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Legalized Recreational Marijuana - What Will You See in the ED?

Pot problems in the ED?

Specialties Emergency Article   posted

traumaRUs specializes in Nephrology, Cardiology, ER, ICU.

As more and more states are legalizing recreational marijuana, emergency departments will be seeing more and different issues.

Legalized Recreational Marijuana - What Will You See in the ED?
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The Emergency Nurses Association's Annual Conference was held in Austin, Texas recently. With almost 200 presentations, the 3800 attendees had the opportunity to learn much and network among colleagues. One of the interesting presentations involved complications of the legalization of recreational marijuana. The presenter was Lisa Wolf, PhD, RN, CEN, FAEN, ENA's Director of Emergency Nursing Research.

allnurses.com was able to interview Dr Wolf. First, we asked what types of complaints do you think will be more commonly seen in the ED due to legalization of recreational marijuana?

  • Hyperemesis syndromes - one of these is cannabinoid hyperemesis syndrome (CHS) which according to Cedars-Sinai hospital is a condition that leads to repeated and severe bouts of vomiting. It is rare and only occurs in daily long-term users of marijuana
  • Pediatric ingestions of edibles (brownies, cookies, and gummies) - According to a Journal of Pediatrics article, "Unintentional cannabis ingestion by children is a serious public health concern and is well-documented in numerous studies and case reports. Clinicians should consider cannabis toxicity in any child with sudden onset of lethargy or ataxia"
  • Geriatric ingestions can also result in a myriad of issues;
    • Acute asthma exacerbation
    • Pneumomediastinum and pneumothorax suggested by tachypnea, chest pain, and subcutaneous emphysemas caused by deep inhalation with breathholding
    • Occasionally angina and myocardial infarction

We discussed the possible increase in MVAs associated with the legalization of recreational marijuana? Dr Wolf stated that this would be difficult to discern as "edibles have a delayed onset of effect, and people may misjudge." Drugged driving is being addressed by state legislatures; "Detection of marijuana in drivers involved in traffic crashes has become increasingly common. According to the National Highway Traffic Safety Administration, 12.6 percent of weekend nighttime drivers in 2013-2014 tested positive for tetrahydrocannabinol (THC), the component that gives marijuana its psychological effects, compared to 8.6 percent in 2007." Some of the first states to legalize recreational marijuana are on the forefront of developing tests to determine impairment:

"In Colorado, the first state to legalize marijuana use, the Colorado State Patrol (CSP) includes specialized drug recognition officers. Any driver arrested after a trooper observes signs of impairment is given a blood test.

“When driving a motor vehicle in Colorado, any driver has given their consent to submitting to a chemical test if they are presumed to be under the influence of drugs or alcohol,” Sgt. Rob Madden, a CSP representative, told Healthline. “Drivers can refuse a test, but that leads to an immediate revocation of their driving privileges.”

Madden also noted that the CSP is entering the final phase of testing of new “oral fluid” devices.

California, where the recreational use of pot became legal on January 1, also has specialized drug recognition officers and rules stipulating drivers arrested for driving under the influence are required to take a blood test if marijuana is the suspected intoxicant.

That suspicion is formed during a 12-step roadside evaluation process that includes some familiar elements — walking in a straight line, standing on one foot, touching fingers to nose — as well as checking pulse rates at three different points in the process and checking pupil size in ambient light, near-total darkness, and direct light."

We then shifted to what ED complaints are being seen in states where there is legalized recreational marijuana. Dr Wolf does live in a state, Massachusetts which has legalized recreational marijuana and she reports the most common complaint they see is hyperemesis.

As more states move to the legalization of marijuana, I asked if she had any tips for those EDs in states where recreational marijuana will soon be legalized to prepare for this suspected onslaught? Her comments included these tips:

  • Educate the ED staff
  • Push for good community education in the same way we educate about alcohol
  • Access protocols for managing cannabinoid hyperemesis (Colorado has some good ones)

Thank you Dr Wolf and ENA for facilitating this interview.

Has legalized recreational marijuana impacted your ED? Please share.

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FolksBtrippin, BSN, RN

Specializes in Psychiatry, Pediatrics, Public Health.

Also marijuana induced psychosis. Probably the most common thing you'll see related to marijuana.

