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“Medibles”: Dangerous Treats
PHARM/TOX CORNER
“MEDIBLES”: DANGEROUS TREATS Author: Charisse Pizarro-Osilla, BSN, MS, Portland, OR Section Editor: Allison A. Muller, PharmD, D.ABAT
he Oregon Poison Center (OPC) received 3 calls in one shift regarding toddlers who had altered mental status. A 3-year-old was described as having “abnormal shaking movements.” Another toddler received intravenous fluids for hypotension, and the last child was intubated for multiple apneic spells in the emergency department. All their symptoms resolved overnight, and they were discharged the next day. These cases were quite perplexing. The symptoms did not really fit any known toxic syndromes or “toxidromes.” The common factor in these cases was the xenobiotic substance that was infused in the food products that they all ingested. These types of food, which are called “medibles,” are commonly sold in Oregon. “Medibles” are marijuana-infused food items sold in medical marijuana dispensary stores. They are eaten as an alternative to smoking or inhaling the vapors of marijuana. The marijuana leaves or extracted oils are mixed in food such as cookies, candies, gummies, ice cream, beverages, and peanut butter. Many of the packages sold are “lookalikes” of popular brand names, especially snack foods. Examples of such packaging are “Pot-tarts” for “Pop-Tarts,” “KeefKat” for the “Kit Kat” candy bar, and “Reefer’s” for “Reese’s” peanut butter spread. Marijuana comes from the Cannabis sativa plant, which contains many different cannabinoid chemicals. The main cannabinoids are cannabinol, cannabidiol, and tetrahydrocannabinol. The principal psychoactive cannabinoid is delta-9-tetrahydrocannabinol (THC). THC and other cannabinoids bind to CB1- and CB2-specific cannabinoid-binding receptors in the brain and immune system. The CB1 receptors are found in the central nervous system. The receptors inhibit adenyl cyclase and stimulate potassium channel conductance. CB1 receptors also inhibit the release of serotonin, dopamine, noradrenaline, acetylcholine, L-glutamate, and γ-aminobutyric acid. CB2 receptors
T
Charisse Pizarro-Osilla is a Certified Specialist in Poison Information and Lead Charge RN Coordinator, Oregon Health & Science University, Oregon Poison Center, Portland, OR. For correspondence, write: Charisse Pizarro-Osilla, BSN, MS, Oregon Poison Center, 3181 SW Sam Jackson Park Rd, CSB 550, Portland, OR 97239; E-mail: [email protected]. J Emerg Nurs ■. 0099-1767 Copyright © 2016 Emergency Nurses Association. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jen.2016.03.023
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are found in the spleen, peripheral nerve terminals, and vas deferens. CB1 activity is believed to be responsible for the clinical effects of cannabinoids. 1 CB1 receptors in the pain pathway of the brain and the spinal cord produce its analgesic effect. Furthermore, the antiemetic properties of the cannabinoids are thought to be secondary to the effect of CB1 receptors. The CB2 receptors modulate the immune system by releasing cytokines—small proteins involved in cell signaling. 2 Oregonians approved marijuana for medicinal use in 1998. 3 The incidence of marijuana-related calls to the OPC remained low and stable year to year until after 2014, when marijuana became legal for recreational use, and began being sold in marijuana retail stores as medibles. At that point, such calls significantly increased. Many of the calls to the OPC related to medible exposures involve children. The children mistake the cookies or candies laying on the table as “regular” food and do not hesitate to open the packages and eat the products. Furthermore, children are more susceptible to overdose because many medibles are packaged as multiple servings. For example, one brownie can contain 100 mg of THC. One serving content of THC on the label of its package can be 10 mg, even though common sense would not consider 1/10 of a brownie to be a single serving. One gummy can also contain 10 mg of THC. A child, or even an adult for that matter, does not usually eat only one tenth of a brownie or just one gummy. As few as two 10-mg servings may be harmful for preschool-aged children. 