San Diego County's only children's hospital reports that it continues to see elevated numbers of young patients arriving in its emergency department with cannabis poisoning, echoing findings from a new analysis released last week by the U.S. Centers for Disease Control and Prevention.
Dr. Natalie Laub, a pediatrician and cannabis researcher at Rady Children's Hospital, said the situation has been most dramatic for children age 5 and younger.
"We were seeing about 20 kids per year, with the average age being 3 years old," Laub said. "Then COVID happened, and now we're seeing upwards of 80 to 100 children a year in 2020, 2021, 2022."
These toddlers, she said, usually arrive in very bad shape.
"We see children coming in with seizures and not breathing," Laub said. "They have altered mental status; they won't wake up.
"In general, if you look at the children who come to the emergency room for cannabis ingestion, over 50 percent of them are admitted to the hospital, and 10 percent go to the intensive care unit."
Those trends are reflected in the CDC's nationwide study of emergency admissions, which shows that those age 15 to 24 represented, by far, the largest share of cannabis-involved visits. However, that group's ER usage peaked in 2020 and 2021, returning to a rate of about 117 cases per 10,000 visits in 2022. That is roughly the same rate observed in 2019.
The CDC also examined case rates for children age 10 and younger, finding that while there was a similar pandemic peak, case rates have remained elevated compared to where they were in 2019 when researchers identified one case per 10,000 ER visits. In late 2022, the observed rate for kids in this group was 2.7 cases per 10,000 visits.
Though a few deaths have occurred nationwide in this age group, Laub said Rady has been able to prevent that outcome locally, though doing so often requires invasive methods such as the insertion of breathing tubes in very young airways.
Those in the age 15 to 24 age bracket, Laub said, are much less likely to be hospitalized due to cannabis overdose, but a small percentage will experience cannabis hyperemesis syndrome, a condition that causes severe vomiting and nausea. The condition is so uncomfortable that it often causes patients to scream while they vomit, which some medical providers describe as "scromiting."
Dr. Roneet Lev, an emergency and addiction medicine specialist at Scripps Mercy Hospital, said hyperemesis has been a regular feature of emergency department work for some time. Many suspect that the syndrome's appearance is linked to the overall increase in potency of marijuana sold today, which can contain up to 100 milligrams of THC, cannabis's main psychoactive substance.
A common dose in the 1990s, Lev said, would have been closer to 50 milligrams of THC.
Many teens and adults, she said, just aren't aware that those who use high-potency marijuana products regularly can experience the syndrome. But it's easy, she said, to know who is experiencing hyperemesis when symptoms get severe enough that they seek out medical attention.
"In the ER, it's what I call an audible diagnosis, because I can hear it," Lev said. "There is nothing that sounds like vomiting and screaming at the same time."
Though the CDC highlighted the impact on emergency rooms by America's youngest last week, Lev pointed out that it's clear that other age brackets are also arriving in ERs more often. In January, UC San Diego researchers published a paper that estimated a 1,804 percent increase in California ER admissions for those age 65 and older, with visits rising from 20.7 per 100,000 in 2005 to 395 per 100,000 in 2019.
"When it comes to cannabis, consumers are not informed to the risks," Lev said. "The risk they don't understand is that one in five may develop psychosis and that, with repeated use, you can develop permanent schizophrenia.
"People also are not informed of the potential interactions with other drugs that adults may already be prescribed and taking."
Science, Loeb added, clearly shows that regular cannabis use in adolescence and young adulthood can affect the development of the body's endocannabinoid system, which helps regulate a wide range of body systems from mood and metabolism to motor control and muscle formation.
The THC in cannabis, Loeb explained, can activate the same receptors used by the cannabinoids produced by the body at a time when the system itself is still developing.
"We know that even doing as little as two cannabis edibles a week, two joints a week, two blunts a week, teenagers are fundamentally changing the architecture of their brain," Loeb said. "We are now seeing that it is leading to lifelong issues with anxiety, trouble with depression, bipolar disorder, schizophrenia."
Research papers generally confirm these concerns, but they are a bit less emphatic, with one review published in 2020 stating that "current evidence indicates that adolescence is a sensitive period during which cannabis use may result in adverse neurocognitive effects that appear to show a level of permanency into adulthood."
Another from the same year concludes "the primary psychiatric symptoms associated with cannabis use in youth are increased risk for addiction, depressive and psychotic symptoms."
One challenge, authors noted, is that most studies are observational, meaning that researchers compare groups of people with a common characteristic such as cannabis use. Correlations can be teased out, but cause and effect cannot be proven because complicating factors, such as the exact amount of drug consumed by each person, are not controlled.
However, just as the latest CDC data show an increase in ER use by those using cannabis, there have recently been increasing reports of cannabis-induced psychosis, which often includes hallucinations, in the region, including a local mother who detailed her son's struggles in 2022.
While reducing cannabis use among adolescents and young adults has been the focus of public outreach campaigns, the approach is much simpler for the three-year-olds showing up in Rady's ER.
Laub said there is a spillover effect in young kids. Her research, she said, has found that about 70 percent of the cannabis exposure in the toddlers she sees in the Rady ER are consumed at home and were purchased by an adult.
"By far and away, the moms and dads and close relatives of the child — someone that they know and are in close contact with," Laub said.
Adults are not intentionally giving cannabis to young kids, the physician said, but many cannabis-infused products — especially gummies — are packaged with colorful artwork that, when encountered by a toddler, looks like harmeless candy.
The most immediate way to stem the tide in the toddler population, she said, is for adults to realize that toddlers cannot distinguish edible cannabis products from other candies and child-safe packaging is not currently required.
"The conversation we're trying to start having with families who have cannabis in their homes is how to keep it safe, how to safely store it, and to treat it as a substance that could, you know, potentially kill a child due to the increased potency," Laub said.
In other words, just like a pair of scissors, cannabis products should not be stored or left anywhere that a toddler could get their hands on them.
She and others have also served as advisers for AB-1207, a bill currently making its way through the California Legislature, which seeks to ban cannabis products that are "attractive to children." This would mean fewer images and descriptions of fruits and candies that kids might find attractive and also the end of flavorings used in cannabis vape pen cartridges.
The bill is backed by local governments and organizations such as the California Society of Addiction Medicine and opposed by a long list of industry player, including the California Cannabis Industry Association and the California Cannabis Manufacturers Association.
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