Cannabanoid hyperemesis is not rare. I've seen it almost every day in the one teensy 30 bed ER I work in---and the users are insanely adamant that "marijuana eases nausea!!!!!!!!!!!!!!!!! you f*(&(&(*(&g idiot!!!!!". It's been the only time I've seen stoners become unhinged---when you tell them that their kush, the God Given Ganja---is slowly killing their gut.

medic981, ADN, RN, EMT-P

Specializes in Emergency Nursing.

Cannabinoid hyperemesis syndrome has been around for many, many years. Healthcare practitioners didn't make the connection until marijuana became legalized in many states and patients began reporting marijuana use.

I see CHS almost daily in the ED (Colorado, the Rocky Mountain High state) and as Solosgirl mentioned, you get the stink eye when you even suggest that their marijuana use could be causing the violent vomiting they are experiencing. All I have to hear is the violent wretching sound and I am pretty sure I know what my line of questioning is going to entail.

It is the cannabinoids that are causing poor memory and cognitive skills. This patient population just doesn't seem to be able to make the connection between their marijuana use and their violent episodes of hyperemesis.

A favorite narcotics anonymous axiom I use to educate these patients when they say that marijuana is supposed to help with nausea is, "insanity is repeating the same mistakes and expecting different results."

Edited by medic981

MunoRN, RN

Specializes in Critical Care.

21 hours ago, SolosGirl said:

Cannabanoid hyperemesis is not rare. I've seen it almost every day in the one teensy 30 bed ER I work in---and the users are insanely adamant that "marijuana eases nausea!!!!!!!!!!!!!!!!! you f*(&(&(*(&g idiot!!!!!". It's been the only time I've seen stoners become unhinged---when you tell them that their kush, the God Given Ganja---is slowly killing their gut.

You'll probably have better luck convincing them that their nausea is due to their excessive marijuana consumption if you present a more informed explanation.

Marijuana includes two different components that affect nausea, one causes nausea, one relieves nausea. The anti-nausea effect of marijuana is well established, including the specific receptor pathway and pharmacology involved. When used infrequently or moderately, the ant-nausea effects win out, when used heavily the nausea inducing effects can increase exponentially resulting in cannabis hyperemesis syndrome.

And no, marijuana is not "slowly killing their gut" as there's no evidence it causes ischemia or any sort of progressive necrosis. The mechanism of cannabis hyperemesis syndrome is not fully understood, but considering it's most reliably treated by applying heat to the scalp, it's more likely it's cause is a CNS pathway and not by direct effects on the gut.

I don't think she meant it was literally killing their gut via an ischemic pathway.

MunoRN, RN

Specializes in Critical Care.

32 minutes ago, egg122 NP said:

I don't think she meant it was literally killing their gut via an ischemic pathway.

There's no evidence it "kills" the gut through any mechanism or pathway.

Ruixi13, BSN, RN

Specializes in MICU RN.

It's naive to think legalization will lead to any more cases of these not common cases. They have surely been common in ED's since MJ use has been common for decades

15 hours ago, MunoRN said:

There's no evidence it "kills" the gut through any mechanism or pathway.

I don't think it was meant as literally killing the gut via any mechanism.

17 hours ago, MunoRN said:

You'll probably have better luck convincing them that their nausea is due to their excessive marijuana consumption if you present a more informed explanation.

Marijuana includes two different components that affect nausea, one causes nausea, one relieves nausea. The anti-nausea effect of marijuana is well established, including the specific receptor pathway and pharmacology involved. When used infrequently or moderately, the ant-nausea effects win out, when used heavily the nausea inducing effects can increase exponentially resulting in cannabis hyperemesis syndrome.

And no, marijuana is not "slowly killing their gut" as there's no evidence it causes ischemia or any sort of progressive necrosis. The mechanism of cannabis hyperemesis syndrome is not fully understood, but considering it's most reliably treated by applying heat to the scalp, it's more likely it's cause is a CNS pathway and not by direct effects on the gut.

It's been studied and documented to a ridiculous degree that cannabanoids not only decrease gastric secretions, but they also inhibit peristalsis:

"Cannabinoids inhibit electrically evoked contractions of isolated small intestine

The ability of cannabinoids to inhibit electrically evoked contractions of isolated preparations of small intestine mounted in organ baths and the underlying mechanisms have been the subject of many investigations over the past 30 years. These have involved experiments, mainly with guinea pig tissue, in which contractions have been produced by electrical stimulation of prejunctional neurones rather than by direct stimulation of intestinal smooth muscle."

https://gut.bmj.com/content/48/6/859

Just one example of one study.

