The impact of cannabis use—a tertiary care paediatric hospital’s experience and approach

INTRODUCTION

Conversations about cannabis and its impact on the health of children and teens are complex, given the expansion of available sources that now include illicit, medically approved, and as of October 2018, legally sourced cannabis for recreational purposes in adults. Two primary foci of this discussion are medical and recreational uses of cannabis in children and teens. These different aspects of use, though related, have important distinctions, intended outcomes and potential risks. Health care professionals working with children, teens, and their families need to be able to navigate this complex and evolving dialogue.

In this commentary, we will identify where cannabis use shows up in our institution, The Hospital for Sick Children (SickKids) in Toronto, and describe the experience of developing various interconnected approaches to the identification, assessment, and management of cannabis-related health issues to date. We will also offer some suggested directions on how Canadian health care institutions caring for children might assist patients and family caregivers as the relationship between cannabis and health continues to evolve.

THE EMERGENCY DEPARTMENT: ACUTE AND CHRONIC CANNABIS EXPOSURE

Second only to alcohol, cannabis is the most commonly used psychoactive substance in Canada (1). As recreational cannabis has been legalized (and with the recent addition of ‘edibles’ to marketed products), the availability at the home and, therefore, the potential for unintentional and intentional exposure in children and youth has risen. There is growing literature about emergency department (ED) presentations for intentional or nonintentional cannabis exposure in children, such as predisposition to trauma. Although severe cannabis intoxication is rare in adults, in infants and young children, it may manifest with neurological symptoms such as altered level of consciousness, and respiratory depression, which may require mechanical ventilation (2–5). In teens, exposure to cannabis, often with chronic use, may manifest in numerous behavioural changes including psychosis and hyperemesis syndrome, to name two.

Clinical vigilance is often required to diagnose cannabis intoxication if history is not available. Frequently, the presentation of nonintentionally exposed children to tetrahydrocannabinol (THC) in cannabis products, such as edibles, includes altered mental status and encephalopathy, frequently leading to invasive diagnostic investigations and therapeutic interventions, such as neuroimaging, lumbar puncture, and administration of wide spectrum antibiotics. To further complicate the picture, the widespread use of medical cannabis, either regulated or unregulated products, presents additional challenges; such formulations can vary significantly in their CBD:THC ratios and concentrations, which may impact the clinical presentation. In addition, some recreational cannabis products are mixed with other substances (e.g., alcohol, unknown excipients), which can potentiate or alter the cannabis effects. There is no specific antidote for acute cannabis intoxication, and treatment is supportive.

We have recently conducted a retrospective chart review of all cases of cannabis exposure presenting to the SickKids ED over a 12-year period. This work is ongoing and may be used to inform clinical approach and practice at the hospital. More than 700 cases were identified, and preliminary results show that ~10% of them were children younger than 10 years with acute intoxication, some required mechanical ventilation and other critical care measures.

ADOLESCENT CANNABIS USE

A United Nations Children’s Fund study found that Canadian adolescents aged 11 to 15 years have the highest rate of cannabis use among the world’s 29 advanced economies (6). Roughly, one in six (17%) teenagers who use cannabis will develop dependence (7).

Adolescents with co-existing health conditions (including mental health disorders) may present to the health care system with unique manifestations that can affect treatment outcomes. Examples from our institution include: cannabis-induced psychosis, cannabis hyperemesis, cannabis use disorder, and cannabis use as part of a polysubstance use disorder. Daily cannabis use is the most frequent reason that teens are referred to our Adolescent Substance Abuse Program. They may be using cannabis combined with tobacco, or with alcohol and other substances such as benzodiazepines or cocaine.

In the ED, adolescents may present with a primary issue related to their cannabis use or with a mental health issue, for which they may see an ED social worker, who will screen them with the CRAFFT, a validated tool for use with adolescents that identifies problematic substance use (8). In inpatient or outpatient settings, cannabis use may be identified with HEADSS screening (a widely used framework for psychosocial screening of adolescents) or with further assessment. In the dedicated Adolescent Medicine (AM) clinics, cannabis use may be one of the main reasons for a patient’s referral, for which they will receive a comprehensive team-based assessment.

How and if their cannabis use is further explored, and by whom, depends on the clinical area and the patient’s individual circumstances. As noted above, routine screening using HEADSS or other assessments may suggest a substance use issue. Consultation is then requested from the AM or the Substance Abuse program teams, which can respond quickly to assess the teen in either the ED, inpatient or outpatient settings. Follow-up can then be arranged depending on a variety of factors, including patient/family motivation and patient’s residence. As we have only recently been able to track referrals more easily through the electronic health record, over the past 6 months, approximately 7% of referrals to the AM consult service have been specifically for a substance use related issue. This is likely an underestimate, as often substance use or misuse is discovered on further assessment; also, some referrals may come directly to the Substance Abuse program and bypass the consult service.

