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Marijuana

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Marijuana, Hashish, Cannabis, THC, THC Wax, THC Honey Oil

  • Class
  1. Relaxant, Euphoriant, and Hallucinogen (high doses)
  2. Federal Schedule I Agent
    1. Medical use is permitted in more than half U.S. States (and D.C.)
    2. Recreational use has been approved by Colorado and Washington legislatures
  • Pharmacology
  • Marijuana (THC)
  1. Derived naturally from hemp, Cannabis sativa
  2. Smoked or eaten (e.g. "Hash Brownies")
  3. Classic hash is dried Marijuana with 70% THC content
  4. Street Names
    1. Pot, Grass, Tea
    2. Dagga, Kif
    3. Joint, Reefer
    4. Weed, Dope
  5. Pharmacokinetics: THC
    1. Delta-9-Tetrahydrocannabinol (THC)
    2. THC (5-20 mg): 2-4 hour duration
    3. Long half life
  • Pharmacology
  • Hemp Oil
  1. Background
    1. Pulverized Marijuana placed for 8 minutes in PVC pipe filled with butane and capped at each end
    2. Results in 90% THC solution (honey oil) or wax (after exposure to Rubbing Alcohol)
    3. Production associated with explosions and fires (related to use of butane)
  2. Street Names
    1. Honey Oil
      1. Concentrated THC in Butane solvent
      2. Smoked (or placed on a Cigarette)
    2. Wax
      1. Solidified honey oil (after exposure to Rubbing Alcohol)
      2. Similar appearance to honeycomb or ear wax
      3. Smoked
  3. References
    1. Nordt and Swadron in Herbert (2014) EM: Rap 14(6):6
  • Pathophysiology
  1. Similar to highly addictive "hard" drugs or Opioids
    1. Results in Dopamine release
    2. Blocked by Naloxone
  2. Marijuana considered a gateway drug
    1. Use may lead to Opiate Abuse
  3. References
    1. Tanda (1997) Science 276:2048-50 [PubMed]
  • Pharmacokinetics
  1. Smoking Marijuana
    1. Bioavailability: 20-50%
    2. Onset: Rapid
    3. Duration: 4 hours
  2. Edible maijuana
    1. Bioavailability: 4-12%
    2. Onset: 1-2 hours
    3. Peaks: 2-6 hours
    4. Duration: Up to 12 hours
    5. Lower peak serum concentration than if smoked (give the same quantity of Marijuana)
    6. However edible products may be associated with greater toxicity for a longer duration
      1. Edible preparations are unregulated and often contain higher potency Marijuana
      2. Marijuana products may be adulterated or replaced completely with Synthetic Marijuana
      3. A single THC serving (e.g. 10 mg) may be contained in one gummy bear
        1. Patients may eat more than a serving as effects are delayed
  • Indications
  • Medical Marijuana
  1. Anti-emetic (especially Chemotherapy related)
    1. Most established use
    2. Consider Dronabinol (Marinol) or Nabilone (Cesamet) instead
    3. However, Cannabinoid Hyperemesis Syndrome may result with increased, sustained use
  2. AIDS Anorexia
    1. Consider Nabilone (Cesamet) instead
  3. Neuropathic pain
  4. Multiple Sclerosis related spasticity and pain
  5. Intractable Seizure Disorder
    1. Consider Cannabidiol (CBD) instead
  • Symptoms
  1. Acute Effects
    1. Euphoria
    2. Relaxed inhibitions
    3. Increased appetite
    4. Decreased alertness
    5. Disoriented behavior
  2. Chronic Use: Amotivational syndrome
    1. Aimless
    2. Uncommunicative
  • Signs
  • Adults
  1. Cardiopulmonary findings
    1. Tachycardia
    2. Hypertension
    3. Tachypnea
  2. Miscellaneous findings
    1. Conjunctival Injection
    2. Dry Mouth
