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6/ 29/ 2015 Objectives Brief review of CDPHE Retail Marij uana Public Health Advisory Committee Marij uana Use Among Marijuana Pediatric Exposure Prevention: Adolescents and Young Adults and Findings A Summary of the Evidence and Resources

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6/ 29/ 2015 The clinical guidance content in this presentation is draft language. The final document will be available this summer. 1

Marijuana Pediatric Exposure Prevention: A Summary of the Evidence and Resources for Colorado Health Care Providers

Tracy Foo MD, MPH Marij uana Clinical Guidelines Coordinat or Colorado Depart ment of Public Healt h and Environment June 2015

Objectives

  • Brief review of CDPHE Retail Marij uana Public

Health Advisory Committee Marij uana Use Among Adolescents and Young Adults and Findings

  • Provide an overview of Pediatric Exposure

Prevention Clinical Guidance Document Development and Content.

  • Describe the marij uana education resources

available from CDPHE for health care providers.

Marijuana Use by Colorado Youth

  • Healthy Kids Colorado S

urvey

  • Administered in Fall 2013 to over 40,000 middle and

high school students.

  • Middle school:
  • 8.8%

reported ever trying marij uana

  • 5.1%

reported marij uana use in past 30 days

  • High school:
  • 36.9%

reported trying marij uana one or more times

  • 19.7%

reported marij uana use in past 30 days

CDPHE: Marijuana and Public Health

  • Monitor health effects of marij uana use
  • Quest ions on marij uana use added t o:

BRFS S , PRAMS , YRBS / Healt hy Kids Colorado survey

  • Dat a collect ion/ analysis, including Colorado ER and

hospit alizat ion dat a, Rocky Mount ain Poison Cont rol dat a

  • Ret ail Marij uana Public Healt h Advisory Commit t ee
  • Medical Marij uana Registry and Research Grant Program
  • Retail Marij uana Education Team
  • Prevent ion campaign
  • Clinical guidelines
  • Yout h prevent ion

Retail Marijuana Public Health Advisory Committee

  • 13 members representing public health, multiple

medical specialties, epidemiology, toxicology

  • Review the scientific literature currently available
  • n health effects of marij uana
  • Developed a lit erat ure review process including rat ing

qualit y of each st udy

  • Translat e science int o public healt h messages
  • Recommend public healt h relat ed policies, surveillance

act ivit ies and research gaps

  • Monitoring Health Concerns Related to Marij uana in

Colorado: 2014

Literature Review Topics

  • Marij uana Use During Pregnancy and

Breastfeeding

  • Neurological and Mental Health Effects
  • Effects on Youth and Unintentional Poisonings
  • Marij uana Dose and Drug Interactions
  • Extra-pulmonary Effects and Inj uries
  • Respiratory Effects and Lung Cancer
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6/ 29/ 2015 The clinical guidance content in this presentation is draft language. The final document will be available this summer. 2

Findings Summary: Health effects in adolescents and young adults

Substantial evidence Moderate evidence Limited evidence Insufficient evidence Mixed evidence Other illicit drug use and addiction after adolescence Impaired cognitive abilities and academic performance after 28 days abstinence Lower IQ after short abstinence Anxiety after adolescence Psychotic symptoms or disorders like schizophrenia Less high school graduation Less likely to earn college degree Depression after adolescence Increased MJ use and addiction after adolescence Suicidal thoughts

  • r attempts

Alcohol or tobacco use and addiction after adolescence Quitting lowers risk of cognitive and mental health effects

Examples of Public Health Statements

  • Regular marij uana use by adolescent s and young adult s is

associat ed wit h impaired learning, memory, mat h and reading achievement , even 28 days aft er last use.

  • These impairment s increase wit h more frequent

marij uana use.

  • Marij uana use by adolescent s and young adult s - even
  • ccasional use - is associat ed wit h fut ure high-risk use of

alcohol, t obacco, and ot her drugs like cocaine, ecst asy,

  • pioids and met hamphet amine.
  • S

t art ing marij uana use during adolescence or young adult hood is associat ed wit h fut ure marij uana addict ion.

