Cannabis intoxication after accidental ingestion in infants: urine and plasma concentrations of Δ-9-tetrahydrocannabinol (THC), THC-COOH and 11-OH-THC in 10 patients

Quantifying Heart Rate Changes After Delta-9-Tetrahydrocannabinol Administration Using a PBPK-PD Model in Healthy Adults

Background: As cannabis becomes legal in several U.S. states, the risk of THC-induced tachycardia increases. This study aimed to develop and verify a physiologically based pharmacokinetic-pharmacodynamic (PBPK-PD) model to assess the impact of THC and its active metabolite, 11-hydroxy-THC (11-OH-THC), on the heart rate of healthy adults. Methods: A PBPK-PD model for intravenous (IV) 11-OH-THC administration was first developed. Secondly, a PBPK-PD model for IV THC, combined with the metabolized 11-OH-THC, was established, verified, and validated. Direct PD models driven by the plasma, brain, and heart concentrations of THC and 11-OH-THC predicted using our previously verified PBPK model were tested for model development. Finally, the risks of tachycardia at a rest condition from various doses of oral and inhaled THC were simulated for 500 individuals aged 18-65 years, with a sex ratio of 1:1 and a baseline heart rate of 70 beats per minute. Results: The PD model was best described by a direct nonlinear Emax model driven by the sum of the total THC and 11-OH-THC concentrations in their effect compartments linked to their heart compartments. In 42 simulated dosing regimens with THC doses ranging from 2 to 69.4 mg, 97% of the observed heart rates or heart rate changes following THC administration fell within the 5th to 95th percentiles of the model-predicted values. Similarly, for two simulated 11-OH-THC IV doses, 93% of the observations fell within this range. Simulations indicated that half of the simulated population would experience tachycardia at doses of 60 mg and 15 mg of THC for oral and inhaled administration, respectively. The simulated risks of tachycardia based on specific conditions should be interpreted with caution. Conclusions: Our verified PBPK-PD model successfully describes the heart rate changes in healthy adults after IV, oral, and inhaled THC administration. This model provides a tool to predict the effects of THC and its primary metabolite on heart rates, offering valuable insights for assessing the risk of tachycardia in both clinical and recreational cannabis use.

Trends in cannabis use in New Jersey: Effects of COVID-19 and cannabis legalization

Objectives

With the legalization of cannabis in New Jersey on April 21, 2022, including the licensing of cannabis dispensaries, concerns have arisen about potential adverse events related to cannabis use. Here, we explore temporal trends and risk factors for cannabis-related harm in both adult and pediatric cannabis-related visits at a tertiary care academic institution.

Methods

We performed a retrospective chart review and temporal trend analysis via the electronic health record from May 1, 2019 to October 31, 2022, covering 2 years before, and 6 months after, cannabis legalization in New Jersey. The pediatric charts identified were analyzed for root causes of adverse events, and changes in the frequency of specific unsafe practices since cannabis legalization were tracked.

Results

We found that adult cannabis ED-related visits significantly increased during the COVID-19 pandemic and remained higher than pre-pandemic levels for the remainder of the study periods, without a significant change upon legalization. Pediatric rates of cannabis-related ED visits did not vary significantly during the study period. The vast majority of visits for children aged 0-12 years were related to accidental cannabis exposures-often a household member's edibles-whereas most visits for older children stemmed from intentional cannabis use.

Conclusion

This project highlights the unintended consequences of wider cannabis access in New Jersey. Notably, cannabis use increased even before its legalization, presumably in response to the COVID-19 pandemic and its attendant mental health effects. Rates of cannabis use disorder and its highlight of other concurrent psychiatric disorders are important topics for both clinicians and lawmakers to consider.

Detection of Cannabinoids in Oral Fluid Specimens as the Preferred Biological Matrix for a Point-of-Care Biosensor Diagnostic Device

