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While debates about marijuana legalization tend to center on morality, commerce, or political party guidelines, a new study reveals a bigger issue that directly affects millions of US children.
While debates about marijuana legalization tend to center on morality, commerce, or political party guidelines, a new study reveals a bigger issue. Marijuana exposure among children aged younger than 6 years increased by 610% between 2006 and 2013 in states that legalized marijuana for medical use prior to 2000.
More than 20 states have legalized marijuana for medical or recreational purposes since 1996, and several others are working toward decriminalization or some form of legalization.
“We’re not getting on a grandstand here,” says Henry A. Spiller, MS, D.ABAT, FAACT. Spiller, director of the Central Ohio Poison Center, Columbus, and adjunct assistant clinical professor at The Ohio State University College of Medicine, Columbus, co-authored the study. “But we need to be careful because we’re seeing an increasing number and they’re serious.”
The study, published in Clinical Pediatrics by a team of researchers at Nationwide Children’s Hospital, Columbus, Ohio, tracked nearly 2,000 cases of marijuana exposure reported to the National Poison Data System (NPDS) between 2000 and 2013.
The highest number of exposures occurred in children aged 1 to 2 years by ingestion. Comparatively, 75% of the children in the study ingested a marijuana product and about 14.5% inhaled it. Most of the children in the study were treated and released with minor or minimal effects such as drowsiness and lethargy lasting between 2 and 24 hours, but about 7% ended up in critical care units, according to the study.
Alaska, Colorado, Oregon, and Washington have legalized marijuana for recreational use. Arizona, California, Connecticut, Delaware, the District of Columbia, Georgia, Hawaii, Illinois, Maine, Maryland, Massachusetts, Michigan, Minnesota, Montana, Nevada, New Hampshire, New Jersey, New Mexico, New York, Rhode Island, and Vermont have either decriminalized marijuana or legalized it for medical purposes only. A handful of other states have decriminalized possession of small amounts of marijuana to some extent, but it is still classified as illegal.
There is already an awareness of keeping cigarettes, alcohol, or prescription drugs out of the reach of children, and Spiller says that, particularly as more states legalize marijuana for various purposes, more focus needs to be on keeping marijuana products out of children’s hands-and mouths.
Spiller says this issue first came to the forefront after physicians in Colorado began noticing an increasing number of children visiting emergency departments (EDs) for marijuana exposure following the legalization of the drug there.
Across the United States, the study found that marijuana exposure in children aged younger than 6 years increased by 147.5% between 2006 and 2013. In states that legalized marijuana prior to 2000, that rate was 610% over the same period. States that legalized marijuana after 2000 saw exposures increase 16% per year each year after legalization, according to the study. States that did not legalize marijuana by 2013 saw a 63% increase in exposures during the study period.
More than 75% of the exposures tracked in the study occurred in children aged younger than 3 years. Although more than 18% of the children who were exposed were hospitalized, the researchers note that some of the hospitalizations were to investigate what led to the exposure in the home, rather than strictly clinical purposes.
The study also notes that the annual rate of exposures did not significantly change from 2000 to 2006 (0.6% per year)-a period during which legalization among states was slowed. From 2006 to 2013, however, the rate increased significantly, by 147.5%. “Most of this increase was attributable to increases in the rate of exposure among states that had legalized marijuana for medical use prior to 2000,” according to the study.
For the entire study period of 2000 to 2013, the findings indicate that the rate of marijuana exposure in states that had legalized the drug for medicinal purposes prior to 2000 was nearly 3 times higher than in states where it had remained illegal. The states in which the drug remained illegal during that period reported no significant increase in exposure cases, according to the report.
However, in states that permitted medical marijuana use before 2000, there was a 34.1% decrease in exposure cases from 2000 to 2006, followed by a 609.6% increase in exposures from 2006 to 2013.
States that transitioned to legalization of medical marijuana during the study period saw a 2.25% increase in exposure rates than what was reported prior to legalization, according to the study. Additionally, in those states, annual exposure rates were not significantly different in the years leading up to legalization, but after legalization they increased by about 16% each year with an additional spike in exposures during the first year of legalization.
Aside from noting the trend related to legalization of marijuana and exposures among children, the study notes that the rate of exposure calls also parallels trends in the number of US marijuana users. The National Survey on Drug Use and Health conducted by the Substance Abuse and Mental Health Services Administration reveals that the percentage of people aged older than 12 years who used marijuana within the past month dropped from 6.2% in 2002 to 5.8% in 2007 before spiking to 7.5% in 2013.
“This suggests that the rate of marijuana exposure among children is associated with the number of marijuana users,” the study concludes.
