Severe outcomes following pediatric cannabis intoxication: a prospective cohort study of an international toxicology surveillance registry

Neta Cohen^{1

2}, Mathew Mathew^{1

2}, Jeffrey Brent^{3

4}, Paul Wax^{5

6}, Adrienne L Davis^{1

2}, Cherie Obilom⁵, Michele M Burns⁷, Joshua Canning⁸, Kevin Baumgartner⁹, Andrew L Koons¹⁰, Timothy J Wiegand¹¹, Bryan Judge¹², Christopher Hoyte¹³, James A Chenoweth¹⁴, Blake Froberg¹⁵, Henry Farrar¹⁶, Jennifer L Carey¹⁷, Robert G Hendrickson¹⁸, Michael Hodgman¹⁹, E Martin Caravati²⁰, Michael R Christian²¹, Brian J Wolk²², Steven A Seifert²³, Yedidia Bentur²⁴, Michael Levine²⁵, Lynn A Farrugia²⁶, David Vearrier²⁷, Alicia B Minns²⁸, Joseph M Kennedy²⁹, Ron I Kirschner³⁰, Kim Aldy^{5

6}, Suzanne Schuh^{1

2}, Sharan Campleman⁶, Shao Li⁶, Daniel T Myran³¹, Lisa Feng², Stephen B Freedman³², Yaron Finkelstein^{1

2

33}

Affiliations

¹ Division of Emergency Medicine, The Hospital for Sick Children, Toronto, Canada.
² Department of Pediatrics, University of Toronto, Toronto, Canada.
³ Departments of Medicine and Emergency Medicine, University of Colorado School of Medicine, Aurora, CO, USA.
⁴ Toxicology Associates, Littleton, USA.
⁵ Department of Emergency Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA.
⁶ American College of Medical Toxicology, Phoenix, AZ, USA.
⁷ Boston Children's Hospital, Boston, MA, USA.
⁸ Department of Medical Toxicology, Banner - University Medical Center, Phoenix, AZ, USA.
⁹ Department of Emergency Medicine, Washington University School of Medicine, St. Louis, MO, USA.
¹⁰ Department of Emergency Medicine, Lehigh Valley Health Network, USF Morsani College of Medicine, Allentown, PA, USA.
¹¹ Department of Emergency Medicine, University of Rochester Medical Center, Rochester, NY, USA.
¹² Department of Emergency Medicine, Michigan State University College of Human Medicine, Grand Rapids, MI, USA.
¹³ Rocky Mountain Poison and Drug Center, Denver Health, Denver, CO, USA.
¹⁴ Department of Emergency Medicine, University of California at Davis, Sacramento, CA, USA.
¹⁵ Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, USA.
¹⁶ Arkansas Children's Hospital, University of Arkansas for Medical Sciences, Little Rock, AR, USA.
¹⁷ UMass Chan Medical School, Worcester, MA, USA.
¹⁸ Oregon Health & Science University, Portland, OR, USA.
¹⁹ Department of Emergency Medicine, Upstate Medical University, Syracuse, NY, USA.
²⁰ Department of Emergency Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA.
²¹ University of Misouri-Kansas City School of Medicine, Kansas City, MO, USA.
²² Loma Linda University School of Medicine, Loma Linda, CA, USA.
²³ Department of Emergency Medicine, University of New Mexico, Albuquerque, NM, USA.
²⁴ Rambam Health Care Campus, Technion-Israel Institute of Technology, Haifa, Israel.
²⁵ Department of Emergency Medicine, University of California at Los Angeles, Los Angeles, CA, USA.
²⁶ UF Health Shands Hospital, University of Florida College of Medicine, Gainesville, FL, USA.
²⁷ Department of Emergency Medicine, University of Mississippi Medical Center, Jackson, MS, USA.
²⁸ Department of Emergency Medicine, University of California San Diego, San Diego, CA, USA.
²⁹ Department of Emergency Medicine, University of Vermont Medical Center, Burlington, VT, USA.
³⁰ NE Regional Poison Center, Omaha, NE, USA.
³¹ Bruyère Research Institute, Ottawa, Ontario, Canada.
³² Departments of Pediatrics and Emergency Medicine, Cumming School of Medicine, University of Calgary, Calgary, Canada.
³³ Division of Clinical Pharmacology and Toxicology, Department of Paediatrics, The Hospital for Sick Children, Toronto, Canada.

PMID: 37603042
DOI: 10.1080/15563650.2023.2238121

Severe outcomes following pediatric cannabis intoxication: a prospective cohort study of an international toxicology surveillance registry

Neta Cohen et al. Clin Toxicol (Phila). 2023 Aug.

. 2023 Aug;61(8):591-598.

doi: 10.1080/15563650.2023.2238121. Epub 2023 Aug 21.