An increasing number of countries have started to decriminalize or legalize the consumption of cannabis for recreational and medical purposes. The active ingredients in cannabis, termed cannabinoids, affect multiple functions in the human body, including coordination, motor skills, memory, response time to external stimuli, and even judgment. Cannabinoids are a unique class of terpeno-phenolic compounds, with 120 molecules discovered so far. There are certain situations when people under the influence of cannabis may be a risk to themselves or the public safety. Over the past two decades, there has been a growing research interest in detecting cannabinoids from various biological matrices. There is a need to develop a rapid, accurate, and reliable method of detecting cannabinoids in oral fluid as it can reveal the recent intake in comparison with urine specimens, which only show a history of consumption. Significant improvements are continuously made in the analytical formats of various technologies, mainly concerning improving their sensitivity, miniaturization, and making them more user-friendly. Additionally, sample collection and pretreatment have been extensively studied, and specific devices for collecting oral fluid specimens have been perfected to allow rapid and effective sample collection. This review presents the recent findings regarding the use of oral fluid specimens as the preferred biological matrix for cannabinoid detection in a point-of-care biosensor diagnostic device. A critical review is presented, discussing the findings from a collection of review and research articles, as well as publicly available data from companies that manufacture oral fluid screening devices. Firstly, the various conventional methods used to detect cannabinoids in biological matrices are presented. Secondly, the detection of cannabinoids using point-of-care biosensors is discussed, emphasizing oral fluid specimens. This review presents the current pressing technological challenges and highlights the gaps where new technological solutions can be implemented.

False-Negative Confirmatory Testing in Patients With Cannabinoid-Positive Urine Drug Screens

This cross-sectional study discusses false-negative results associated with a change in the reporting threshold of 11-nor-9-carboxy-Δ9-tetrahydrocannabinol.

Predicting Maternal and Infant Tetrahydrocannabinol Exposure in Lactating Cannabis Users: A Physiologically Based Pharmacokinetic Modeling Approach

A knowledge gap exists in infant tetrahydrocannabinol (THC) data to guide breastfeeding recommendations for mothers who use cannabis. In the present study, a paired lactation and infant physiologically based pharmacokinetic (PBPK) model was developed and verified. The verified model was used to simulate one hundred virtual lactating mothers (mean age: 28 years, body weight: 78 kg) who smoked 0.32 g of cannabis containing 14.14% THC, either once or multiple times. The simulated breastfeeding conditions included one-hour post smoking and subsequently every three hours. The mean peak concentration (Cmax) and area under the concentration-time curve (AUC(0-24 h)) for breastmilk were higher than in plasma (Cmax: 155 vs. 69.9 ng/mL; AUC(0-24 h): 924.9 vs. 273.4 ng·hr/mL) with a milk-to-plasma AUC ratio of 3.3. The predicted relative infant dose ranged from 0.34% to 0.88% for infants consuming THC-containing breastmilk between birth and 12 months. However, the mother-to-infant plasma AUC(0-24 h) ratio increased up to three-fold (3.4-3.6) with increased maternal cannabis smoking up to six times. Our study demonstrated the successful development and application of a lactation and infant PBPK model for exploring THC exposure in infants, and the results can potentially inform breastfeeding recommendations.

The Potential Proconvulsant Effects of Cannabis: a Scoping Review

INTRODUCTION

Cannabis' effect on seizure activity is an emerging topic that remains without consensus and merits further investigation. We therefore performed a scoping review to identify the available evidence and knowledge gaps within the existing literature on cannabis product exposures as a potential cause of seizures in humans.

METHODS

A scoping review was conducted in accordance with the PRISMA Extension for Scoping Reviews guidelines. The PubMed and Scopus databases were searched over a 20-year period from the date of the database query (12/21/2020). Inclusion criteria were (1) English language original research articles, (2) inclusion of human subjects, and (3) either investigation of seizures as a part of recreational cannabinoid use OR of exogenous cannabinoids as a cause of seizures.

RESULTS

A total of 3104 unique articles were screened, of which 68 underwent full-text review, and 13 met inclusion/exclusion criteria. Ten of 11 studies evaluating acute cannabis exposures reported a higher seizure incidence than would be expected based on the prevalence of epilepsy in the general and pediatric populations (range 0.7-1.2% and 0.3-0.5% respectively). The remaining two studies demonstrated increased seizure frequency and/or seizure-related hospitalization in recreational cannabis users and those with cannabis use disorder.

CONCLUSIONS

This scoping review demonstrates that a body of literature describing seizures in the setting of cannabis exposure exists, but it has several limitations. Ten identified studies showed a higher than expected incidence of seizures in populations exposed to cannabis products. Based on the Bradford Hill criteria, delta-9 tetrahydrocannabinol (THC) may be the causative xenobiotic for this phenomenon.

Critical care interventions in children aged 6 months to 12 years admitted to the pediatric intensive care unit after unintentional cannabis exposures

BACKGROUND

Cannabis exposures in children have risen sharply in recent years, resulting in increased hospital visits and admission to pediatric intensive care units (PICUs). The intent of this study was to describe the proportion of pediatric patients admitted to the PICU after unintentional cannabis ingestion that received critical care interventions (CCIs) along with describing trends over time in hospitalization, admission to the PICU, and clinical effects and treatments outside of the PICU.

