With the legalization of recreational cannabis in Canada, doctors there expected to see a jump in drug poisonings among young children, especially as edibles such as chocolates and candies became available.
They got that and more.
The incidence in emergency departments (EDs) of cannabis poisonings ― a term cannabis advocates consider inflammatory ― in young children in Ontario rose ninefold in the aftermath of legalization, an increase far greater than researchers in Ottawa expected compared with similar changes in the United States.
Dr Daniel Myran
“After legalization, Colorado saw around a doubling of emergency department visits. We saw a ninefold increase,” Daniel Myran, MD, a family physician and public health and preventive medicine specialist at the Ottawa Hospital and the University of Ottawa Department of Family Medicine, said. “We saw more frequent and severe ED visits due to cannabis poisoning in children under 10 following the legalization of cannabis, and the legalization of edible cannabis products appears to be a key factor.”
Myran and his colleagues reported their findings as a research letter in JAMA Network Open.
Myran said the mismatch in findings between the United States and Canada likely partly reflects the use of different sources of data. Whereas in the United States, the numbers mainly come from reports to state poison control centers or ED visits to hospital networks, the Canadian researchers measured all ED reports of inadvertent exposures to cannabis in young children in Ontario.
The Ontario research team examined three periods: prelegalization; after flower-based cannabis products and oils were legalized in October 2018; and after commercial cannabis edibles, including gummies and chocolates, and other products were legalized and became available for sale in late January 2020.
Although single hospitals have reported on child cannabis poisonings before, Myran called the new analysis the largest study to date to assess all healthcare visits for a regional population (2.35 million children in the province from 2016 through 2021).
The study found 522 ED visits for cannabis exposures in children from infancy through age 10: 81 visits recorded before legalization in 2016–2018, 124 in the first stage of legalization in 2018–2020, and 317 in 2020–2021, when edibles were legalized.
The average number of ED visits increased ninefold between the prelegalization period and the 2020–2021 period ― 2.5 visits per month on average rising to 22.6 visits per month on average.
Children who went to the ED on average were about 4 years old, according to the researchers.
No deaths were recorded. Only 3.6% of patients (19 in total) were admitted to the intensive care unit, but 38.5% (122) were hospitalized, they report.
Jenna Nikolaides, MD, a medical toxicologist at the Illinois Poison Center, Chicago, agreed that differences in how the data are reported n Canada and the United States may have led to the seeming spike.
She said the experience in the United States has been similar to that in Canada, but pioneering states such as Colorado introduced recreational drugs all at once rather than phasing them in.
“It was like the Wild West, with smoking, vaping, and edibles all introduced at once,” said Nikolaides, who also is assistant professor of emergency medicine at Rush University Medical Center, Chicago. “There was a huge explosion of unintended consequences, including pediatric poisonings.”
Nikolaides said evidence-based regulations typically were not used in the introduction of recreational cannabis, so lessons have been learned the hard way.
Myran stressed the challenge of regulating legal cannabis in Canada and elsewhere.
“In many ways, the goals of the Cannabis Act [which legalized the drug in 2018] are in opposition: eliminate the illicit market but avoid health impacts, such as poisonings or increases in youth cannabis use. If you make cannabis products too accessible or appealing, you can end up with a scenario where you will see greater youth cannabis use and increases in poisonings in very young children,” he said.
“The cannabis industry is interested in expanding sales as quickly as possible and replacing the illicit market,” Myran added. “It’s the role of government regulators to ensure that legal sales are not harming the health of the population, and that balance right now may not be adequately protecting very young children.”
Nikolaides said regulators in some states, such as Colorado, had to undergo legislative redos, such as banning gummy bears and prohibiting chocolate bar knockoffs that closely resemble branded sweets. “These are too enticing to children,” she said.
“Once they’ve been removed from their packaging, these products are identical to something very appealing to kids,” Myran said. “They look just like a cookie, just like soft candy. And a large number of children appear to be consuming them and coming to emergency departments”
Myran said Canada, like Colorado, may have to consider legislative revisions to prevent cannabis exposures.
Paul Armentano, deputy director of the National Organization for the Reform of Marijuana Laws (NORML), which has been pushing for reform of the cannabis legislation for more than 50 years, called the term poisonings “sensational” and preferred to call them “inadvertent exposures.”
“In general, inadvertent cannabis exposures resulting in either calls to poison control centers and/or hospitalizations certainly do occur, but it seems sensational to label these incidents as ‘poisonings,’ ” Armentano told Medscape Medical News. “Cannabis and/or THC exposure, regardless of quantity, is incapable of causing fatal overdose, and exposure to the substance itself does not result in the types of outcomes, such as organ failure and death, associated with the intake of traditionally toxic substances — like laundry detergent pods or alcohol.”
He stressed that little to no medical interventions are required in these cases, unlike traditional poisonings, in which children inadvertently consume alcohol or laundry detergent pods.
The researchers have disclosed no relevant financial relationships.
JAMA Netw Open. Published online January 7, 2022. Full text
Howard Wolinsky is a medical writer in Chicago.
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