Examples of Research Gaps:

  • Evaluat e effect s of occasional marij uana use vs. regular/ heavy

use

  • More st udies wit h varied t ime periods of abst inence t o assess

t he durat ion of cognit ive impact of marij uana use

  • Evaluat e effect of marij uana use on males vs. females
  • Compare fact ors associat ed wit h init iat ion of use by

adolescent s in st at es wit h different legal st at us

  • Assess causalit y rat her t han only report ed associat ions

Marijuana Clinical Guidelines

  • S

B 14-215: Contract for the creation of clinical guidelines as a resource for health care providers when they recognize that a person is at risk from marij uana use or exposure.

  • To develop evidence-based guidance for Colorado

health care providers to talk with patients about marij uana exposure

  • Challenges: limitation in evidence, avoid
  • verstating the available evidence

Guidance Development Process

  • Review Retail Marij uana Public Health Advisory

Committee findings summaries

  • Healthcare Provider S

urvey

  • Engaged multiple, diverse stakeholders
  • Guidance Development Committee
  • Focus group input
  • Formatting and pilot testing

Guidance Document

  • Encourages providers t o t alk wit h parent s/ pat ient s about

marij uana along wit h ot her subst ance use.

  • Many st at ement s have associat ed middle school reading level

language t o use wit h parent s/ pat ient s.

  • It is not int ended as a read t hrough document .
  • Ideally, providers will familiarize themselves with the information

and use the document as a reference when needed.

  • Providers can choose what information that they want to share with

their patient based on the patient type/ situation.

  • It is also not int ended t o replace your facilit y’ s policies or

guidelines.

  • colorado.gov/ cdphe/ marij uana-clinical-guidelines
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6/ 29/ 2015 The clinical guidance content in this presentation is draft language. The final document will be available this summer. 3

2 Pediatric Guidance Documents:

  • Discussions with parents/ guardians,

including age specific talking points to use with parents/ guardians of children age 0-8 and 9-20

  • Discussions with adolescents/ young

adults age 9-20

Pediatric Exposure Prevention Guidance

  • S

creening questions

  • Talking points: S

afe storage, safe environments, health effects, medical marij uana

  • S

econdhand smoke

  • Breastfeeding
  • Mandatory reporters
  • Parenting and safety: driving
  • Accidental Ingestion/ Using Too Much
  • Common myths about marij uana
  • Resources for health care providers and patients

Key Points

  • Screen for marij uana use at all visits
  • Talk about potential risks of marij uana

use by youth

  • Talk about marij uana safety with parents

and youth

Discussion with parents:

Age specific talking points to use with parents of children age 0-8 and 9-20

DISCUSSIONS WITH PARENTS

Screening Questions for Parents

Language for all parent s: Now t hat marij uana is legal in Colorado, we would like t o t alk wit h you about it t o help you keep kids safe. How do you st ore subst ances t hat may harm a child in your home? S uch subst ances include alcohol, marij uana, t obacco, prescript ion drugs, over t he count er medicines, cleaning product s or ot her pot ent ially harmful chemicals. Does anyone smoke in your home (marij uana or t obacco)? Does anyone in your home use any ot her form of marij uana, such as vaping, edibles or t inct ures? Does anyone else who cares for your child use marij uana or have it in t heir home?

Talking to parents: Safe Storage

Language for parents of children 0-8:

  • Remember t hat kids can get int o all kinds of t hings t hat you assume

are out of reach or not of int erest .

  • Like household chemicals or bleach; marij uana, alcohol and some

medicat ions are dangerous f or children.

  • Keep all pot ent ially harmf ul subst ances in a locked area, out of sight

and out of reach of children.

  • Lock boxes or locked cabinet s are examples of saf e st orage
  • pt ions.
  • If you don’ t have a locked area, make sure product s are out of

reach and out of sight of children.

  • Keep in mind, saf e st orage f or young children may not st op older

children or t eens.

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6/ 29/ 2015 The clinical guidance content in this presentation is draft language. The final document will be available this summer. 4

Talking to parents: Safe Storage

Language for parents 9-20:

  • Make sure t o st ore any marij uana, alcohol or prescript ion drugs in

a locked area so your child cannot get t o t hem.

  • Be sure t hose it ems are securely locked, not j ust out -of -sight . Lock

boxes or locked cabinet s are examples of saf e st orage opt ions.

  • As yout h get older, t hey may get int o it ems you t hink are saf ely

st ored. This is why it is also import ant t o t alk t o yout h about t he risks of using t hose subst ances.