METHODS

This was a retrospective database study utilizing the National Poison Data System (NPDS) from 1/1/2000 to 12/31/2020. Children 6 months to 12 years of age with single substance cannabis exposures were included.

RESULTS

A total of 12,882 cases were included. There was an increase in the proportion of cases seen in a hospital over time from 43.8% in 2000 to 54.6% in 2020 (range 29.1-62.6%). In patients seen in a HCF, the proportion admitted to the PICU was 9.5% in 2000 and 14% in 2020 (range: 5.6-29.0%). The 875 (6.8%) children admitted to the PICU were analyzed for the primary outcome. CCIs were performed in 69/875 (7.9%) cases that were admitted to the PICU. The most common CCIs in the PICU were intubation and sedation, 4.9 and 3.7%, respectively.

CONCLUSIONS

Unintentional pediatric cannabis exposures are associated with clinically significant effects, including respiratory depression, hypotension, and bradycardia, but fewer than 5% of exposures were treated with CCIs, like intubation or vasopressors, in patients admitted to the PICU. Further work should assess specific reasons for admission to the PICU.

Unintentional cannabis poisoning in toddlers: A one year study in Marseille

France is the country with the highest prevalence of cannabis use in Europe, despite the fact that cannabis has not been legalized. This prevalence is still increasing along with THC content in cannabis products. In the meantime, unintentional cannabis poisoning by ingestion in toddlers is constantly rising. The aim of this study was to document children's cannabis poisoning biologically and clinically. Plasma and urine samples were extracted by solid phase extraction and analyzed by liquid chromatography coupled to tandem mass spectrometry. Children under 4 years old admitted in pediatric emergency departments for cannabis intoxication between February 1st 2019 and January 31st 2020 were included in this study. Twenty-six children were included (14 female and 12 male), the mean age was 17 months (10-41 months). THC, 11-OH-THC and THC-COOH plasma concentrations ranged from 2.9 to 93 ng/mL, 2.6-65 ng/mL and 29-914 ng/mL, respectively. The most frequent symptoms were drowsiness and hypotonia. Six critical cases were observed: 5 coma and 1 respiratory depression. All children having THC plasma concentrations over 60 ng/mL were in coma. Cannabis poisoning in toddlers become more frequent, 9 cases/year were reported in Marseille in 2007 and 26 cases/year in this study. There is a rising in severe clinical cases, particularly coma. These observations could be explained by an increase in THC content in cannabis products, and a trivialization of cannabis consumption. The unintentional ingestion of cannabis by children is a serious public health concern, and cannabis legalization could worsen this problem.

Setting the baseline: a description of cannabis poisonings at a Canadian pediatric hospital prior to the legalization of recreational cannabis

INTRODUCTION

This study describes the events and circumstances preceding children aged 16 years or younger being treated for cannabis poisoining in the emergency department (ED) of a Canadian pediatric hospital.

METHODS

We extracted cannabis poisoning treated in the ED at British Columbia Children's Hospital (BCCH) between 1 January, 2016 and 31 December, 2018, from the Canadian Hospitals Injury Reporting and Prevention Program (CHIRPP) database. The poisonings were distinguished by the inadvertent or intentional ingestion of cannabis. We reviewed the hospital's electronic health information system and the patients' health records to obtain additional information on the context, including spatial and temporal characteristics.

RESULTS

Of the 911 poisonings treated at BCCH, 114 were related to intentional cannabis use (12.5%). Fewer than 10 poisonings resulted from inadvertent ingestions by children and the median age for these was 3 years. All inadvertent ingestion occurred at home and involved cannabis belonging to the patient's family. The vast majority of poisonings resulted from the intentional use of cannabis only (28.9%) or cannabis use with other psychoactive substances (co-ingestions; 71.1%). The median patient age was 15 years. Most patients reported consuming cannabis through inhalation with peers. Cannabis and co-ingestion poisonings were more often reported on weekdays than weekends. The consumption of cannabis leading to poisoning more often occurred in private residences. Patients with cannabis poisoning more often sought medical treatment themselves or were helped by their family.

CONCLUSION

The characteristics of cannabis poisonings among children are described for the three-year period prior to recreational cannabis legalization in Canada in order to set a baseline for future comparisons. Implications for improving injury prevention initiatives and policies are discussed.