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Marijuana
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Marijuana
, Hashish, Cannabis, THC, THC Wax, THC Honey Oil
See Also
Synthetic Cannabinoid
(e.g. K2, JWH, Spice)
Chemical Dependency
Substance Abuse Evaluation
Cannabinoid Hyperemesis Syndrome
Prescription Cannabinoid
Class
Relaxant, Euphoriant, and
Hallucinogen
(high doses)
Federal Schedule I Agent
Medical use is permitted in more than half U.S. States (and D.C.)
Recreational use has been approved by Colorado and Washington legislatures
Pharmacology
Marijuana (THC)
Derived naturally from hemp, Cannabis sativa
Smoked or eaten (e.g. "Hash Brownies")
Classic hash is dried Marijuana with 70% THC content
Street Names
Pot, Grass, Tea
Dagga, Kif
Joint, Reefer
Weed, Dope
Pharmacokinetics: THC
Delta-9-
Tetrahydrocannabinol
(THC)
THC (5-20 mg): 2-4 hour duration
Long half life
Pharmacology
Hemp Oil
Background
Pulverized Marijuana placed for 8 minutes in PVC pipe filled with butane and capped at each end
Results in 90% THC solution (honey oil) or wax (after exposure to
Rubbing Alcohol
)
Production associated with explosions and fires (related to use of butane)
Street Names
Honey Oil
Concentrated THC in Butane solvent
Smoked (or placed on a
Cigarette
)
Wax
Solidified honey oil (after exposure to
Rubbing Alcohol
)
Similar appearance to honeycomb or ear wax
Smoked
References
Nordt and Swadron in Herbert (2014) EM: Rap 14(6):6
Pathophysiology
Similar to highly addictive "hard" drugs or
Opioid
s
Results in
Dopamine
release
Blocked by
Naloxone
Marijuana considered a gateway drug
Use may lead to
Opiate Abuse
References
Tanda (1997) Science 276:2048-50 [PubMed]
Pharmacokinetics
Smoking Marijuana
Bioavailability: 20-50%
Onset: Rapid
Duration: 4 hours
Edible maijuana
Bioavailability: 4-12%
Onset: 1-2 hours
Peaks: 2-6 hours
Duration: Up to 12 hours
Lower peak serum concentration than if smoked (give the same quantity of Marijuana)
However edible products may be associated with greater toxicity for a longer duration
Edible preparations are unregulated and often contain higher potency Marijuana
Marijuana products may be adulterated or replaced completely with
Synthetic Marijuana
A single THC serving (e.g. 10 mg) may be contained in one gummy bear
Patients may eat more than a serving as effects are delayed
Indications
Medical Marijuana
Anti-emetic
(especially
Chemotherapy
related)
Most established use
Consider
Dronabinol
(
Marinol
) or
Nabilone
(
Cesamet
) instead
However,
Cannabinoid Hyperemesis Syndrome
may result with increased, sustained use
AIDS
Anorexia
Consider
Nabilone
(
Cesamet
) instead
Neuropathic pain
Multiple Sclerosis
related spasticity and pain
Intractable
Seizure
Disorder
Consider
Cannabidiol
(CBD) instead
Symptoms
Acute Effects
Euphoria
Relaxed inhibitions
Increased appetite
Decreased alertness
Disoriented behavior
Chronic Use: Amotivational syndrome
Aimless
Uncommunicative
Signs
Adults
Cardiopulmonary findings
Tachycardia
Hypertension
Tachypnea
Miscellaneous findings
Conjunctiva
l Injection
Dry Mouth
Decreased coordination
Signs
Children
Exposures
Accidental Ingestion
of joint or edible Marijuana
Secondhand Smoke
is unlikely to cause significant effects
Timing
Maximal effects occur within first 10 minutes of inhalation, but not for 2-4 hours of ingestion
Ingested Marijuana effects may persist up to 6-12 hours
Typically admit children (esp. under age 6 years) for observation
Central Nervous System
effects (esp. under age 6 years old)
CNS depression (somnolent to obtunded)
Cerebellar dysfunction (e.g.
Ataxia
)
Other effects
Borderline low
Blood Pressure
Normal
Heart Rate
References
Claudius and Levine in Herbert (2018) EM: Rap 18(5): 5-6
Adverse Effects
Gene
ral
Dizziness
Dry Mouth
Fatigue
Drowsiness
Cognitive
Impairment
Respiratory symptoms (when smoked)
Withdrawal (for the 9% of users who are dependent)
Anorexia
Insomnia
Anxiety
Depressed Mood or dysphoria
Irritability
Toxicity
Dysphoria
Sinus Tachycardia
Orthostatic Hypotension
May increase
Myocardial Infarction
risk
Cannabinoid Hyperemesis Syndrome
with frequent use
May precipitate psychiatric illness
Latent
Schizophrenia
Anxiety Disorder
Dysphoria
Paranoia
Drug Interactions
CNS Depressant
s (increased sedation,
Dizziness
)
Opioid
s
Benzodiazepine
s
Antithrombotics
Increased bleeding risk
Management
Toxicity
See
Synthetic Cannabinoid
(e.g. K2, JWH, Spice)
Usually no specific treatment needed
Benzodiazepine
s for severe reactions
Toxicity may be related to polysubstance abuse (consider other
Drugs of Abuse
combined with THC)
Marijuana
Intoxication
in children may present with greater CNS depression
Toxicity may be associated with masking agent
Overdose
Some THC users have
Overdose
d on
Niacin
(
Vitamin B3
) in attempt to mask the
Urine Drug Screen
(UDS)
No evidence
Niacin
actually masks THC in the urine, but this has resulted in emergency department visits
Mittal (2007) Ann Emerg Med 50:587-590 [PubMed]
Legalized Marijuana in 4 U.S. States (CO, OR, WA, AL) as of 2015 has been associated with increased ED visits
Increased cyclic
Vomiting
(2x) and accidental childhood
Poisoning
s
Kim (2016) Ann Emerg Med 68(1): 71-5 [PubMed]
Complications
Emergency
Myocardial Infarction
Acute Kidney Injury
Seizure
Longterm effects from excessive and persistent use
Cannabinoid Hyperemesis Syndrome
Neuropsychological decline in older adults
Cardiac Toxicity
Premature atherosclerosis (e.g. CAD, CVA)
Increased
Acute Coronary Syndrome
within first hour of use
May be related to acutely increased sympathetic tone,
Hypertension
and
Tachycardia
Arrhythmia
association (e.g.
Atrial Fibrillation
in teens)
Congestive Heart Failure
Swaminathan and Mattu in Herbert (2019) EM:Rap 19(8): 7-8
Rezkalla (2018) Cardiovasc Med S1050-1738(18)30141-5 +PMID:30447899 [PubMed]
References
Moore, Behar, Claudius and Farrah in Herbert (2018) EM:Rap 18(5):11-2
(2017) Presc Lett 24(9): 51
(2012) Presc Lett 20(2): 11
Fontes (2014) Crit Dec Emerg Med 28(1): 14-24
Mason (2016) EM:Rap 16(8): 5
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