Talking to parents: Effects of use by Youth

Adolescents and young adults who regularly use marij uana are more likely than non-users to have impairment of cognitive and academic abilities for at least 28 days after last use. Language for all parents: Yout h who use marij uana regularly are more likely t o have problems wit h learning and memory as well as lower mat h and reading

  • scores. Marij uana can make it harder t o learn,

somet imes f or weeks af t er quit t ing.

Talking to parents: Medical marijuana

Medical marij uana is legal for anyone over age 18 in Colorado t hat has t he appropriat e document ed diagnosis of one of t he approved medical condit ions. If a yout h under t he age of 21 has a medical marij uana card, let parent s know t hat t here may be ot her opt ions t hat are safer ways t o t reat t hese issues. Discuss t he risks/ benefit s

  • f marij uana use by yout h and pot ent ial alt ernat ives, as

appropriat e. Learn more about approved condit ions for medical marij uana and how t he laws differ for receiving a card if t he pat ient is under age 18 at colorado.gov/ cdphe/ medicalmarij uana.

Talking to parents: Medical marijuana

Language for parents of medical marijuana patients: Can you t ell me about why you are using medical marij uana t o t reat your child? How does medical marij uana help your child? How do you feel about your son or daught er using medical marij uana? Has your son or daught er’ s healt h condit ion improved wit h medical marij uana use? Have t here been any problems wit h his or her medical marij uana use? The decision t o use medical marij uana (as wit h any medicat ion) is based on if t he benefit s of t he t reat ment

  • ut weigh t he pot ent ial risks t o t he young person. That is

somet hing we should discuss (or you can furt her discuss wit h your child’ s primary healt h care provider).

Talking to parents: About MJ

  • The brain is st ill developing and growing unt il about

age 25.

  • Tet rahydrocannabinol (THC) is t he chemical in

marij uana t hat makes a person f eel “ high.” THC is psychoact ive, meaning it af f ect s t he brain.

  • Because marij uana af f ect s t he brain, it can have

harmf ul ef f ect s on yout h brain development . For t he best chance of healt hy brain development and t o allow yout h t o reach t heir f ull pot ent ial, yout h of any age should not use marij uana.

  • It is illegal t o give ret ail or recreat ional marij uana t o

anyone under t he age of 21.

Talking to Parents: Safety

Marij uana use can affect a person’ s abilit y t o make decisions. This can affect a person’ s abilit y t o care for a child. It is import ant t o know t hat t he acut e effect s of marij uana use can last 8 hours or

  • more. It is appropriat e for parent s t o ask about marij uana or ot her

subst ance use before let t ing a person care for a child. Language for all parent s:

  • Marij uana can affect your abilit y t o make decisions for 8 hours
  • r more aft er use. S
  • even if you don’ t st ill feel high, marij uana

may affect your j udgment .

  • Being high or even buzzed while caring for a child is not safe. Do

not let anyone who is under t he influence of marij uana t ake care

  • f your child.
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6/ 29/ 2015 The clinical guidance content in this presentation is draft language. The final document will be available this summer. 5

Answers to Common Questions about Marijuana

Even though marijuana is natural, natural products can be dangerous or poisonous. Marij uana, like ot her plant s such as t obacco or poisonous berries, can harm people. The chemical in marij uana t hat makes you feel “ high,” t et rahydrocannabinol or THC, can have harmful effect s on brain development in yout h, including problems wit h learning, memory and school performance. Legal does not mean safe. Think about alcohol or cigaret t es. Bot h are legal t o use for adult s, but can have serious healt h risks. Marij uana use also has risks even t hough it is now legal for adult s 21 years and older. Being legal does not make marij uana safe, especially for yout h.

Discussion with parents:

Age specific talking points to use with youth ages 9-20

DISCUSSIONS WITH OLDER CHILDREN AND ADOLESCENTS Screening Questions

Now t hat marij uana is legal in Colorado, we recommend asking all adolescent s and young adult s about marij uana use. This should be done in addit ion t o asking about alcohol, t obacco and ot her drug use (including prescript ion drugs), as well as ot her safet y measures such as seat belt or bike helmet use. Do any of your friends or classmat es or anyone in your home use marij uana? Have you ever t hought about t rying marij uana? Have you ever used marij uana? If yes: When was t he last t ime you used? What form of marij uana do you use (smoking, edibles, vaping)? How oft en do you use and how much? How does marij uana help you?

