JHanson 2019 Reefer Madness 1936 American propaganda film - PowerPoint PPT Presentation

JHanson 2019

Reefer Madness  1936 American propaganda film  Extolling risks of marijuana use in high school students  Suicide, hallucinations, attempted rape, manslaughter  Film “rediscovered” in early 1970s and gained new life as an unintentional satire among advocates of cannabis reform.  “Turn on, tune out, don’t worry be happy.”

Marijuana in Pregnancy  Mother  Fetus  Neonate  Infant

Maternal Comments  “It must be safe, it is legal.”  “It is natural, not a drug.”  “The internet says it is safe and can improve developmental outcomes.”  “Pot shops say it is safe and effective for treating morning sickness.”  “Better than methamphetamines, cocaine, or heroin.”  “I will take the chance.”

Marijuana, the New Panacea  Morning sickness  Intractable childhood seizure disorders  Autism spectrum disorders.  “Good for what ails you, modern day equivalent of epsom salts.”  Pure mineral compound: magnesium and sulfate.  “A wonder drug in search of a disease!” JHanson

THC and Autism Spectrum Disorder  Pediatrics, Vol 143, No 2, Feb 2019  Broad Diagnostic Category  Complementary Health Approaches (CHA)  An array of modalities developed outside of or parallel to mainstream medicine  Specific vitamins, herbal supplements, mind/body practices (yoga), chelation therapy.  THC is newest CHA

THC, Autism, Questions  Define exactly what child is receiving.  How much THC or CBD in current product?  May be efficacious in a few selected cases of refractory seizures  What is the safety profile of THC and CBD?  Recommendation for use of benzodiazepine (valium, ativan) before THC. (behavioral health/psychiatry)  Is the state legislature now determining who has autism and appropriate treatment modalities based on a few testimonials?

Full Disclosure  Never had prescriptive authority for medical marijuana.  Do not own a pot shot or grow house.  Discussion not a comment on general use of marijuana.

Main Concern  What is the effect on the developing brain?  Fetus  Neonate  Infant

Thinking About Cannabis  Joseph P Cannavo, MD  Regional Service Chief, Addiction Treatment Services  Divisional Value Advisor, Specialty Psychiatry  Colorado Permanente Medical Group.

Marijuana  Source: dried leaves/flowers of hemp plant: Cannabis sativa.  Active agreement: Tetrahydrocannabinol: THC  Medical marijuana same as street marijuana.  Back in the day  Pot, Hash, Hash Oil  Getting up to date  Edibles, Waxes, Tinctures  Increased potency

Mechanism of Action  Interacts with all parts of the brain, a vast modulatory network.  Endocannabinoid System:  CNS, PNS, other physiological processes.  Memory, Mood, Appetite and Energy, Balance, Pain Sensation, Vision, Stress Responses, Reproduction, Sleep, Thermoregulation, Inflammatory/Immune Response.

Hazardous Cannabis Use  Miracle Plant of Evil Weed?  Polarized debate.  Unlike alcohol: Use thresholds not well-defined.  Problematic pharmacokinetics

Is Cannabis Addictive?  Chemical Reward>Pathology of drive/reward>Addiction.  9% cannabis users become addicted.  16% when use begins in teens.  50% with daily use.

Cognition  Divergent literature.  Acute: Impaired learning, memory, attention and executive function.  Pharmacokinetics: Cannabinoids accumulate with regular use.  Heavy users: Impairment for days to weeks after cessation.

Cognition: Children/Adolescents  Not neurotoxic like alcohol.  Dunedin Cohort: 1037 New Zealanders: Birth to 38 yrs.  Adolescents with heavy use: decrease 8 IQ points @ 38 yr.  Hazard: Irreversible cognitive loss.  Insidious life trajectory effect.  Role of genetics, environment?

Withdrawal  Severity: Think nicotine  Common: Irritability, dysphoria, sleep difficulty, decreased appetite, restlessness.  Dysphoria: anxiety, depression, restlessness  Less Common: physical symptoms: GI, tremors, sweating, fever, chills, headache.  Hazard: Sustained daily use: likely withdrawal.

Safety and Side Effects of THC in Children  Pediatrics, Vol 143, N02, Feb 2019  Short Term  Decrease in working memory, IQ, executive function, sustained attention, motor coordination.  Long Term  Altered brain development, addiction, poor educational outcomes, diminished life achievement, increased risk for chronic psychosis disorder.

