnicities including Caucasian-American and African-American ancestries, albeit at different rates. For both ancestries cannabis legalization elevated TCR. Dose-response and causal relationships are demonstrated.
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Affiliation(s)
- Albert Stuart Reece
- Division of Psychiatry, University of Western Australia, Crawley, Western Australia, 6009, Australia. .,School of Medical and Health Sciences, Edith Cowan University, Joondalup, Western Australia, 6027, Australia.
| | - Gary Kenneth Hulse
- Division of Psychiatry, University of Western Australia, Crawley, Western Australia, 6009, Australia.,School of Medical and Health Sciences, Edith Cowan University, Joondalup, Western Australia, 6027, Australia
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Abstract
In recent years, there has been an emergence of numerous novel drugs. Such toxicity may occur in both adolescents and adults. This article discusses the opioid epidemic and several emerging opioids, including buprenorphine, loperamide, fentanyl, fentanyl derivatives, and others. Kratom, a plant occasionally used for opiate detoxification, along with the sedatives etizolam and phenibut, will be discussed. Lastly, this article discusses the phenethylamines and marijuana.
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Affiliation(s)
- Michael Levine
- Department of Emergency Medicine, University of California, Los Angeles, 924 Westwood Boulevard Suite 300, Los Angeles, CA 90095, USA.
| | - Frank Lovecchio
- Department of Emergency Medicine, Arizona State University, College of Health Solutions, Valleywise Health, 2601 East Roosevelt, Phoenix, AZ 85006, USA
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