Tips for providers

Start the conversation about marijuana use early with young adolescents and continue to address it with them as they get

  • lder. Of Colorado high school seniors who say t hey ever used

marij uana, more t han one-t hird first t ried it before age 15. Engage youth in open conversations. List en carefully and non- j udgment ally and provide age-appropriat e and fact -based

  • answers. Building a posit ive rapport while discussing risk behaviors

wit h yout h can help t hem make healt hier decisions. How you talk to youth is important. Consider using mot ivat ional int erviewing or screening, brief int ervent ion, referral t o t reat ment (S BIRT) t echniques in your conversat ions wit h adolescent s.

Talking to adolescents

  • Brain development cont inues unt il age 25. Talk about how

marij uana can harm t heir developing brains.

  • Language for patients:
  • Tet rahydrocannabinol, orTHC, is t he chemical in marij uana t hat

makes you “ high.” THC affect s your brain.

  • Your brain is st ill growing (unt il you are 25), so prot ect it from

marij uana.

  • Talk about how using marij uana can get in t he way of t heir goals.
  • There are consequences if yout h use marij uana.
  • Language for patients:
  • You should also know t hat many employers st ill do drug t est s, and

if you t est posit ive f or marij uana or any ot her drug, it could hurt your abilit y t o get or keep a j ob.

  • If you use marij uana and drive, you could get a DUI or lose your

driver’ s license.

Talking t o adolescent s: Driving

  • Marij uana can af f ect your abilit y t o make decisions. These ef f ect s can

last 8 hours or longer af t er using, even if you don’ t f eel high anymore.

  • Being high or even buzzed can make some act ivit ies more dangerous.

Driving a car while high or buzzed is not saf e f or t he driver or t he passengers.

  • Do not drive if you are high, buzzed or under t he inf luence of

marij uana, alcohol or ot her drugs. You can get a DUI if you use marij uana and drive.

  • Do not ride in a car if t he driver is under t he inf luence of

marij uana, alcohol or ot her drugs.

  • Even act ivit ies like riding a bike or scoot er while high or buzzed

are not saf e. You can also get a DUI if you use marij uana bef ore riding a bike or scoot er.

  • Make a plan wit h a parent or an adult you t rust t o always have a saf e

ride available if you need one.

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6/ 29/ 2015 The clinical guidance content in this presentation is draft language. The final document will be available this summer. 6

Health Care Provider Resources:

  • If concern for subst ance use disorder:
  • Cannabis Use Disorders Ident ificat ion Test (CUDIT-R)

ht t p:/ / www.bpac.org.nz/ BPJ/ 2010/ June/ docs/ addict ion_CUD IT-R.pdf or t he CRAFFT ht t p:/ / www.ceasar- bost on.org/ CRAFFT/

  • S

creening, Brief Int ervent ion, Referral t o Treat ment Guidance from S BIRT Colorado ht t p:/ / improvinghealt hcolorado.org/ clinical-guidelines- healt hcare-providers/

  • For more informat ion on mot ivat ional int erviewing and resources

ht t p:/ / www.mot ivat ionalint erviewing.org

  • For Colorado subst ance use disorder referral informat ion:
  • 1-800-CHILDREN/ 1-866-LAS

FAMILIAS (S panish Language)

  • www.linkingcare.org

Health Care Provider Resources

  • Ret ail Marij uana Public Healt h Advisory Commit t ee Report

Monit oring Healt h Concerns Relat ed t o Marij uana in Colorado: 2014

  • Colorado Mandat ory Report er Training

coloradocwt s.com/ communit y-t raining

  • For age specific t ips on t alking t o yout h and example t alking

point s, visit S peakNowColorado.org (HableAhoraColorado.org)

  • For marij uana pat ient fact sheet s and clinical guidance

document s, visit t he CDPHE Marij uana Healt h Care Provider page: colorado.gov/ cdphe/ marij uana-clinical-guidelines

Parent/Patient Resources:

  • Be sure you know Colorado’ s marij uana laws, visit

GoodToKnowColorado.com

  • For more informat ion including fact sheet s on marij uana in

Colorado, visit Colorado.gov/ marij uana (includes S panish language resources at bit .ly/ MJ_EnEspanol)

  • For age specific t ips on t alking t o yout h and example t alking

point s, visit S peakNowColorado.org (HableAhoraColorado.org)

  • For more informat ion on keeping kids safe from alcohol,

marij uana, t obacco, prescript ion medicat ions and ot her drugs, visit S mart ChoicesS afeKids.org

  • Call 1-800-CHILDREN/ 1-866-LAS
  • FAMILIAS

for free t o connect t o st at ewide resources for parent s wit h any concerns, including subst ance use.