4 In a publicized incident in Southern Oregon, an 8-year-old boy was hospitalized after eating one packaged marijuana cookie he found. The cookie contained 50 mg of THC. 4,5 In addition to accidental ingestion of large amounts of medibles, other cases have involved adults overdosing by ingesting multiple doses in a short period. When inhaling marijuana smoke, the onset of effect usually occurs within 6 to 20 minutes. However, the onset of effect for medibles usually starts 30 to 60 minutes later, and the peak effect may be delayed for several more hours. 2 It takes longer for the cannabinoid to be absorbed from the gastrointestinal tract than from the pulmonary tract. Because the oral ingestion does not give users the desired effect right away, they may take more until they start feeling some untoward effects. Callers to the OPC commonly report nausea, vomiting, restlessness, and tachycardia. When the person affected is an adult and someone is available to watch him or her, we generally manage these cases at home. Such
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PHARM/TOX CORNER/Pizarro-Osilla
persons usually are not referred to the hospital unless they have cardiac symptoms. We refer children to the emergency department for medible ingestions if they are symptomatic, if their ingestion was not witnessed, or if they were seen ingesting more than one bite. The symptoms we have noted among children ingesting medibles are lethargy, ataxia, irritability or agitation, confusion, vomiting, respiratory depression, bradycardia, and hypotension. Treatment is supportive and symptomatic. What may be surprising to some persons is that children who are naïve to marijuana can have serious respiratory depression requiring ICU admission, as described in a report from Denver Children’s Hospital. 5 We monitor patients until their symptoms have resolved, and typically patients are discharged about 24 hours later. Child-resistant packaging, accurate labeling, and appropriate dosing of marketed medibles are factors that can help obviate unintentional overdoses of children and adults. Some rules and regulations are already being discussed and implemented. One of our toxicologists is participating in the 2 committees that examine and establish the guidelines for regulating the packaging, labeling, and dosing of medibles. The regulating agency in Oregon has already adopted the federal childproof packaging standards for all retail sales. 6 Purchased marijuana products must leave the dispensary in a child-resistant package. However, because the THC content of medibles can vary from state to state and in homemade products not for retail sale, the amount of THC in one candy, baked product, or soft drink can still contain high concentrations of marijuana. Moreover, public education is paramount in preventing accidental ingestion and overdoses of medibles. Proper storage and dosing
2
amount and intervals should be a major issue of discussion as part of our service to the public. Your local poison center is available 24 hours a day via the national toll-free number (1-800-222-1222) to discuss the management of any patients poisoned by medibles and other products. Acknowledgment
I thank Gillian Beauchamp, MD, and Zane Horowitz, MD, for their assistance with this article. REFERENCES 1. McGuigan M. Cannabinoids. In: Hoffman RS, Nelson L, Howland M, et al, eds. Goldfrank’s Manual of Toxicologic Emergencies. New York, NY: McGrawHill Companies; 2007:675-678. 2. Micromedex Healthcare Series. Poisindex management. Plants-Marijuana. Ann Arbor, MI: Truven Health Analytics; 2016. 3. Crombie N. Legal marijuana in Oregon: a look at the state’s pot history. http:// www.oregonlive.com/marijuana/index.ssf/2014/11/legal_marijuana_ in_oregon_a_lo.html. Published November 7, 2014. Accessed April 11, 2016. 4. Hendrickson R, Lewis P. State rules for edible pot must protect children. http:// www.oregonlive.com/opinion/index.ssf/2016/02/state_rules_for_ edible_pot_mus.html. Published February 23, 2016. Accessed April 11, 2016. 5. Wang GS, Roosevelt G, Heard K. Pediatric marijuana exposures in a medical marijuana state. JAMA Peds. 2013;167(7):630-633. 6. Crombie N. Marijuana-infused cookie sends Oregon boy to the hospital. http:// www.oregonlive.com/marijuana/index.ssf/2016/02/klamath_falls_ boy_sickened_tak.html. Published February 16, 2016. Updated February 23, 2016. Accessed April 11, 2016.
