1 Blazing the Trail in Colorado Marijuana and Public HealthMike Van Dyke, Ph.D., CIH Branch Chief Environmental Epidemiology, Occupational Health and Toxicology

2 Outline Medical Marijuana Recreational Marijuana History RegistryConditions Research Recreational Marijuana Public Health Health Effects Surveillance findings

3 History of Medical Marijuana in ColoradoAmendment 20 - November 2000 July 2001 – Registry established Ogden Memorandum – 2009 Commercial production/distribution HB & SB

4 Medical Marijuana RegistryIssues registry identification cards Maintains database of registered users Reviews petitions for adding debilitating medical conditions

5 Debilitating Conditions for MMJ UseCancer Glaucoma HIV positive or AIDS Cachexia (wasting syndrome) Persistent muscle spasms (MS) Seizures (epilepsy) Severe nausea Severe pain

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7 Efficacy of MMJ “Medical Establishment View”Condition Hill1 Whiting et al2 Belendiuk et al3 Chronic Pain High Quality Moderate Quality Some Evidence Spasticity Insufficient Evidence Nausea/Vomiting Low Quality HIV Weight Gain Moderate Support Hill, K.P. Medical marijuana for treatment of chronic pain and other medical and psychiatric problems: A clinical review. JAMA. 2015; 313(24) Whiting et al. Cannabinoids for medical use: a systematic review and meta-analysis. JAMA. 2015; 313(24) Belendiuk, K.A., Baldina, L.L., Bonn-Miller, M.O. Narrative review of the safety and efficacy of marijuana for the treatment of commonly state-approved medical and psychiatric disorders. Addict Sci Clin Pract 2015; 10:10

8 Efficacy of MMJ “Popular View”Parkinson’s disease Epilepsy Crohn’s disease Hepatitis C ALS Alzheimer’s disease Mitochondrial disease Sickle cell disease Muscular dystrophy Lupus Tourette’s syndrome Inflammatory bowel disease Huntington’s disease Cancer Glaucoma HIV/AIDS Cachexia Pain Nausea Seizures Muscle pasms Multiple sclerosis PTSD Anorexia Arthritis Migraines

9 Medical Marijuana Research Grant ProgramMMJ Registry budget surplus - $10 M “Concerning Grant Funding for Medical Marijuana Health Effects Studies”’ (SB ) CDPHE shall “gather objective scientific research regarding the efficacy of administering marijuana and its component parts as part of medical treatment.” Passed by legislature & signed by governor - May 2014

10 Applications 44 applications 16 different institutionsTopics: Pain, epilepsy, cancer, alcohol/opiate use, PTSD, anxiety, aging, IBD, MS, cardiovascular, etc.

11 Colorado Medical Marijuana Research GrantsObservational Studies IBD in adolescents/young adults PTSD Efficacy of CBD for pediatric epilepsy Pharmacokinetics of CBD for pediatric epilepsy Quality of life from using MJ in children with CNS tumors Sleep disorders Randomized Clinical Trials MJ (4 potencies THC & CBD) for PTSD in veterans CBD for tremor in Parkinson’s Disease MJ versus oxycodone for chronic spine pain All studies currently underway!

12 November 2012

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14 Public Health ResponsibilitiesCreate a scientific advisory panel to review literature and emerging science Monitor patterns of use Monitor health concerns Prevention and education Consultative role: Contamination limits and laboratory certification, edibles safety, safe disposal of product and byproducts

15 CDPHE and Retail Marijuana (C.R.S. 25-1.5-111 & SB-13-283)Retail Marijuana Public Health Advisory Committee  An appointed panel of scientists and health care professionals with expertise in cannabinoid physiology to monitor emerging health effects and other information. Systematically review the scientific literature Review public health surveillance data Recommend public health related policies Recommend public health surveillance activities Identify research gaps important to public health May include Poison Control physician addiction and substance abuse experts public health/preventive medicine experts, and others with subject matter expertise

16 Defined Expertise and RepresentationDrug epidemiology Surveillance epidemiology Medical toxicology Pediatric Medicine Rocky Mountain Poison and Drug Center Psychiatry/Drug Addiction Pharmacology Pulmonary Medicine Obstetrics and Gynecological Health Local public health representative Colorado School of Public Health representative

17 Topics Covered Marijuana Use During Pregnancy and BreastfeedingAdolescent and Young Adult Effects Neurological, Cognitive, and Mental Health Effects Unintentional Marijuana Exposures in Children Marijuana Dose and Drug Interactions Marijuana Use and Driving Marijuana Use and Injury Respiratory Effects Cancer Cardiovascular Effects Gastrointestinal and Reproductive Effects