Fact Sheets

  • Tips for Parents**
  • Y
  • uth and Marij uana**
  • Marij uana and Y
  • ur Baby**
  • Tips for Y
  • uth-S

erving Professionals

  • Answers to Common Questions about Marij uana
  • Retail Marij uana: Methods of Use
  • Retail Marij uana: Laws and Responsible Use
  • Retail Marij uana: Information for Visitors
  • Health Effects of Retail Marij uana (coming soon)

**now available in Spanish

Bottom Line

  • We need to talk to parents and patients early and

educate them about the potential risks of marij uana use by youth.

  • Resources are available for health care providers:

colorado.gov/ cdphe/ marij uana-clinical-guidelines

Thank you!

A big t hank you t o all who part icipat ed in t his guidance development process (healt h care provider survey, draft guidance feedback, focus group part icipant s and our Guidance Development Commit t ee).

Guidance Development Commit t ee: Lalit Baj aj , MD, MPH Ken Gershman, MD, MPH Michael Kosnet t , MD, MPH Amy S ass, MD, MPH S am Wang, MD, FAAP Kat hryn Wells, MD, FAAP

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6/ 29/ 2015 The clinical guidance content in this presentation is draft language. The final document will be available this summer. 7

References

  • Adolescent Healt h Dat a, Healt hy Kids Colorado Survey. Colorado

Health and Environmental Data 2013 [cited 2014; Available from: http:/ / www.chd.dphe.state.co.us/ t opics.aspx?q=Adolescent_Health_D ata

  • Colorado Department of Public Health and Environment: Retail

Marij uana Public Health Advisory Committee Report: Monitoring Health Concerns Related to Marij uana in Colorado: 2014.

Annual Update September 16, 2014 Retail Marijuana Education Program

Ali Maffey, Retail Marij uana Education Program Manager

General Education and Awareness Campaign

  • Purpose: Inform and ensure all Colorado residents and visitors

understand the parameters of safe, legal, and responsible marij uana use

  • Launched 1/5/2015
  • Multiple media avenues for delivery
  • Social media
  • GoodToKnowColorado.com
  • Campaign resources
  • Webcast recording of regional t rainings

Toolkits for local efforts Targeted education and prevention campaign

  • Continue to educate the public on legal use
  • Retailers
  • Edibles
  • High risk groups: Youth, Pregnant/ breastfeeding

women, tourists

  • Safe storage

On-going Campaign Efforts Youth Prevention Message

  • Purpose: Reinforce the reasons not to engage in underage

marij uana use and deter youth from trying it.

  • Target audience: Colorado yout h age 12-20
  • Message medium: heavy video, digit al, social media
  • Strategy: Message based on format ive research, focus group

t riads, Yout h Public Healt h Council and askable adult s

  • Production Stage: Recording video, developing websit e and

preparing for launch

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6/ 29/ 2015 The clinical guidance content in this presentation is draft language. The final document will be available this summer. 8

Insights from youth prevention research:

  • Young people rej ected language that was preachy
  • r presented as a scare tactic

Research shows:

  • Fear appeals and scare tactics do not line up with

personal experiences

  • Leads to lack of trust in prevention

Scare tactics

Source: Prevention First (2008). Ineffect iveness of fear appeals in yout h, alcohol, t obacco and ot her drug (ATOD) prevent ion. Springfield, IL: Prevention First.

Youth-focused messaging

Video, digital, social media

  • A message young people want t o promot e
  • An int eract ive plat form for young people t o share digit ally
  • Emot ional level
  • Somet hing t hey can own

An aspirat ional message: Young people want to make choices that lead to happiness today and in the future- but they need skills and askable adults

Askable Adults

  • Trust
  • Open, honest conversations about the risks
  • Reinforce messaging
  • Provide more in-depth information

Adult education to support youth Resources for You

  • Marij uana website portal: colorado.gov/ marij uana
  • S

panish: colorado.gov/ marihuana

  • Find more information
  • Print and share fact sheets

Questions?

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