Submissions to this column are encouraged and may be sent to Allison A. Muller, PharmD, D.ABAT, [email protected]
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JOURNAL OF EMERGENCY NURSING
Master Proof ymen2950.pdf
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“MEDIBLES”: DANGEROUS TREATS Author: Charisse Pizarro-Osilla, BSN, MS, Portland, OR Section Editor: Allison A. Muller, PharmD, D.ABAT
he Oregon Poison Center (OPC) received 3 calls in one shift regarding toddlers who had altered mental status. A 3-year-old was described as having “abnormal shaking movements.” Another toddler received intravenous fluids for hypotension, and the last child was intubated for multiple apneic spells in the emergency department. All their symptoms resolved overnight, and they were discharged the next day. These cases were quite perplexing. The symptoms did not really fit any known toxic syndromes or “toxidromes.” The common factor in these cases was the xenobiotic substance that was infused in the food products that they all ingested. These types of food, which are called “medibles,” are commonly sold in Oregon. “Medibles” are marijuana-infused food items sold in medical marijuana dispensary stores. They are eaten as an alternative to smoking or inhaling the vapors of marijuana. The marijuana leaves or extracted oils are mixed in food such as cookies, candies, gummies, ice cream, beverages, and peanut butter. Many of the packages sold are “lookalikes” of popular brand names, especially snack foods. Examples of such packaging are “Pot-tarts” for “Pop-Tarts,” “KeefKat” for the “Kit Kat” candy bar, and “Reefer’s” for “Reese’s” peanut butter spread. Marijuana comes from the Cannabis sativa plant, which contains many different cannabinoid chemicals. The main cannabinoids are cannabinol, cannabidiol, and tetrahydrocannabinol. The principal psychoactive cannabinoid is delta-9-tetrahydrocannabinol (THC). THC and other cannabinoids bind to CB1- and CB2-specific cannabinoid-binding receptors in the brain and immune system. The CB1 receptors are found in the central nervous system. The receptors inhibit adenyl cyclase and stimulate potassium channel conductance. CB1 receptors also inhibit the release of serotonin, dopamine, noradrenaline, acetylcholine, L-glutamate, and γ-aminobutyric acid. CB2 receptors
T
Charisse Pizarro-Osilla is a Certified Specialist in Poison Information and Lead Charge RN Coordinator, Oregon Health & Science University, Oregon Poison Center, Portland, OR. For correspondence, write: Charisse Pizarro-Osilla, BSN, MS, Oregon Poison Center, 3181 SW Sam Jackson Park Rd, CSB 550, Portland, OR 97239; E-mail: [email protected]. J Emerg Nurs ■. 0099-1767 Copyright © 2016 Emergency Nurses Association. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jen.2016.03.023
■
are found in the spleen, peripheral nerve terminals, and vas deferens. CB1 activity is believed to be responsible for the clinical effects of cannabinoids. 1 CB1 receptors in the pain pathway of the brain and the spinal cord produce its analgesic effect. Furthermore, the antiemetic properties of the cannabinoids are thought to be secondary to the effect of CB1 receptors. The CB2 receptors modulate the immune system by releasing cytokines—small proteins involved in cell signaling. 2 Oregonians approved marijuana for medicinal use in 1998. 3 The incidence of marijuana-related calls to the OPC remained low and stable year to year until after 2014, when marijuana became legal for recreational use, and began being sold in marijuana retail stores as medibles. At that point, such calls significantly increased. Many of the calls to the OPC related to medible exposures involve children. The children mistake the cookies or candies laying on the table as “regular” food and do not hesitate to open the packages and eat the products. Furthermore, children are more susceptible to overdose because many medibles are packaged as multiple servings. For example, one brownie can contain 100 mg of THC. One serving content of THC on the label of its package can be 10 mg, even though common sense would not consider 1/10 of a brownie to be a single serving. One gummy can also contain 10 mg of THC. A child, or even an adult for that matter, does not usually eat only one tenth of a brownie or just one gummy. As few as two 10-mg servings may be harmful for preschool-aged children. 