Experts stress need to keep pot edibles, especially candies, locked up

[00:00:00] Host Amber Smith: Upstate Medical University in Syracuse, New York invites you to be "The Informed Patient" with the podcast that features experts from Central New York's only academic medical center. I'm your host, Amber Smith. As more and more communities legalize recreational marijuana, the rate and severity of cannabis intoxication among children is also growing. Dr. Michael Hodgman is an Upstate toxicologist from the department of emergency medicine and the Upstate New York Poison Center, and he contributed to a recent article about this in the journal Clinical Toxicology, and he's here to tell about it. Welcome to "The Informed Patient," Dr. Hodgman.

[00:00:40] Michael Hodgman, MD: Thank you, Amber. It's a pleasure to be here.

[00:00:44] Host Amber Smith: This article had contributions from colleagues in 17 states in addition to New York, plus Canada and Israel. So it seems like this is a concern nationally and internationally.

[00:00:56] Michael Hodgman, MD: Yes. I mean with the increasing legalization of marijuana here in the United States as well as in other countries and in particular, the what I call now, the retail availability of cannabis products, particularly edibles, we're just seeing a dramatic increase in the number of exposures to these products. Really, not only in kids, but in adults as well who may be naive to some of the effects of these drugs.

[00:01:29] Host Amber Smith: Well, for your study, what was the time period that you looked at?

[00:01:33] Michael Hodgman, MD: This study was between 2017 and 2020, so you might say it was in the three years right before the Covid era struck us. We have a consortium called Toxic, T-O-X-I-C, which involves a number of academic centers here in the United States, most of them who have medical toxicology fellowships, as well as several hospitals in Canada and a few in other countries.

And what we do with that... we have a database, and every patient that we see at the bedside gets entered into this database. And so it really allows us to do some really high quality research and epidemiology by involving so many centers. And one of the sub registries we had had to do with pediatric marijuana exposures, and this is the first report that comes out of that sub registry.

[00:02:37] Host Amber Smith: So by children, or pediatrics, is this 18 and younger?

[00:02:42] Michael Hodgman, MD: Yeah, this was really, I mean some of the, you might say an 18 year old is really an adult, so this was quite a broad range of ages. It went up to 18 and all the way down to under a year of age.

[00:02:55] Host Amber Smith: And you looked at different modes of ingestion, smoking or eating?

[00:03:01] Michael Hodgman, MD: Yeah. The only criteria, really, for entry into this sub registry was the patient was seen by a medical toxicologist and the diagnosis was cannabis intoxication, or cannabis was the primary reason for their intoxication. So it could be from ingestion or it could be from smoking. It really could be it just had to do with cannabis by some route, leading to intoxication.

[00:03:32] Host Amber Smith: And so we're looking at a three year plus time period. How many pediatric cases were included during that time?

[00:03:40] Michael Hodgman, MD: There were about 140 cases.

[00:03:43] Host Amber Smith: And were some of them Central New York?

[00:03:46] Michael Hodgman, MD: Yeah. I don't recall how many I put into this, but I would think we probably had two, three or four cases. And I know also that Strong (Memorial Hospital) in Rochester is also a member of the Toxic consortium. And they contributed at least to a case as well. Again, I don't know the exact numbers. But I would guess that maybe up to five cases, five cases in this report, came from upstate New York.

[00:04:12] Host Amber Smith: Can you tell us about the outcome for the kids that were included in this study that had an overdose of cannabis? Were they all admitted to the hospital, or what ended up happening to them?

[00:04:25] Michael Hodgman, MD: Well one thing is, this was a, you might say, somewhat select group, because they were more significantly intoxicated, which is why we may have been consulted to see them at the bedside. And so the majority of these kids ended up getting admitted, and it was usually for something like CNS, or central nervous system depression. So they were profoundly lethargic. Or they may have been confused. Or they may have had some vital sign abnormalities.

[00:04:58] Host Amber Smith: So that sounds like what you're also saying is there's a lot of other cases that don't rise to that level that can be handled without an admission.

[00:05:08] Michael Hodgman, MD: Right. Again, these are cases entered at academic medical center, larger centers, more severe population. And yeah, we know, through the poison center, we know that there are many, many exposures that are not quite this bad.

[00:05:25] Host Amber Smith: Did you discover how to predict which of the patients who arrive at the emergency department with cannabis intoxication would go on to recover, versus go on to require intensive care?

[00:05:39] Michael Hodgman, MD: Well, one of the findings from the study was that there were really two flags of who might need hospitalization, two major ones. And one was if it was an edible ingestion. And I have to say that was skewed by the fact that these were primarily in the younger children. In fact, most of them were under the age of five.

