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Toxicology Rounds: Epidemic of Toddlers on THC Just Beginning

Gussow, Leon MD

doi: 10.1097/01.EEM.0000433398.01044.f9
Toxicology Rounds

Dr. Gussow is a voluntary attending physician at the John H. Stroger Hospital of Cook County in Chicago (formerly Cook County Hospital), an assistant professor of emergency medicine at Rush Medical College, and a consultant to the Illinois Poison Center. He is also the editor of his own blog, The Poison Review.

It's easy to see why emergency departments are treating an increasing number of toddlers stoned after inadvertent cannabinoid ingestion if you browse through the online catalogs of medical marijuana providers.

Dixie Elixirs in Denver, whose CEO was called the “Willy Wonka of Weed” by Fast Company magazine, features edible marijuana products such as medicated chocolate truffles, crispy rice treats, and chewy Dixie rolls (“just what the doctor ordered!”). A variety of beverages are spiked with cannabinoids, including lemonade, sweet tea, sparkling peach elixir, and sarsaparilla (“a comforting old-timey soda”).

The Green Door in San Francisco sells THC-laced brownies, lollipops, “Gummi Cares,” peanut butter cups, caramel popcorn, s'mores, pies, and streusels. Their catalog also lists salves, sprays, lozenges, balms, tonics, and something called Ganja Glycerin (“3-5 full droppers per dose, 7-12 doses per bottle” sublingual).

Elsewhere online one can find all sorts of other THC-supplemented products hawked by so-called “ganjapreneurs,” including butter, extra virgin olive oil, ice cream, peanut-butter-and-jelly sandwiches, and even lasagna.

No doubt about it, the market for edible forms of cannabis is a growth industry. As of this writing, 18 states plus the District of Columbia have legalized medical marijuana. (See table.) Several additional states are considering similar measures. Washington and Colorado have also passed laws permitting some degree of recreational use. Tripp Keber, the managing partner of Dixie Elixirs, estimates that medical marijuana — a $2 billion business in 2012 — will grow to $9 billion by 2016.

Many states that have legalized medical or recreational cannabis do not have requirements that products be provided in childproof containers or that customers be counseled on keeping edibles away from children. The risk that young children may unknowingly ingest significant amounts of THC is obvious because so many of these are cookies, candies, and such. Several articles have been posted online recently highlighting this risk.

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Pediatric Marijuana Exposure in a Medical Marijuana State

Wang GS, Roosevelt G, Heard K

JAMA Pediatr

2013 May 27 [Epub ahead of print]

The US Justice Department decided in October 2009 that it would no longer arrest and prosecute users and suppliers of medical marijuana if they were in compliance with state law. This decision resulted in an exponential increase in the number of medical marijuana cards issued in Colorado. This study from the Rocky Mountain Poison Center looked retrospectively at visits to a tertiary-care pediatric emergency department for unintentional marijuana ingestion in patients age 12 and under.

They found that there were no visits from January 2005 through September 2009, but 14 patients from October 2009 through the end of 2011. They concluded that the increased number of these cases was an unintended consequence of the change in DOJ policy.

I'm sure this conclusion is at least partly correct, although it is possible that at least some of the cases surfaced because of heightened clinician sensitivity for suspecting cannabinoid intoxication along with lowered threshold for ordering a urine drug screen. The most interesting part of this paper, however, resides in the descriptions of the individual cases.

The patients' ages ranged from 8 months to 12 years. The source of exposure in the 14 cases included medical marijuana prescribed for the parents (four children) and grandparents (four children). The specific product involved a marijuana cookie, candy, or cake in at least half the cases. Eight children required hospitalization, with two admitted to the pediatric intensive care unit. One 5-year-old boy who ingested his grandfather's marijuana developed respiratory insufficiency. The most common signs and symptoms documented were lethargy or somnolence (eight patients).

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Anticipated Medical Effects on Children from Legalization of Marijuana in Colorado and Washington State: A Poison Center Perspective

Hurley W, Mazor S

JAMA Pediatr

2013 May 27 [Epub ahead of print]

This commentary, which accompanied the paper by Wang et al, noted that the potency of marijuana in the United States has almost quadrupled since the 1960s and 1970s, a development that increases the chance for significant adverse reaction following ingestion. The authors pointed out that the signs and symptoms of cannabinoid toxicity are varied and non-specific. (See table.) Occult pediatric marijuana intoxication is still not a common presentation, so the authors suggest that practitioners “may need additional training to recognize and manage significant marijuana toxic reactions.”

There are important take-home lessons for the emergency medicine practitioner in all this. Cannabinoid ingestion should be included in the differential diagnosis for pediatric patients who present with the vague signs and symptoms listed in the table, especially in states where medical marijuana is legal. Parents and caregivers should be specifically asked whether the child had access to any medical marijuana products.

One potential pitfall to keep in mind: a urine drug screen positive for THC suggests exposure, but does not by itself establish toxicity or prove that the child's presenting signs and symptoms are caused by cannabinoids. Other more serious conditions — such as CNS infections or metabolic disorders — should be considered and ruled out as necessary.

It is possible that almost half of the 50 states will have legalized medical marijuana by the end of 2013. Pantries and refrigerators from Hawaii to Rhode Island will be stocked with delicious-looking marijuana-laced baked goods, candies, and soft drinks. The epidemic of toddlers on THC is just beginning.

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© 2013 by Lippincott Williams & Wilkins