How Marijuana Harms a Developing Baby’s Brain  Dana Smith; Scientific American: Nov 7, 2018  Previous research: infants exposed to cannabis inutero 50% likely to be low birth weight and premature.  Society for Neuroscience: Nov 2018, 3 new studies suggest prenatal cannabis exposure: serious consequences for fetal brain development.

Washington State University Study  Newborn rat pups exposed to THC, similar to 2 joints/day took longer to learn new rule (pushing a lever for food).  Finally press correct lever x 2 then press wrong lever.

Auburn University  THC exposed rat pups impaired on several different memory tasks involving mazes.

University of Maryland School of Medicine  Finding of impairments of memory and changes of glutamate in brains of rats exposed to THC.  Increased levels of kynurenic acid, decreased glutamate levels with THC exposure.  Kynurenic acid regulates glutamate and other important neurochemicals.  Glutamate: important neurochemical for brain growth and neuronal electrical transmission.

Medicinal Effects?  Clear “medicinal beneficial effects”, great potential for cannabinoid therapeutics.  Chronic pain, nausea, wasting syndromes, spasticity, seizures, cancers, psychiatric.

Money Talks

By The Numbers: DP: Jan 2019 Steamboat Marijuana tax CO Marijuana Sales revenue  2014: $618 million  2015: $366,456  2015: $995 million  2016: $431,112  2016: $1.3 billion  2017: $489,885  2017: $1.5 billion  2018: $534,753  2018: $1.4 billion  Total: $1,822,206  Total: $6 billion  Total: $1 billion in marijuana tax, licensing, and fee revenue

Magnitude of Problem  Bob Troyer; former US Attorney Colorado: Denver Post Commentary, 10/2018.  CO youth use marijuana 85% higher than national av.  Marijuana-related traffic fatalities: up 151%.  Increased alcohol consumption, not decreased.  Denver Health Study  70% of 400 licensed pot shops surveyed recommend pregnant women use marijuana to treat morning sickness, 35% state safe for baby.

Pediatrics: S.Ryan, 9/2018  Marijuana: most common recreational drug used by pregnant and lactating women.  Up to 36% of women report having used marijuana at some point in pregnancy.  18% report using it while breastfeeding.  Level of THC metabolites in breast milk was 8 times higher than in mother’s plasma level.

Colorado Birth Statistics 2015  Total Births: 66,566  Potential neonates exposed to THC  36%: 23,963 (~24,000)  Mothers that smoked during pregnancy:  6.4%: 4,217  6 times as many babies exposed to THC than nicotine.

THC  Highly lipophilic  Accumulates in fat-rich organs: brain.  Accumulation of THC in brain tissue when growth is greatest: 1 st 2 yrs of life.  Brain grows for 1 st 20 years of life.  THC can disrupt normal axonal growth and development in growing human brain.

Most Important Question  What are the short term and long term effects of marijuana exposure in the developing fetus, newborn, and infant?  Note: there are no associated physical findings.

Questions asked in NICU  Will my baby survive?  How long will my baby be in the hospital?  Will my baby be normal?  “What is normal?” JHanson

Factors that determine outcome  Genes  Environment

Developmental Outcome  Motor  Verbal  Cognition

THC use during pregnancy and while breastfeeding.  Safety:  No known safe level of use.  Increased risk of premature birth, low birth weight  Increased risk of behavioral and learning complications.  Neonates exposed to THC: may manifest:  Tremors in arms, legs,  Poor eating coordination.  Difficulty with weight gain.  Delays in motor growth.  Visual complications.

Is Marijuana safe while breastfeeding.  No known safe level of use during breastfeeding.  Benefits of breastfeeding  Maternal infant bonding  Less obesity  Decreased incidence of reactive airway disease (asthma)  Improved developmental outcomes.  Value judgment:  Breastfeeding with or without THC  “Just say no.

Studied Outcomes  No long term prospective studies regarding outcomes.  Confounding variables.  Simultaneous exposure to other drugs:  Methamphetamines  Cocaine  Opioids  Cigarettes  Ethanol  Dose effects

THC and morning sickness  Morning sickness  Occurs: week 4-16 weeks  Peak incidence 8-12 weeks  Critical time for brain development.  Question  Once morning sickness abates, does THC use persist?