18 CDPHE Goal Translate Science into Public HealthDevelop consensus statements that convey the quality and quantity of scientific evidence behind a finding Translate consensus statements into plain language statements in a standardized way Guide the development of evidence-based prevention campaigns

19 Marijuana Use Among Adolescents

20 Public Health StatementsWeekly or more frequent marijuana use by adolescents and young adults is associated with impaired learning, memory, math and reading achievement, even 28 days after last use. These impairments increase with more frequent marijuana use. Marijuana use by adolescents and young adults is strongly associated with developing psychotic symptoms in adulthood, such as hallucinations, paranoia, and delusional beliefs. This risk is higher with more frequent marijuana use. This risk may be higher among those who start using marijuana at a younger age. Daily or near daily marijuana use by adolescents and young adults is associated with developing a psychotic disorder such as schizophrenia in adulthood.

21 Detailed Report Google – “Retail Marijuana Public Health Advisory Committee”

22 CDPHE and Retail Marijuana (C.R.S. 25-1.5-111 & SB-13-283)Surveillance Role "Monitor changes in drug use patterns, broken down by county and race and ethnicity, and the emerging science and medical information relevant to the health effects associated with marijuana use.”

23 Monitoring Patterns of UseWho is using? age, gender, ethnicity, county, etc. How are they are they using? Smoking, vaporizing, ingesting, dabbing, etc. How often are they using? Are they following safe practices when using? Safe storage away from children, not driving while under the influence, etc. Collecting this type of info and monitoring trends can help focus prevention efforts to the right target populations

24 Marijuana use during pregnancy and breastfeeding

25 U.S. 3.85% During pregnancy

26 Adolescent and young adult marijuana use

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30 High School Alcohol, Marijuana and Tobacco Use in CO (HKCS)

31 Adult marijuana use

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36 Patterns of Use- SummaryData available do not suggest a substantial increase in current marijuana use among Colorado adults and youth Higher current use among Colorado adults compared to most other states Higher current use among certain demographics (men, low income, GLBT, lower education levels) Methods of use show mostly smoking with co-use of edible products Substantial possibility for child exposure through secondhand smoke and edibles Concerns about use during pregnancy and breastfeeding 2.6% Hawaii PRAMS, 3.2% WIC 3.9% Child Health Survey – CO ~20% Healthy Kids Colorado Adult use decreases with age – highest use is among 18-24

37 Monitoring Health ConcernsAdverse events Emergency Department Visits Hospitalizations Calls to poison center

38 Child Marijuana Exposuresa ICD-9-CM codes and E854.1 were used to determine HD and ED visits with possible marijuana exposures. b The Ns are the total number of HD or ED visits with possible marijuana exposures, diagnoses, or billing codes in the specified time period. * Rate significantly increased from previous time period with a p-value <0.001. Major Findings Rates of HD and ED visits had an increasing trend from ( for ED visits) to January through June 2014. Rates of HD with possible marijuana exposures in children up to 9 years significantly increased from to by more than 5-fold. The highest rates for both HD and ED visits were in January to June of 2014 of 9.5 and 26.4 respectively. The rate of ED visits for January through June 2014 was not statistically significantly different from the time period. The rate of HD for January through June 2014 increased more than three-fold, a statistically significant increase. Data Details Data source: Colorado Hospital Association (CHA) 2014 data is January 1, 2014 through June 30, NA=Data not available. A single individual can be represented more than once in the data; therefore, the rate is HD or ED visits per 100,000 HD or ED visits in children under 9.

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41 Out-of-State Residents

42 Comparing Hospitalizations with and without Marijuana Codes

43 Health Concerns- SummaryIncreases in unintentional poisonings among children since legalization Increases in marijuana exposure calls to the poison center since legalization Relative number small compared to other substances Increases in emergency department visits and hospitalizations related to marijuana since legalization Causes for these increases unclear – casual vs. social change in reporting Larger increases for out-of-state residents ED and hospitalizations related to marijuana remain a small proportion of all visits (< 2%%) 2.6% Hawaii PRAMS, 3.2% WIC 3.9% Child Health Survey – CO ~20% Healthy Kids Colorado Adult use decreases with age – highest use is among 18-24

44 Adult Education Campaign

45 Youth Prevention Campaign

46 Pregnancy and Breastfeeding Campaign

47 Clinical Guidelines

49 Questions?