Authors

Affiliations

¹ Division of Emergency Medicine, The Hospital for Sick Children, Toronto, Canada.
² Department of Pediatrics, University of Toronto, Toronto, Canada.
³ Departments of Medicine and Emergency Medicine, University of Colorado School of Medicine, Aurora, CO, USA.
⁴ Toxicology Associates, Littleton, USA.
⁵ Department of Emergency Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA.
⁶ American College of Medical Toxicology, Phoenix, AZ, USA.
⁷ Boston Children's Hospital, Boston, MA, USA.
⁸ Department of Medical Toxicology, Banner - University Medical Center, Phoenix, AZ, USA.
⁹ Department of Emergency Medicine, Washington University School of Medicine, St. Louis, MO, USA.
¹⁰ Department of Emergency Medicine, Lehigh Valley Health Network, USF Morsani College of Medicine, Allentown, PA, USA.
¹¹ Department of Emergency Medicine, University of Rochester Medical Center, Rochester, NY, USA.
¹² Department of Emergency Medicine, Michigan State University College of Human Medicine, Grand Rapids, MI, USA.
¹³ Rocky Mountain Poison and Drug Center, Denver Health, Denver, CO, USA.
¹⁴ Department of Emergency Medicine, University of California at Davis, Sacramento, CA, USA.
¹⁵ Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, USA.
¹⁶ Arkansas Children's Hospital, University of Arkansas for Medical Sciences, Little Rock, AR, USA.
¹⁷ UMass Chan Medical School, Worcester, MA, USA.
¹⁸ Oregon Health & Science University, Portland, OR, USA.
¹⁹ Department of Emergency Medicine, Upstate Medical University, Syracuse, NY, USA.
²⁰ Department of Emergency Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA.
²¹ University of Misouri-Kansas City School of Medicine, Kansas City, MO, USA.
²² Loma Linda University School of Medicine, Loma Linda, CA, USA.
²³ Department of Emergency Medicine, University of New Mexico, Albuquerque, NM, USA.
²⁴ Rambam Health Care Campus, Technion-Israel Institute of Technology, Haifa, Israel.
²⁵ Department of Emergency Medicine, University of California at Los Angeles, Los Angeles, CA, USA.
²⁶ UF Health Shands Hospital, University of Florida College of Medicine, Gainesville, FL, USA.
²⁷ Department of Emergency Medicine, University of Mississippi Medical Center, Jackson, MS, USA.
²⁸ Department of Emergency Medicine, University of California San Diego, San Diego, CA, USA.
²⁹ Department of Emergency Medicine, University of Vermont Medical Center, Burlington, VT, USA.
³⁰ NE Regional Poison Center, Omaha, NE, USA.
³¹ Bruyère Research Institute, Ottawa, Ontario, Canada.
³² Departments of Pediatrics and Emergency Medicine, Cumming School of Medicine, University of Calgary, Calgary, Canada.
³³ Division of Clinical Pharmacology and Toxicology, Department of Paediatrics, The Hospital for Sick Children, Toronto, Canada.

PMID: 37603042
DOI: 10.1080/15563650.2023.2238121

Abstract

Introduction: An increasing number of jurisdictions have legalized recreational cannabis for adult use. The subsequent availability and marketing of recreational cannabis has led to a parallel increase in rates and severity of pediatric cannabis intoxications. We explored predictors of severe outcomes in pediatric patients who presented to the emergency department with cannabis intoxication.

Methods: In this prospective cohort study, we collected data on all pediatric patients (<18 years) who presented with cannabis intoxication from August 2017 through June 2020 to participating sites in the Toxicology Investigators Consortium. In cases that involved polysubstance exposure, patients were included if cannabis was a significant contributing agent. The primary outcome was a composite severe outcome endpoint, defined as an intensive care unit admission or in-hospital death. Covariates included relevant sociodemographic and exposure characteristics.

Results: One hundred and thirty-eight pediatric patients (54% males, median age 14.0 years, interquartile range 3.7-16.0) presented to a participating emergency department with cannabis intoxication. Fifty-two patients (38%) were admitted to an intensive care unit, including one patient who died. In the multivariable logistic regression analysis, polysubstance ingestion (adjusted odds ratio = 16.3; 95% confidence interval: 4.6-58.3; P < 0.001)) and cannabis edibles ingestion (adjusted odds ratio = 5.5; 95% confidence interval: 1.9-15.9; P = 0.001) were strong independent predictors of severe outcome. In an age-stratified regression analysis, in children older than >10 years, only polysubstance abuse remained an independent predictor for the severe outcome (adjusted odds ratio 37.1; 95% confidence interval: 6.2-221.2; P < 0.001). As all children 10 years and younger ingested edibles, a dedicated multivariable analysis could not be performed (unadjusted odds ratio 3.3; 95% confidence interval: 1.6-6.7).

Conclusions: Severe outcomes occurred for different reasons and were largely associated with the patient's age. Young children, all of whom were exposed to edibles, were at higher risk of severe outcomes. Teenagers with severe outcomes were frequently involved in polysubstance exposure, while psychosocial factors may have played a role.

Keywords: Cannabis; emergency medicine; intoxication; pediatric; poisoning.

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Severe outcomes following pediatric cannabis intoxication: a prospective cohort study of an international toxicology surveillance registry

Affiliations

Severe outcomes following pediatric cannabis intoxication: a prospective cohort study of an international toxicology surveillance registry

Authors

Affiliations

Abstract

MeSH terms

Substances