    3. Decreased coordination
  • Signs
  • Children
  1. Exposures
    1. Accidental Ingestion of joint or edible Marijuana
    2. Secondhand Smoke is unlikely to cause significant effects
  2. Timing
    1. Maximal effects occur within first 10 minutes of inhalation, but not for 2-4 hours of ingestion
    2. Ingested Marijuana effects may persist up to 6-12 hours
      1. Typically admit children (esp. under age 6 years) for observation
  3. Central nervous system effects (esp. under age 6 years old)
    1. CNS depression (somnolent to obtunded)
    2. Cerebellar dysfunction (e.g. Ataxia)
  4. Other effects
    1. Borderline low Blood Pressure
    2. Normal Heart Rate
  5. References
    1. Claudius and Levine in Herbert (2018) EM: Rap 18(5): 5-6
  • Adverse Effects
  1. General
    1. Dizziness
    2. Dry Mouth
    3. Fatigue
    4. Drowsiness
    5. Cognitive Impairment
    6. Respiratory symptoms (when smoked)
  2. Withdrawal (for the 9% of users who are dependent)
    1. Anorexia
    2. Insomnia
    3. Anxiety
    4. Depressed Mood or dysphoria
    5. Irritability
  3. Toxicity
    1. Dysphoria
    2. Sinus Tachycardia
    3. Orthostatic Hypotension
    4. May increase Myocardial Infarction risk
    5. Cannabinoid Hyperemesis Syndrome with frequent use
  4. May precipitate psychiatric illness
    1. Latent Schizophrenia
    2. Anxiety Disorder
    3. Dysphoria
    4. Paranoia
  • Drug Interactions
  1. CNS Depressants (increased sedation, Dizziness)
    1. Opioids
    2. Benzodiazepines
  2. Antithrombotics
    1. Increased bleeding risk
  • Management
  • Toxicity
  1. See Synthetic Cannabinoid (e.g. K2, JWH, Spice)
  2. Usually no specific treatment needed
  3. Benzodiazepines for severe reactions
  4. Toxicity may be related to polysubstance abuse (consider other Drugs of Abuse combined with THC)
  5. Marijuana Intoxication in children may present with greater CNS depression
  6. Toxicity may be associated with masking agent Overdose
    1. Some THC users have Overdosed on Niacin (Vitamin B3) in attempt to mask the Urine Drug Screen (UDS)
    2. No evidence Niacin actually masks THC in the urine, but this has resulted in emergency department visits
      1. Mittal (2007) Ann Emerg Med 50:587-590 [PubMed]
  7. Legalized Marijuana in 4 U.S. States (CO, OR, WA, AL) as of 2015 has been associated with increased ED visits
    1. Increased cyclic Vomiting (2x) and accidental childhood Poisonings
    2. Kim (2016) Ann Emerg Med 68(1): 71-5 [PubMed]
  • Complications
  1. Emergency
    1. Myocardial Infarction
    2. Acute Kidney Injury
    3. Seizure
  2. Longterm effects from excessive and persistent use
    1. Cannabinoid Hyperemesis Syndrome
    2. Neuropsychological decline in older adults
    3. Cardiac Toxicity
      1. Premature atherosclerosis (e.g. CAD, CVA)
      2. Increased Acute Coronary Syndrome within first hour of use
        1. May be related to acutely increased sympathetic tone, Hypertension and Tachycardia
      3. Arrhythmia association (e.g. Atrial Fibrillation in teens)
      4. Congestive Heart Failure
      5. Swaminathan and Mattu in Herbert (2019) EM:Rap 19(8): 7-8
      6. Rezkalla (2018) Cardiovasc Med S1050-1738(18)30141-5 +PMID:30447899 [PubMed]
  • References
  1. Moore, Behar, Claudius and Farrah in Herbert (2018) EM:Rap 18(5):11-2
  2. (2017) Presc Lett 24(9): 51
  3. (2012) Presc Lett 20(2): 11
  4. Fontes (2014) Crit Dec Emerg Med 28(1): 14-24
  5. Mason (2016) EM:Rap 16(8): 5