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

[traumaRUs]

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.

[MunoRN, RN]

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]

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]

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]

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]

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]

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.

[avado, BSN]

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.

[avado, BSN]

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