Cause and effect essay

11. Meier MH, Caspi A, Ambler A, et al. Persistent cannabis users show neuropsychological decline from childhood to midlife [published online August 27, 2012].PNAS. doi:10.1073/pnas.1206820109.12. Johnston LD, O'Malley PM, Bachman JG, Schulenberg JE.Monitoring the Future National Results on Adolescent Drug Use: Overview of KeyFindings, 2011.Ann Arbor: Institute for Social Research, the University of Michigan; 2012.

Anticipated Medical Effects on Children From Legalization of Marijuana in Colorado and Washington State A Poison Center Perspective William Hurley, MD; Suzan Mazor, MD On November 4, 2012,Amendment 64 passed in Colorado and Initiative 502 passed in Washington State to legalize the pos- session of small amounts of marijuana and marijuana-related products by adults. Possession by anyone younger than 21 years and the growing of marijuana without authorization remain illegal in both states. In Colorado, adults are permitted to pos- sess up to 1 oz of marijuana or 6 marijuana plants. In Wash- ington, adults are permitted to possess up to 1 oz of mari- juana, 16 oz of marijuana-infused product in solid form, 72 oz of marijuana-infused product in liquid form, or any combina- tion of all 3. The possession of marijuana remains illegal un- der federal law and marijuana remains a Schedule I agent un- der the Drug Enforcement Administration.

The medical use of marijuana and marijuana-infused prod- ucts is legal in 18 states and the District of Columbia. Seven ad- ditional states are considering legalization of medical mari- juana. The medical use of marijuana has been legal in Colorado since 2009.

In this issue, Wang et al 1describe an increase in cases of accidental ingestion of marijuana by children after decrimi- nalization of medical marijuana in Colorado. Marijuana in- gested by the majority of the children described in the article was in the form of a food prod- uct. The medical marijuana in- dustry provides attractive and palatable marijuana-infused solid and liquid products, includ- ing cookies, candies, brownies, and beverages. The legalization of recreational marijuana, es- pecially the solid and liquid-infused forms permitted in Wash- ington, will provide children greater access to cookies, can- dies, brownies, and beverages that contain marijuana.

Ingestion of marijuana results in the absorption of delta-9-tetrahydrocannibinol (THC) and stimulation of can- nabinoid receptors in the central nervous system. This pro- duces stimulation with hallucinations and illusions, fol- lowed by sedation. 2Toxic reactions are usually mild after acute accidental ingestion but can cause significant seda- tion in children. 3Respiratory insufficiency and the need for ventilatory support are described in the article. In older chil- dren, the stimulatory phase and hallucinations can produce anxiety and panic episodes when not anticipated in an acci- dental ingestion. The potency of marijuana in the United States has progressively increased over the past 40 years,with THC levels climbing from around 2% to nearly 8%. 4 The risk of significant toxic reactions from exposures is more likely today than in the past.

Emergency medicine, pediatric emergency medicine, and primary care pediatric providers will be first to see patients ac- cidentally exposed to marijuana. They may need additional training to recognize and manage significant marijuana toxic reactions. Signs and symptoms can include anxiety, halluci- nations, panic episodes, dyspnea, chest pain, nausea, vomit- ing, dizziness, somnolence, central nervous system depres- sion, respiratory depression, and coma. 5Similar signs and symptoms occur in a large variety of diseases and poisonings.

The providers and staff should investigate the availability of marijuana in the child’s environment and use rapid tests to identify the metabolites of marijuana in the urine. 6No anti- dote exists for marijuana toxic reactions and supportive care should be provided, including control of anxiety, control of vomiting, airway control, and ventilation as needed. The re- gional Poison Center should be contacted to report the epi- sode and obtain additional advice on evaluation and manage- ment.

Increased accidental exposure after increased availabil- ity of an agent is a consistent lesson in toxicology. Our cur- rent increase in laundry-pod ingestion in children is the re- sult of increased availability coupled with attractive packaging. 7 The ready availability of pain medications led to opioids sur- passing motor vehicle crashes as the leading cause of acciden- tal death in the United States. This profound poisoning prob- lem went unrecognized for nearly a decade and has only recently come to the attention of health care providers and policy makers. 8A recent analysis of Poison Center data shows a parallel increase in severe poisonings, emergency depart- ment visits, and hospitalizations in children. 9A similar rise in marijuana exposure and toxic reactions is anticipated from the increased availability of marijuana in the child’s environ- ment. Timely analysis of Poison Center data and emergency department records will provide an opportunity to quickly rec- ognize and respond.

Intervention strategies in Washington State have begun to reduce the death rate from opioid exposure. These were mod- eled on successful interventions in poison prevention and in- clude public education on the risks of opioid use, provider edu- cation on safe prescribing practices, prescription monitoring programs, and home naloxone hydrochloride programs. 10,11 Editorialpage 600 Related articlepage 630 OpinionEditorial 602 JAMA PediatricsJuly 2013 Volume 167, Number 7jamapediatrics.com Similar approaches can be used to prevent marijuana expo- sure and toxic reactions:

•Changing societal norms through education of parents, chil- dren, and providers on the short-term and potential long- term effects of marijuana in children through advertising, tele- vision, movies, video games, and other media sources in homes, schools, hospitals, and provider offices.