They were probably between the ages of, most of them were between the ages of two to three, maybe four years of age. And the reason for that is, is that that's an age when exploratory behavior is very common. Anyone who has young kids at home knows that they'll get into everything. And so, No. 1, they have a predisposition to get into things.

And No. 2, these are attractive looking. These edibles are very attractive. They look like candy. They look like food. And so, the one predictor was an edible exposure in a younger child. The other predictor was in the older children, teenagers basically, who had used cannabis and also used something else. So they were intoxicated with several things. So it might be marijuana as well as alcohol, or perhaps an opioid or a sedative drug like a benzodiazepine such as Valium or Ativan or something like that. But they had several drugs on board. So in the older kids, a predictor of requirement for more, a higher level, you might say, of hospitalization was a polysubstance exposure, including marijuana. And then in the younger kids it was just exposure to an edible.

[00:07:22] Host Amber Smith: This is Upstate's "The Informed Patient" podcast. I'm your host, Amber Smith. I'm talking about cannabis intoxication with Dr. Michael Hodgman, a toxicologist at Upstate from the department of emergency medicine and the Upstate New York Poison Center.

I'm curious, since the study covered cannabis intoxication in a variety of communities across the world, is the treatment the same everywhere?

[00:07:48] Michael Hodgman, MD: I would say yes. Realistically for this, it's supportive. I mean, with the more severe intoxications, occasionally we'll see respiratory depression. And in a very select few cases, sometimes they have to be placed on a, ventilator to support their breathing for a while. Uncommon, but a very severe outcome.

In young kids, we've occasionally had complications, including seizures, which is really, really rare in an adult related to cannabis. But in these really young kids, we've seen that. And that may require special interventions. And, also, again, more in the younger age group, we'll sometimes see issues with low blood pressure and very slow heart rates.

[00:08:37] Host Amber Smith: Did any of your colleagues in other parts of the world have unique ways that their communities are dealing with this relative sudden availability of cannabis or how they're making sure kids don't get their hands on it?

[00:08:53] Michael Hodgman, MD: Well, I can't extrapolate on that from this study, but what I can say is in Upstate New York and colleagues in other states that our real focus is on prevention, and particularly in young kids with edibles. And so, here in New York state now that marijuana is legal, there are very specific packaging laws for these products so that the packaging has to be child resistant and tamper-proof. And it has to not be attractive to children. I mean, it can't have, it's not supposed to look like a candy. You know unfortunately, there's a lot of illicit products out there that violate every one of those rules.

There's also rules on the maximum unit dose that's allowable as a recreational marijuana product. So there's a lot of packaging rules and again, unfortunately, there's illicit products that are being sold that don't follow those.

And then in the home, what we encourage is to treat this like any other drug when you have young kids in the house. And that's doing things to keep them out of reach of children. And one thing we in particular support here is the use of a lockbox, like you might for your medications. Use a lockbox to keep your edibles in it as well, and try and reduce that potential that one of your kids is going to accidentally get into one of these products.

[00:10:26] Host Amber Smith: Now the study you were involved in was pre-Covid, and here we are kind of post-Covid in Central New York. What are the numbers looking like now? Are you still seeing that this is an issue with especially younger kids having access to cannabis?

[00:10:42] Michael Hodgman, MD: Absolutely. Absolutely. In fact, I have to say as far as with the teenage exposures, I can't comment specifically, but at the time of this study in children under 10, it was exclusively exposure to edibles, because you can understand they're not going to be smoking or anything like that. So the exposures in young kids are exclusively edibles. And in teenagers at the time of this study, about three quarters of the exposures in teenagers were from smoking, either plant material or perhaps vaping a THC (tetrahydrocannabinol) product.

And I suspect that we're seeing a greater percentage of the teenage exposures now are due to edible products as well, because edible products are the growth industry or growth product for marijuana producers, you might say. for example, in Canada,they legalized marijuana. I don't recall the (year) maybe 2019 or so. But it was about a year later before retail sales were allowed in Ontario, and on the first day there were retail recreational marijuana products for sale the stores in Ontario sold out of edible products. I mean, it was, it was crazy. And we're seeing the same thing in other states where the products that are having the greatest year to year change in growth are these edible products.

[00:12:11] Host Amber Smith: There's a range of edibles, right? They're not all candy. And there are a variety of candies. Some are chocolates, and some are fruity flavored or hard candies. And aren't there drinkable beverages too?

[00:12:23] Michael Hodgman, MD: Yeah, there's infused beverages. We've even had a few cases with infused hot sauce, infused barbecue chips. I mean, it's just crazy.