4 In a publicized incident in Southern Oregon, an 8-year-old boy was hospitalized after eating one packaged marijuana cookie he found. The cookie contained 50 mg of THC. 4,5 In addition to accidental ingestion of large amounts of medibles, other cases have involved adults overdosing by ingesting multiple doses in a short period. When inhaling marijuana smoke, the onset of effect usually occurs within 6 to 20 minutes. However, the onset of effect for medibles usually starts 30 to 60 minutes later, and the peak effect may be delayed for several more hours. 2 It takes longer for the cannabinoid to be absorbed from the gastrointestinal tract than from the pulmonary tract. Because the oral ingestion does not give users the desired effect right away, they may take more until they start feeling some untoward effects. Callers to the OPC commonly report nausea, vomiting, restlessness, and tachycardia. When the person affected is an adult and someone is available to watch him or her, we generally manage these cases at home. Such
■ • ■
WWW.JENONLINE.ORG
Master Proof ymen2950.pdf
1
PHARM/TOX CORNER/Pizarro-Osilla
persons usually are not referred to the hospital unless they have cardiac symptoms. We refer children to the emergency department for medible ingestions if they are symptomatic, if their ingestion was not witnessed, or if they were seen ingesting more than one bite. The symptoms we have noted among children ingesting medibles are lethargy, ataxia, irritability or agitation, confusion, vomiting, respiratory depression, bradycardia, and hypotension. Treatment is supportive and symptomatic. What may be surprising to some persons is that children who are naïve to marijuana can have serious respiratory depression requiring ICU admission, as described in a report from Denver Children’s Hospital. 5 We monitor patients until their symptoms have resolved, and typically patients are discharged about 24 hours later. Child-resistant packaging, accurate labeling, and appropriate dosing of marketed medibles are factors that can help obviate unintentional overdoses of children and adults. Some rules and regulations are already being discussed and implemented. One of our toxicologists is participating in the 2 committees that examine and establish the guidelines for regulating the packaging, labeling, and dosing of medibles. The regulating agency in Oregon has already adopted the federal childproof packaging standards for all retail sales. 6 Purchased marijuana products must leave the dispensary in a child-resistant package. However, because the THC content of medibles can vary from state to state and in homemade products not for retail sale, the amount of THC in one candy, baked product, or soft drink can still contain high concentrations of marijuana. Moreover, public education is paramount in preventing accidental ingestion and overdoses of medibles. Proper storage and dosing
2
amount and intervals should be a major issue of discussion as part of our service to the public. Your local poison center is available 24 hours a day via the national toll-free number (1-800-222-1222) to discuss the management of any patients poisoned by medibles and other products. Acknowledgment
I thank Gillian Beauchamp, MD, and Zane Horowitz, MD, for their assistance with this article. REFERENCES 1. McGuigan M. Cannabinoids. In: Hoffman RS, Nelson L, Howland M, et al, eds. Goldfrank’s Manual of Toxicologic Emergencies. New York, NY: McGrawHill Companies; 2007:675-678. 2. Micromedex Healthcare Series. Poisindex management. Plants-Marijuana. Ann Arbor, MI: Truven Health Analytics; 2016. 3. Crombie N. Legal marijuana in Oregon: a look at the state’s pot history. http:// www.oregonlive.com/marijuana/index.ssf/2014/11/legal_marijuana_ in_oregon_a_lo.html. Published November 7, 2014. Accessed April 11, 2016. 4. Hendrickson R, Lewis P. State rules for edible pot must protect children. http:// www.oregonlive.com/opinion/index.ssf/2016/02/state_rules_for_ edible_pot_mus.html. Published February 23, 2016. Accessed April 11, 2016. 5. Wang GS, Roosevelt G, Heard K. Pediatric marijuana exposures in a medical marijuana state. JAMA Peds. 2013;167(7):630-633. 6. Crombie N. Marijuana-infused cookie sends Oregon boy to the hospital. http:// www.oregonlive.com/marijuana/index.ssf/2016/02/klamath_falls_ boy_sickened_tak.html. Published February 16, 2016. Updated February 23, 2016. Accessed April 11, 2016.
Submissions to this column are encouraged and may be sent to Allison A. Muller, PharmD, D.ABAT, [email protected]
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JOURNAL OF EMERGENCY NURSING
Master Proof ymen2950.pdf
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