•Increasing provider awareness through effective education (conferences and online programs).

•Encouraging just-in-time intervention with prompts and re- minders in patient management and documentation soft- ware to encourage conversations about the use of mari- juana in the home and the need to control access to marijuana products by children.

•Increasing consumer awareness and safety behaviors by post- ing warning signs at the site of sale and attaching warning la- bels on marijuana and marijuana-infused products on the risks of marijuana exposure and the need to keep such prod- ucts out of easy reach of children.

•Control of access through the sale of marijuana-infused prod- ucts (especially cookies, candy, brownies, and beverages) in child-resistant containers.Methods to prevent accidental exposures to marijuana need to be studied for efficacy and progressively developed.

Parents and providers should be encouraged to call the Poi- son Center for data collection, information, education, and management advice.

We expect the legalization of marijuana to increase acci- dental exposures to marijuana in children. We need real-time monitoring of exposures and toxic reactions, as well as track- ing of the efficacy of intervention and prevention efforts. The Poison Center network in the United States provides real- time surveillance of emerging trends in exposure and poisoning. 12A national number is available to provide case management and prevention advice to parents, adolescents, providers, policy makers, and health care systems (1-800-222- 1222). The lessons we learn will provide an opportunity for Washington, Colorado, and other states to adjust existing and future legislation, media, and clinical practice to limit mari- juana exposure and toxic reactions in children. ARTICLE INFORMATION Author Affiliations:School of Medicine, University of Washington, and Washington Poison Center, Seattle (Hurley); Division of Emergency Medicine, Seattle Children’s Hospital, Seattle, Washington (Mazor).

Corresponding Author:Dr Hurley, University of Washington, School of Medicine, Washington Poison Center, 155 NE 100th Street, Ste 100, Seattle, WA 98125-8007 ([email protected]).

Published Online:May 27, 2013.

doi:10.1001/jamapediatrics.2013.2273.

Author Contributions:Study concept and design:

Hurley and Mazor.

Acquisition of data:Hurley.

Analysis and interpretation of data:Hurley.

Drafting of the manuscript:Hurley.

Critical revision of the manuscript for important intellectual content:Mazor.

Administrative, technical, and material support:

Hurley.

Study supervision:Hurley and Mazor.

Conflict of Interest Disclosures:None reported.REFERENCES 1. Wang GS, Roosevelt G, Heard K. Pediatric marijuana exposures in a medical marijuana state [published online May 27, 2013].JAMA Pediatr.

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2. Hall W, Degenhardt L. Adverse health effects of non-medical cannabis use.Lancet.

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4. Sevigny EL. Is today’s marijuana more potent simply because it’s fresher?Drug Test Anal.

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6. Amirav I, Luder A, Viner Y, Finkel M.

Decriminalization of cannabis: potential risks for children?Acta Paediatr. 2011;100(4):618-619.

7. Centers for Disease Control and Prevention (CDC). Health hazards associated with laundrydetergent pods: United States, May-June 2012.

MMWR Morb Mortal Wkly Rep. 2012;61(41):

825-829.

8. Centers for Disease Control and Prevention (CDC). CDC grand rounds: prescription drug overdoses. a U.S. epidemic.MMWR Morb Mortal Wkly Rep. 2012;61(1):10-13.

9. Bond GR, Woodward RW, Ho M. The growing impact of pediatric pharmaceutical poisoning.

J Pediatr. 2012;160(2):265-270; e1.

10. Boyer EW. Management of opioid analgesic overdose.N Engl J Med. 2012;367(2):146-155.

11. Kendrick D, Smith S, Sutton A, et al. Effect of education and safety equipment on poisoning-prevention practices and poisoning:

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12. Hendrickson RG, Osterhoudt KC. Reflections on the 2011 report of the US National Poison Data System.Clin Toxicol (Phila). 2012;50(10):869-871.

Can We Keep It Simple?

Mark S. Schreiner, MD For more than 30years, investigators, institutional review boards (IRBs), and editorialists have been decrying the defi- ciencies with consent docu- ments. Most subjects sign docu- ments that they can neither completely read nor fully com- prehend. Despite numerous studies to improve the consent document, the goal of ensuring informed participation seemsmore elusive than ever. Instead of simplicity and plain lan- guage, subjects face an overwhelming deluge of information written in technical and legalistic terms. Instead of brevity, con- sent forms remain verbose, increasing in length by approxi- mately 1.5 pages per decade, with some well in excess of 20 pages.

While it is feasible to simplify long, technical consent forms to create concise documents written at a fifth- to eighth-grade Related articlepage 640 EditorialOpinion jamapediatrics.comJAMA PediatricsJuly 2013 Volume 167, Number 7603 Copyright ofJAMA Pediatrics isthe property ofAmerican MedicalAssociation andits content maynotbecopied oremailed tomultiple sitesorposted toalistserv without the copyright holder'sexpresswrittenpermission. However,usersmayprint, download, oremail articles forindividual use.