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

• utcomes, 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

CO Marijuana Sales

Steamboat Marijuana tax revenue

 2014: $618 million  2015: $995 million  2016: $1.3 billion  2017: $1.5 billion  2018: $1.4 billion  Total: $6 billion  Total: $1 billion in marijuana

tax, licensing, and fee revenue

 2015: $366,456  2016: $431,112  2017: $489,885  2018: $534,753  Total: $1,822,206

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: 1st 2 yrs of life.

 Brain grows for 1st 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?

Remember Thalidomide?

 Immunomodulatory drug  1957 marketed in West Germany  Indications:

 Anxiety, insomnia, gastritis, tension, morning sickness

 Teratogen

 Phocomelia: malformed limbs

 40% survival  Deformed eyes, hearts, GI, GU tracts, blindness, deafness.

 “The road to Hell is paved with good intentions.”

Admonition

 What long term effects do today’s therapies portend?  Denver Post: 1/24/2019.

 Use of TCH for autism spectrum disorder.

Pervasive Developmental Disorders and Autism Spectrum Disorders

 Autism  Asperger’s Syndrome  Rett’s Syndrome  Childhood Disintegrative Disorder  Pervasive Developmental Disorder

Value of anecdotal evidence

 History of medicine replete with anecdotal

testimonials.

 Need to be tested in a prospective, randomized

double-blinded cohort study as to efficacy, safety.

 Long-term consequences

 Not known  May take years to become apparent.

RMHC/PSL Experience

 ~10% - 12% THC exposure in premies admitted to

NICU.

 NICU

 85 bed NICU, ~ 830 admissions/yr, 5 state referral

region.

 4% “opioid babies”  Captive population: all neonates encouraged to use

breast milk.

 Donor premie milk if maternal THC use documented.  3 weeks off THC, before maternal milk used (pump and

dump).

Question

 What is the number of term neonates who are exposed

to THC?

 Unknown.

Observation

 THC use crosses all socioeconomic classes.

Law

 Marijuana now legal for recreational use in Colorado.  Child welfare laws are set by federal government.  THC is a scheduled 1 substance (www.dea.gov).  Exposing child to marijuana during pregnancy is

considered a reportable offense to county child welfare agencies.

 Reality: These agencies overwhelmed with cases, THC

is low priority.

Recommendations

 AAP  ACOG  CDC

 All counsel against use of THC during pregnancy or

breastfeeding.

Questions?

 Money talks, reason walks?  Effect on critical thinking ability?

Fact

 There is no benefit from marijuana exposure to the

developing brain of the fetus, newborn, or infant.

 Anyone that says otherwise is either ignorant or not

truthful.

Question

 Would any of you want your baby or grandbaby

exposed to marijuana?

Observation

 The marijuana dollars are addictive.

Future Actions

 Mandate that all pots shops have visible, accessible

information regarding risks of marijuana to pregnant mothers, babies, children.

 Not a safe treatment for morning sickness.  Require this for state licensure for business.  Information is power.

Tell Your Children

 Alex Berenson: NYTimes reporter, author  Tell Your Children The Truth About Marijuana, Mental

Illness, and Violence; Free Press, 2019

 Wife, a psychiatrist who specializes in examining

mentally ill criminals.

 Quote: The loveliest trick of the Devil is to persuade

you that he does not exist.

 –C.P.Baudelaire, The Generous Gambler