Let's follow this critical line of thinking then, to it's conclusion. Basic nursing principles teach the novice nurse that "checking for bowel sounds", particularly after surgery or in the possibility of obstruction---is essential. If the bowel is obstructed in any way or peristalsis is suspended because of anesthesia or other medications---it then becomes difficult or impossible for food to traverse the intenstines.

What then, is the outcome of sluggish or paralyzed (densensitized receptors due to consistent and constant cannabanoid intake) bowel?

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4972088/

This dysfunction causes many things---especially malnutrition, obstruction of the bowel, possible perforation of the bowel---

Many of which----lead to the death of the patient.

Does the death of the patient include the bowel as well?

PeakRN

Specializes in Adult and pediatric emergency and critical care.

On 10/17/2019 at 11:12 AM, FolksBtrippin said:

Also marijuana induced psychosis. Probably the most common thing you'll see related to marijuana.

While marijuana has been shown to be consumed in higher amounts by those with mental illness, it has not been shown to cause the development on any kind of long term mental health disease. Any alteration in mental status from marijuana alone (exclusive of concomitant drug use or other disease process such as hypoxia) will resolve with time.

It certainly does not trigger or cause psychosis in the way that methamphetamine, synthetic drug mimics (bath salts, spice, K2, black mamba, et cetera), and many other substances can.

PeakRN

Specializes in Adult and pediatric emergency and critical care.

We see no shortage of recreational marijuana use in the ED.

The largest volume we see are adults who have not used marijuana since they were young several decades ago who are now consuming a drug that is several times more potent than what they used to use. We also see a fair number of people who take a large does of edibles either by accident not realizing that they are only supposed to eat a small portion of what they purchased. Many packages contain 100 mg of THC including some drinks that are only intended to have a small portion consumed but could easily be misunderstood to be consumed in it's entirety. Typically a 'normal' amount of an edible is 5-10 mg. Many patients also consume several 'doses' as it can take up to two hours for the high to kick in and they assume that they simply aren't getting high, then have profound changes when the drugs effects are actually in effect.

The second highest patient population we see is those with marijuana induced cyclic vomiting.

Pediatric ingestions (outside of intentional adolescent users) are very rare. While always very emotionally frustrating it has largely been sensationalized. Certainly different centers will see different volumes, but in past couple of years I can only think of one kid that got admitted to our PICU, and we see very small number in the ED who are discharged. This isn't to say that it isn't a public health concern or that we shouldn't have good controls about how marijuana is kept safe. I see far more accidental ingestions from other medications or toxic substances than marijuana, in fact I've seen more accidental ingestions of methamphetamine than marijuana.

MunoRN, RN

Specializes in Critical Care.

7 hours ago, SolosGirl said:

It's been studied and documented to a ridiculous degree that cannabanoids not only decrease gastric secretions, but they also inhibit peristalsis:

"Cannabinoids inhibit electrically evoked contractions of isolated small intestine

The ability of cannabinoids to inhibit electrically evoked contractions of isolated preparations of small intestine mounted in organ baths and the underlying mechanisms have been the subject of many investigations over the past 30 years. These have involved experiments, mainly with guinea pig tissue, in which contractions have been produced by electrical stimulation of prejunctional neurones rather than by direct stimulation of intestinal smooth muscle."

https://gut.bmj.com/content/48/6/859

Just one example of one study.

Let's follow this critical line of thinking then, to it's conclusion. Basic nursing principles teach the novice nurse that "checking for bowel sounds", particularly after surgery or in the possibility of obstruction---is essential. If the bowel is obstructed in any way or peristalsis is suspended because of anesthesia or other medications---it then becomes difficult or impossible for food to traverse the intenstines.

What then, is the outcome of sluggish or paralyzed (densensitized receptors due to consistent and constant cannabanoid intake) bowel?

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4972088/

This dysfunction causes many things---especially malnutrition, obstruction of the bowel, possible perforation of the bowel---

Many of which----lead to the death of the patient.