Just getting back to your question, what's changed is we're continuing... I've been more interested in the younger age groups, so I've been looking at 0 to 5 and 6 to 12, and we're just seeing year to year, exposures are continuing, at least calls to the poison center that we're getting. And so this is a real focus for us at the poison center for prevention and education. And to your point, I think the No. 1 exposure product that we get called to the poison center are gummies. I mean, they're just unbelievably popular. And again, they're easy to leave laying around, and these young kids get into them, and it's been a real issue.

[00:13:19] Host Amber Smith: For the people that are purchasing gummies does reading the label help protect you from taking too much, or taking them the wrong way? Do the labels specify a safe way to use them?

[00:13:32] Michael Hodgman, MD: In New York State, there's very specific labeling requirements. And again, this is for a product that's following all the rules and comes from a licensed dispensary. And the rollout of licensed dispensaries in New York State has been very, very slow. And I believe right now there's still only one in Syracuse, but there's a lot of places that you can go in and get one of these products.

So a lot of these products, they're not following the New York State labeling. But if the label's proper, first of all, it's got to be kind of a bland label with bland font for the print. It can't be like real colorful print or anything. And it has to have what the total amount of THC is in the package, what the unit dose is. The maximum unit dose for a single dose for an adult is 10 milligrams. And so the product has to have that, the total dose. It also has to have precautions on it. about the differences in when you experience the clinical effects when you ingest THC versus when you smoke it.

Again, when you smoke marijuana, the absorption through their lungs is very rapid to the brain, and the clinical effects are within minutes. When someone ingests a THC edible, the onset of clinical effects may not be for 60 to 90 minutes after you ingest the product. And there's a real risk there. Somebody can take it and a half hour later say, "huh, nothing's happened. I'm going to eat another one." And so this is something we call dose stacking. And so by the time you start getting the effect from the first one, then there's more after that. So the onset of effects is delayed, and anyone who's not aware of that. And the duration of effects from edibles is more prolonged than it is from smoking because, again, when somebody smokes it, they have the clinical effect very rapidly. And so they're able to titrate the effect because then they stop. Whereas with these edibles, if you've still got more that's going into your system, it can last a lot longer.

And if we go back to young kids, the other problem with young kids is whatever a unit dose is, that's a big dose for a little child. When you consider that a 10 milligram dose is what an adult should get. You get a 2-year- old that takes that same dose, that's a lot more. But the problem is also it's a gummy. It tastes good. Or it's a piece of candy. It tastes good. So how many stop with one or two pieces of candy, or how many people have only eaten one barbecue chip? The dose effect in these young kids can be really, really significant.

[00:16:13] Host Amber Smith: Could a gummy ingestion kill a child under the age of 2?

[00:16:19] Michael Hodgman, MD: Well, it's really hard to titrate the exact dose in young kids. We don't know, sometimes, how many they took. But if we just consider maybe a 2-year-old child that weighs 25, let's say 30 pounds, or about 15 kilograms that would be. And there have been some estimates that a dangerous dose in a kid that age could be about 1.7 milligrams per kilogram, or that might bemaybe 25 milligrams. So you could say a kid, a young child who just eats two to three gummies, they've already crossed that threshold to the potential for severe intoxication.

A lot of the kids that we see that just get into a few, I mean their clinical course is like you might expect with an adult. They're a little goofy, a little lethargic. Their behavior isn't quite normal.

But then the more severe effects, as I said we can sometimes see, is really profound sedation. Paradoxically, some kids will get very, very agitated and restless. And so we can see the whole spectrum of changes there.

[00:17:26] Host Amber Smith: So those are some good red flags for parents, because they may not see a child eat this. The eating may happen out of the parent's sight, and they would maybe just notice symptoms afterward.

[00:17:40] Michael Hodgman, MD: Correct. Correct. And, a real change in practice in the emergency department, I think in 2023, compared to maybe 10 or 15 years ago, we never saw this in toddlers. But in the differential of a toddler that is brought in, that's altered now. Cannabis is right there with all the other things that we have to think about as an emergency physician, as perhaps the reason for their not being themselves. So, yeah, it's just, it's added one more thing there.

[00:18:16] Host Amber Smith: Well, this is really helpful. Dr. Hodgman, thank you so much for making time for this interview.

[00:18:22] Michael Hodgman, MD: You're welcome.

[00:18:23] Host Amber Smith: My guest has been Dr. Michael Hodgman, a toxicologist at Upstate from the department of emergency medicine and the Upstate New York Poison Center. "The Informed Patient" is a podcast covering health, science and medicine, brought to you by Upstate Medical University in Syracuse, New York, and produced by Jim Howe. Find our archive of previous episodes at upstate.edu/informed. If you enjoyed this episode, please tell a friend to listen too. And you can rate and review "The Informed Patient" podcast on Spotify, Apple, YouTube, or wherever you tune in. This is your host, Amber Smith, thanking you for listening.