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Cannabis in Colorado Emergency Departments: a Cautionary Review of Negative Health and Safety Effects

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Cannabis in Colorado Emergency Departments: a Cautionary Review of Negative Health and Safety Effects REVIEW ARTICLE Legalized Cannabis in Colorado Emergency Departments: A Cautionary Review of Negative Health and Safety Effects Brad A. Roberts, MD University of New Mexico, Department of Emergency Medicine, Albuquerque, New Mexico Partner, Southern Colorado Emergency Medicine Associates, Pueblo, Colorado Section Editor: Brandon Wills, DO, MS Submission history: Submitted July 20, 2018; Revision received April 2, 2019; Accepted April 8, 2019 Electronically published Mark I. Langdorf, MD, MHPE Full text available through open access at http://escholarship.org/uc/uciem_westjem DOI: 10.5811/westjem.2019.4.39935 Cannabis legalization has led to significant health consequences, particularly to patients in emergency departments and hospitals in Colorado. The most concerning include psychosis, suicide, and other substance abuse. Deleterious effects on the brain include decrements in complex decision-making, which may not be reversible with abstinence. Increases in fatal motor vehicle collisions, adverse effects on cardiovascular and pulmonary systems, inadvertent pediatric exposures, cannabis contaminants exposing users to infectious agents, heavy metals, and pesticides, and hash-oil burn injuries in preparation of drug concentrates have been documented. Cannabis dispensary workers (“budtenders”) without medical training are giving medical advice that may be harmful to patients. Cannabis research may offer novel treatment of seizures, spasticity from multiple sclerosis, nausea and vomiting from chemotherapy, chronic pain, improvements in cardiovascular outcomes, and sleep disorders. Progress has been slow due to absent standards for chemical composition of cannabis products and limitations on research imposed by federal classification of cannabis as illegal. Given these factors and the Colorado experience, other states should carefully evaluate whether and how to decriminalize or legalize non-medical cannabis use. [West J Emerg Med. 2019;20(4)X–X.] INTRODUCTION limited to five patients are allowed. As of January 2018 in the United States, nine states • 2010-2012: Medical marijuana is commercialized and have legalized cannabis for recreational use, with another 29 regulated with licensed dispensaries, grow operations, legalizing it for medical use. These policy changes have created and product manufacturers open in jurisdictions allowing broad interest in understanding the effects on public health and these types of businesses. This corresponded with the the healthcare system. Ogden memorandum issued in October 2009, which The Colorado Department of Public Safety report, “Impacts instructed U.S. Attorneys not to “focus federal resources of Marijuana Legalization in Colorado: A Report Pursuant in your States on individuals whose actions are in clear to Senate Bill 13-283,” includes a timeline for marijuana and unambiguous compliance with existing state laws legalization in Colorado with five distinct periods in both providing for the medical use of marijuana.”2 The the legal status and commercial availability of marijuana in commercialization of medical marijuana followed and Colorado.1 These include the following: the number of patients registered with CDPHE increased • Prior to 2000: It is illegal to possess or grow marijuana. dramatically from about 5000 in 2009 to almost 119,000 • 2000-2009: Amendment 20 is approved and medical in 2011. marijuana is legalized. The Colorado Department of • 2013: Amendment 64 takes effect. Personal possession and Public Health and Environment (CDPHE) issues registry grow limits for recreational marijuana are in place but sales identification cards to individuals who have received are not commercialized. Medical continues as a regulated, recommendations from a doctor that marijuana will help a commercial market. debilitating medical condition. No regulated market exists. • 2014 to present: Recreational and medical marijuana Individual grow operations or caregiver grow operations is fully regulated and commercialized. Licensed retail 1 Western Journal of Emergency Medicine Legalized Cannabis in Colorado EDs: Negative Health and Safety Effects Roberts stores open January 1, 2014. This corresponded with the Cole memorandum, which gave further guidance Population Health Research Capsule to U.S. Attorneys: “[I]n jurisdictions that have enacted laws legalizing marijuana in some form and that have What do we already know about this issue? also implemented strong and effective regulatory Legalized cannabis has led to increased and enforcement systems to control the cultivation, cannabis related presentations to emergency distribution, sale, and possession of marijuana, conduct