As far as treatment, about half the exposures were managed at a healthcare facility, including 30% who were treated and released, 11% who were admitted to non-critical-care units, and 7% who were admitted to critical-care units. However, the study notes that the exposures are trending toward more frequent incidences, with the annual proportion of children admitted to healthcare facilities increasing from 12.8% in 2000 to 30.8% by 2013. Children aged younger than 2 years accounted for the highest number of admissions at 21%. Acuity is increasing as well, with major to moderate clinical effect increasing from 6.4% in 2000 to 16.4% by 2013.
Of the 40.7% of cases in which clinical effects related to exposure were reported, neurological effects were most common, with drowsiness or lethargy reported in 29.5% of cases, agitation or irritability in 3.3% of cases, and confusion in 2.5% of cases. More serious clinical effects were rare but included coma, respiratory depression, and single or multiple seizures, according to the study. Comas were only reported in children aged younger than 4 years.
The exposure cases in the study are not related to drug experimentation, however. The researchers assert that the exposures can be attributed to the exploratory behavior of the age group and the increasing popularity of marijuana food products.
“These marijuana food products look and taste similar to their non-marijuana- containing counterparts, thus making them attractive to young children,” the study states. “Although NPDS data do not distinguish between smoking marijuana and marijuana food products, a report of a series of children treated for marijuana exposure in a Colorado children’s ED found that many of the exposures were ingestions of marijuana food products. Ingestions of marijuana-containing cookies were also documented in several case reports.”
The psychoactive ingredient in marijuana-tetrahydrocannabinol, or THC-can be particularly high in food items made with the drug, and researchers believe this may have contributed to the effects noted in the study group. “Our concern is really in the edibles, not necessarily the plant material,” Spiller adds, echoing the data from the study.
As the legal consumer market for marijuana grows, Spiller says it is being sold in many forms that are appealing to children-brownies, gummies, chocolate drinks, and other treats.
“It doesn’t matter if you put a red ‘X’ on the package or a big skull and crossbones that adults will recognize. These kids can’t read,” Spiller says, referring to the most common victims of ingestion-1- and 2-year-old children.
Spiller says the children in the study are inadvertently, in most cases, finding marijuana products in their parents’ home and ingesting them. “They’re accidentally getting into things in their home,” he says. “These kids aren’t trying to get high.”
“Because more states are considering marijuana legalization, educating parents about the prevention of unintentional poisoning is an important component of a comprehensive prevention approach, but education alone is not sufficient,” the researchers note. “Child-resistant packaging is a more effective strategy and should be combined with education.”
According to the study, the Poison Prevention Packaging Act of 1970 requires child-resistant containers for select medications, and it has been highly effective in preventing medication exposures and accidental ingestion in children.
“It is imperative that commercially available marijuana products be sold in opaque, child-resistant packaging to mitigate the risk of child exposure,” the study authors urge. “However, marijuana does not fall under any existing federal legislation that mandates that it be sold in opaque or child-resistant packaging. Although some states have enacted their own legislation to mandate opaque or child-resistant packaging, these laws vary from state to state and often come years after legalization, following recognition of the increased number of pediatric marijuana exposures.”
The researchers also caution that because exposure rates spiked during the first year following legalization, packaging regulations to protect children should be incorporated into initial legalization legislation to ensure safety from the moment products are available for sale.
Spiller says he would like the study to result in an effort to develop regulations requiring better child-resistant packaging for marijuana products, and to increase awareness among consumers who are also parents.
“We’re not going to stop it, but we need to let them know this is a new world for these exploring little toddlers,” Spiller says, adding that 45% of children exposed to marijuana in the study ended up in the ED. “This is something where it’s ending up with unintentional hospitalizations.”
Spiller says it is especially dangerous when a child overeats the marijuana products. For example, when a single gummy containing marijuana is a dose for an adult, and a child eats a handful or a whole bag, the effects can be tremendous. “It’s an enormous overdose when you’re 25 pounds, and when you eat double the dose, it’s a significant overdose,” he says. “You have to take special care when you have children in the home.”
As more states look at legalization for either recreational or medicinal purposes, the study highlights the fact that marijuana exposure was nearly 3 times higher in states where the drug was legalized before 2000.
“Because more states are likely to pass legislation legalizing medical and recreational use of marijuana, increased efforts to establish child-focused safety requirements regarding packaging of commercially sold marijuana products are needed to help prevent more children from being exposed to this schedule I substance,” the study cautions.
Most of the incidents were ruled unintentional (92.2%), and 83% of the cases occurred in the child’s own home, according to the study.
Pediatricians and other healthcare providers must work to educate parents on the hazards associated with marijuana exposure in children, and be counseled on proper storage and use of any marijuana products, the study notes. Although it may seem to go without saying, parents and caregivers also should be cautioned about using nonedible marijuana products in the vicinity of children. Almost 15% of the exposure cases in the study were attributed to inhalation, most often from secondhand smoke.
“When [pediatricians] find out [parents] have it in the home, they have to let them know we have seen this increase,” Spiller says. “If you knew this was your heart medicine, you’d lock it up and keep it out of each.”