Legalized Marijuana Can Create Tough Tasks For EPs

What's it like to be an emergency physician in a state where marijuana is legal? Some places see patients using more frequently, giving rise to cannabinoid hyperemesis syndrome and DUIs. Some see tourists swoop into the state and overdo it, not knowing how to regulate their use. Others find children mistaking edibles for brownies and the like, resulting in ED visits.

Thirty-three states have legalized medical marijuana, 10 have approved medical and recreational cannabis, and 13 states and some cities have decriminalized marijuana, reducing or eliminating legal penalties for possessing small amounts.

Its use, however, is still against federal law, which considers it a Schedule I drug with high potential for abuse and no accepted use. The U.S. Food and Drug Administration recently approved cannabidiol (CBD) to treat rare diseases that cause seizures because it does not contain THC and will not cause a high. The Rohrabacher-Farr amendment prohibits the U.S. Justice Department from spending funds to interfere with the implementation of state laws that legalize marijuana use, leaving emergency physicians with a morphing and uncertain landscape.

It's not enough to ask emergency department patients if they use marijuana, said Matthew Zuckerman, MD, an assistant professor of emergency medicine-medical toxicology, and pharmacology at the University of Colorado at Denver. “Often, if they are regular marijuana users, they won't consider that a drug,” he said. Colorado approved medical marijuana in 2000. Recreational marijuana for those over 21 in 2012. In a way, Dr. Zuckerman said, legalizing recreational use took some onus off EPs. For one thing, patients are more willing to say that they have smoked it. “I had a 14-year-old ask me for a medical marijuana card for anxiety,” he said. (He didn't provide it.) He feels obligated, however, to tell pregnant women that the effects of marijuana on unborn fetuses are unknown.

Dr. Zuckerman said respected researchers are looking into its effects, but those results will not be available for some time. Medical marijuana is not being approved along usual guidelines with schedules for safety, dose, and effectiveness. Its current use most resembles that of a Schedule IV or post-marketing study drug.

The Dangers of Edibles

A fairly new condition associated with marijuana called cannabinoid hyperemesis syndrome is being seen more frequently in the ED, but diagnosis can be difficult because “patients often underestimate their use and won't admit they use it,” said Sam Torbati, MD, an emergency physician at Cedars-Sinai Medical Center in Los Angeles.

These patients are also difficult to treat because it takes years and years to develop the condition, said Dr. Zuckerman. “Usually what they've been doing is using marijuana for anxiety,” he said. “Then they notice that they are getting nauseous, so they smoke marijuana to make the nausea go away. Then by the time I see them in the emergency department, they're really refractory. They have horrible pain, horrible vomiting that is very hard to control. ... It's a hard conversation to have because in order to be cured from cannabinoid hyperemesis, studies suggest you have to abstain for 10 to 30 days. That's a long period for these people.”

Another frequent problem is acute intoxication that affects marijuana tourists from other states and children who ingest the drug unintentionally. “Tourists come and decide to try it out because they're not used to it,” said Dr. Zuckerman. “Sometimes the edibles can be a bigger contributor. They try one piece. They don't feel anything. Then they try another piece. By that time, the first one kicked in, and then the second one kicks in. Some people have anxiety or reactions to that.”

Dr. Torbati said they saw an uptick in people using edibles, often from a prescription that was for someone else. They would find the room spinning. Call 9-1-1 because of dizziness. Since California approved both uses of marijuana, he said he has not seen a dramatic increase in people coming to the emergency department with problems related to its use.

Dr. Zuckerman, also a medical toxicologist who sometimes consults at the children's hospital next door, said edibles are a problem for children. “A child who would never have access to a bottle of Vicodin with the child safety cap can see a brownie or a marijuana gummy on the counter and eat it,” he said. “The concern is the form of the edible. The smaller size of the child. When you have a 20 kg child ingesting a dose of marijuana, you have a greater effect.”

Driving Under the Influence

One study also found that the number of fatal motor vehicle crashes with marijuana-positive drivers increased compared with the period right before legalization. (Drug Alcohol Depend 2014;140:137; http://bit.ly/2DSuC0p.) Similar changes were not seen in states where the drug was not legalized, however: A study in 2017 found that changes in motor vehicle crash fatality rates for Washington and Colorado (the first two states to approve recreational use of marijuana) were not statistically different from those in eight states without legal marijuana. (Am J Public Health 2017;107[8]:1329.)

A study at the University of Michigan Addiction Center found that half of people taking medical cannabis for chronic pain reported driving under the influence of the drug at least once in the prior six months. (Drug Alcohol Depend 2019;195:193.) Lead author of the study Erin E. Bonar, PhD, an assistant professor of psychiatry and a practicing psychologist at the University of Michigan Treatment Services, found the results troubling. “It is a possibility that we will see increases in DUI related to cannabis and cannabis-related motor vehicle crashes,” she wrote in an email to EMN. “For example, recent data from 2018 out of Colorado suggest this could be the case. It can be difficult to determine what role cannabis plays in any single motor vehicle crash if it is found in the driver's system. Depending on the types of tests administered, cannabis can be detected by some tests days after use, which may mean a person was impaired by marijuana at the time of the crash. This is a challenge for law enforcement.”

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Ms. SoRellehas been a medical and science writer for more than 40 years, previously at the University of Texas MD Anderson Cancer Center, the Houston Chronicle, and Baylor College of Medicine. She has received more than 60 awards, including the Texas Human Rights Foundation Award. She has been a contributor to EMN for more than 20 years.