in departments (ED). compliance with those laws and regulations is less likely to threaten federal priorities… [E]nforcement of state law What was the research question? by state and local law enforcement and regulatory bodies What have been the negative impacts to should remain the primary means of addressing marijuana- emergency departments, particularly in related activity.”3 This memorandum was widely the state of Colorado, following cannabis interpreted to mean that the federal government would not legalization? interfere with state marijuana laws;4 however, in January 2018 the Cole memorandum was rescinded by then U.S. What was the major finding of the study? Attorney General Jeff Sessions.4 Cannabis legalization has been correlated with multiple adverse outcomes that impact EDs. Changes in past-month cannabis use by year and age group for Colorado and Kansas (non-legalized state) are shown in How does this improve population health? Figures 1 and 2. (Kansas was chosen for proximity; other non- Healthcare policy makers may take the adverse legalized states in proximity, including Wyoming and Idaho, had outcomes described into consideration when similar graphs to Kansas.)5 considering if and/or how to legalize cannabis. Over this time span cannabis potency has increased. Current commercialized cannabis is near 20% tetrahydrocannabinol (THC), the primary psychoactive constituent of cannabis, while in the 1980s concentration was <2%. This 10-fold increase in potency does not include other formulations such as oils, waxes, and dabs, which can reach 80-90% THC.6 reviewed literature. It will conclude with a short review of the This general increase in cannabis use and increase in medicinal use of cannabis products. cannabis potency has led to cannabis-related presentations to emergency departments (ED) and hospitalizations across the Cannabis Effects on Healthcare Resources in Colorado state. This review will focus on negative health and safety ED visits and hospitalizations with marijuana-related effects Colorado has experienced with inclusion of relevant peer- billing codes have increased following legalization. Mental 35% 30% 25% 20% Age Group 15% 12 to 17 Prevalence 18 to 25 10% 26 or older 5% 0% 2002-03 2003-04 2004-05 2005-06 2006-07 2007-08 2008-09 2009-10 2010-11 2011-12 2012-13 2013-14 2014-15 2015-16 2016-17 Year Figure 1. Marijuana use in the past month in Colorado, by age group. Reproduced from Substance Abuse and Mental Health Services Administration National Survey on Drug Use and Health: State Estimates. Available at: https://pdas.samhsa.gov/saes/state. Accessed November 2018. Western Journal of Emergency Medicine 2 Roberts Legalized Cannabis in Colorado EDs: Negative Health and Safety Effects 35% 30% 25% 20% Age Group 15% 12 to 17 Prevalence 18 to 25 10% 26 or older 5% 0% 2002-03 2003-04 2004-05 2005-06 2006-07 2007-08 2008-09 2009-10 2010-11 2011-12 2012-13 2013-14 2014-15 2015-16 2016-17 Year Figure 2. Marijuana use in the past month in Kansas, by age group. Reproduced from Substance Abuse and Mental Health Services Administration National Survey on Drug Use and Health: State Estimates. Available at: https://pdas.samhsa.gov/saes/state. Accessed November 2018. illness represents a concerningly large number of marijuana- drug screens of all types increased 2.7-fold from 1.8 per 1000 in related visits. A retrospective review by Wang et al. reported 2009 to 4.9 per 1000 in 2015 (N = 161 in 2005 to 777 in 2015). Colorado Hospital Association hospitalizations and ED visits Behavioral health consultations increased 2.7-fold from 1.2 per with marijuana-related billing codes. Between 2000 and 2015, 1000 in 2009 to 3.2 per 1000 in 2015 ( N = 84 in 2005 to 500 hospitalization rates increased 116% from 274 to 593 per 100,000 in 2015). These data indicate that despite national survey data hospitalizations. For primary diagnosis categories, the prevalence suggesting the rate of adolescent marijuana use is flat, there of mental illness was five-fold higher (5.07; 95% confidence has been a significant increase in adolescent ED/UC visits with interval [CI], 4.96 - 5.09) for ED visits and nine-fold higher cannabis-associated ICD codes or positive urine drug screens.9 (9.67; 95% CI, 9.59 - 9.74) for hospital admissions for patients Figure 4 displays these visits by year. with marijuana-related billing codes compared to those without.7 This data compared diagnostic categories between patients with a Cannabis Effects on Mental Health marijuana-related diagnostic code and those without. Psychosis and Schizophrenia Subsequent data by the CDPHE show significant increases Previous studies, including large reviews by the World in hospitalizations in each phase of marijuana legalization, Health Organization (WHO) and the National Academies of increasing from 575 per 100,000 hospitalizations in 2000 to 2413 Sciences, Engineering, and Medicine
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