Does the death of the patient include the bowel as well?

There are a number of processes that can cause varying degrees of reduced peristalsis, eating cheese or bread for instance, your assumption that because marijuana can cause a relatively mild reduction in peristalsis that it can then cause death is a bit silly.

The mechanism by which marijuana slows peristalsis is self-limiting, and unlike other processes that can slow peristalsis marijuana has never been associated with bowel obstruction, perforation, or bowel ischemia, which is why it's sometimes used for therapeutic slowing of peristalsis for conditions such as IBS. The number of deaths related to marijuana-associated decreased motility is zero.

I get that there's a long-established stigma related to marijuana use and marijuana aficionados have a habit of overstating it's benefits, but don't think deceptively vilifying it or hostility towards those who use it is productive either.

subee, MSN, CRNA

Specializes in CRNA, Finally retired.

Can anyone explain to me what happens to the qualitative measurements of MJ when it changes from a medicinal category to recreational? Is "medical quality" MJ still available or does it become a free for all once it's sold as recreational? Just wondering. I got burned with some medical MJ from Colorado which made me highly suspicious of qualitative measurements of this product which claimed to be low in THC's and high in CBD's...not.

MunoRN, RN

Specializes in Critical Care.

19 minutes ago, subee said:

Can anyone explain to me what happens to the qualitative measurements of MJ when it changes from a medicinal category to recreational? Is "medical quality" MJ still available or does it become a free for all once it's sold as recreational? Just wondering. I got burned with some medical MJ from Colorado which made me highly suspicious of qualitative measurements of this product which claimed to be low in THC's and high in CBD's...not.

Legalization of 'medical marijuana' typically hasn't included strict requirements for laboratory analysis testing. I don't know about the more recent states, but at least with the first two states to legalize recreational marijuana, Washington and Colorado, the legalization legislation included strict requirements for testing by a third party lab, so the percentages of cannabinoids should be fairly reliable. In Colorado for instance, there weren't really any requirements for reliable laboratory testing prior to it becoming legalized for recreational use.

Walti, LPN, LVN, RN, EMT-I

Specializes in ICU/ER mostley ER 25 years.

Wow, far out man, this was really good, like it blew my mind away. Hey does anyone want pizza?

What can I say I was young in the 60s and 70s. I don't know that I've ever seen a case of hyperemesis D/T cannabis use. ON the other hand it might just be because we didn't check for that as a cause. I kind of think that most personal use of cannabis has fewer medical complications than other abusable substances. I do have concerns about the implications involving other medical issues. Of particular concern is patient education, I doubt that most patients will recall discharge instructions and allowing them to drive home after treatment is also a concern.

I do get so tired of the argument about if it wasn't safe they wouldn't have legalized it. I truly believe that it is dumbing down society.

subee, MSN, CRNA

Specializes in CRNA, Finally retired.

In the 70's, I went to MD Anderson in Houston to take a class in chemotherapy nursing (all very new at the time). I did a rotation in the out-patient clinic where many patients were staying in near-by motel rooms for their treatments and secretarial crew members were calling constantly for taxis. The patients were smoking weed freely around the clinic and by the time their cabs arrived they would be wandering around admiring the trees:). It was like herding cats.

myoglobin, ASN, BSN, MSN

Specializes in ICU, trauma, neuro.

What will we see in the ED with legalized cannabis?

a. Perhaps less DUI's and trauma related accidents if fewer people drink and drive and instead stay home and utilize cannabis.

b. Perhaps less injuries from shootings, fights, and stabbings given that the drug is associated with less aggression (in most people) than most other drug alternatives.

There are many bad things about chronic cannabis use including psychosis in those with specific gene mutations, and documented negative impacts on intelligence (to say nothing of lung damage if it is smoked rather than eaten). However, it is far less deadly than alcohol and not even in the same ballpark with nicotine.

Edited by myoglobin

I have seen in a teen would was extremely thin and developed all the clinical signs in C.H.S as example needing to take hot showers, tiger balm, smokes a bowl a/day, retching, and losing weight with no relief inpatient. CT scan showed the secondary diagnosis of Superior Mesenteric Artery Syndrome. Basically compression from loss of fat stores. Pt was transferred to get stented in larger facility.

Don't forget the crushing chest pain from over-eating edibles!!

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