Anticipated Medical Effects on Children From Legalization of Marijuana in Colorado and Washington State

Abstract

On November 4, 2012, Amendment 64 passed in Colorado and Initiative 502 passed in Washington State to legalize the possession of small amounts ofmarijuana andmarijuana-related productsbyadults.Possessionbyanyoneyounger than21years and the growing of marijuana without authorization remain illegal in both states. InColorado, adults are permitted topossess up to 1 oz of marijuana or 6 marijuana plants. In Washington, adults are permitted to possess up to 1 oz of marijuana, 16 oz ofmarijuana-infused product in solid form, 72 oz ofmarijuana-infusedproduct in liquid form, or any combination of all 3. The possession of marijuana remains illegal under federal law andmarijuana remains a Schedule I agent under the Drug Enforcement Administration. Themedicaluseofmarijuanaandmarijuana-infusedproducts is legal in 18 states and theDistrict ofColumbia. Sevenadditional states are considering legalization of medical marijuana.Themedicaluseofmarijuanahasbeen legal inColorado since 2009. In this issue, Wang et al1 describe an increase in cases of accidental ingestion of marijuana by children after decriminalization of medical marijuana in Colorado. Marijuana ingested by themajority of the children described in the article was in the form of a food product. The medical marijuana industry provides attractive and palatable marijuana-infused solidand liquidproducts, including cookies, candies, brownies, andbeverages. The legalizationof recreationalmarijuana, especially the solid and liquid-infused formspermitted inWashington, will provide children greater access to cookies, candies, brownies, and beverages that contain marijuana. Ingestion of marijuana results in the absorption of delta-9-tetrahydrocannibinol (THC) and stimulation of cannabinoid receptors in the central nervous system. This produces stimulation with hallucinations and illusions, followed by sedation.2 Toxic reactions are usually mild after acute accidental ingestion but can cause significant sedation in children.3 Respiratory insufficiency and the need for ventilatory support are described in the article. In older children, the stimulatory phase and hallucinations can produce anxiety and panic episodes when not anticipated in an accidental ingestion. The potency of marijuana in the United States has progressively increased over the past 40 years, with THC levels climbing from around 2% to nearly 8%.4 The risk of significant toxic reactions from exposures is more likely today than in the past. Emergencymedicine, pediatric emergencymedicine, and primary carepediatric providerswill be first to seepatients accidentally exposed to marijuana. They may need additional training to recognize andmanage significant marijuana toxic reactions. Signs and symptoms can include anxiety, hallucinations, panic episodes, dyspnea, chest pain, nausea, vomiting, dizziness, somnolence, central nervous system depression, respiratory depression, and coma.5 Similar signs and symptomsoccur in a large variety of diseases andpoisonings. The providers and staff should investigate the availability of marijuana in the child’s environment and use rapid tests to identify the metabolites of marijuana in the urine.6 No antidote exists for marijuana toxic reactions and supportive care should be provided, including control of anxiety, control of vomiting, airway control, and ventilation as needed. The regional Poison Center should be contacted to report the episode andobtain additional advice on evaluation andmanagement. Increased accidental exposure after increased availability of an agent is a consistent lesson in toxicology. Our current increase in laundry-pod ingestion in children is the resultof increasedavailabilitycoupledwithattractivepackaging.7 The ready availability of pain medications led to opioids surpassingmotor vehicle crashes as the leading causeof accidental death in the United States. This profound poisoning problem went unrecognized for nearly a decade and has only recently come to the attention of health care providers and policymakers.8 A recent analysis of PoisonCenter data shows a parallel increase in severe poisonings, emergency department visits, andhospitalizations in children.9 A similar rise in marijuanaexposureand toxic reactions is anticipated fromthe increased availability of marijuana in the child’s environment. Timely analysis of Poison Center data and emergency department recordswill provideanopportunity toquickly recognize and respond. Intervention strategies inWashingtonStatehavebegun to reduce thedeath rate fromopioid exposure. Theseweremodeled on successful interventions in poison prevention and includepublic educationon the risksofopioiduse,providereducation on safe prescribing practices, prescription monitoring programs, and home naloxone hydrochloride programs.10,11 Editorial page 600