The literature on treatment for cannabis and other substance use disorders in adolescence suggests that psychosocial interventions including cognitive behavioural therapy (CBT) and motivational enhancement approaches are effective (9). We are also introducing the use of acceptance and commitment therapy, a ‘third wave CBT’ modality (10). Our team is developing a brief, motivational interviewing intervention to be used with any adolescent using cannabis (or other substances), with a plan to assess outcomes of its use. Future research is also needed on the use, role and effectiveness of interventions that utilize technology as a platform of treatment delivery.

MEDICAL CANNABIS

Patients and family caregivers may attribute significant symptom relief for a variety of health conditions to the use of medical cannabis for nausea, vomiting, chronic pain, and seizures. Evidence suggests that cannabinoid preparations that are higher in CBD may reduce seizures associated with certain forms of epilepsy, such as Dravet’s Syndrome (11,12). Beyond seizure management, there continues to be limited rigorous, scientific evidence of the effectiveness and safety of medical cannabis in paediatrics. There is some evidence of benefit to support the use of synthetic cannabinoids (e.g., nabilone, dronabinol) for chemotherapy-induced nausea and vomiting (13).

Currently, cannabis is not an approved therapeutic substance in Canada; however, providers may authorize patients to access cannabis for medical purposes under regulations in the 2018 Cannabis Act. In our experience, patients that are using cannabis for medical purposes seek authorization from a community provider, outside of their regular care team. Patients or caregivers then manage the purchase, administration, and often dosing, based on advice from these providers.

In order to continue the administration of cannabis during hospital stay, careful attention and partnerships between the patient, family caregiver, most responsible hospital based provider, and interprofessional care team members are critical. Appreciating cannabis as a complex substance, interpreting cannabis and health care provider regulations, and understanding the stigma and political landscape surrounding its use are all important factors for providing the comprehensive support required to foster trust and mitigate risk to patients.

In early 2016, the SickKids’ Medical Cannabis Advisory Group was formed out of a recognition that the institution would need to respond to a growing number of families and patients that are legally accessing medical cannabis independent of their health care providers. The advisory group consists of professional practice leaders, registered nurses, nurse practitioners, physicians, pharmacists, and representatives from legal and risk management. The initial scope of this group was to explore whether staff could legally and safely administer medical cannabis. Quickly, the scope advanced to include continued oversight and attention to the evolving nature of medical cannabis in paediatrics. Recognizing the value of partnership, the group collaborates with other institutions that provide care to patients with complex health conditions and/or palliative care needs. This collaboration also enables supportive and seamless patient transitions across respective institutions.

Driven by this group and in consultation with patients and families, an approach was developed to manage the administration of legally authorized medical cannabis to accommodate patient needs while staying within the limits of cannabis regulations and prioritizing safety. This approach aims to provide interprofessional teams with the tools they need to support a patient’s continued use of medical cannabis during a hospital stay. This child and family-centred approach was built around many guiding principles, including remaining consistent with, and being responsive to legislative, regulatory requirements and organizational policies, supporting individual choice and meeting the unique needs of the child and family, providing a balanced approach to patient preferences and safety, providing clarity to health care providers, and acknowledging the moral and ethical implications inherent in health professionals’ regulatory responsibilities.

In order to operationalize this vision and meet regulatory requirements, a policy and internal resource website were developed, and implemented through many education and communication forums.

Mandatory processes and provisions include some of the following:

• • Confirming proof of authorization prior to ordering, handling, storing or administering a patient’s own medical cannabis supply. Examples and principles for adequate authorization documentation are outlined in policy and resource materials.

• When proof of authorization cannot be confirmed and/or is not in place, discussions with patients and/or family caregivers are critical to provide them with information and education. Once the discussion has occurred, the determination to continue or discontinue the use of cannabis must be managed collaboratively in order to account for the unique needs of each patient and their care plan; mitigating risk to the patient, staff, and organization is paramount. Requirements also include the confirmation that the product is sourced from a Health Canada-approved Licensed Producer.

• • Ensuring compliance with routine medication administration steps, such as ensuring a complete order is in place. As part of the policy and resource materials, a decision guide helps staff determine the mandatory components required prior to their involvement in administration. A provider order is one mandatory component for allowing staff to administer a patient’s own medical cannabis.

• • Addressing safe storage in collaboration with the patient and/or family caregiver. Medical cannabis is required to be secured in one of the following ways: 1) In the sole possession of the family caregiver or patient at all times and never left unattended, or 2) double-locked and secured in a storage safe in the unit medication room. Additionally, hospital staff are asked not to handle cannabis unless proof of authorization is confirmed.

• • Accessing resources for safe monitoring and management. Policy requires routine review of staff support resources. Adjunct resources include an interprofessional decision-making algorithm and intranet resource web page where several tip sheets, which include medication reconciliation considerations, known adverse effects, conversation guides, and frequently asked questions are published internally.

• • Escalating concerns and managing if exceptional circumstances are identified. There is a clear process for escalation to others in the institution. Commonly received concerns include reinforcing policy guidance and documentation requirements, assisting with verification of proof of authorization, documentation of special accommodations related to inhalation methods, such as smoking or vaping off the property, coaching through conversations where patients may be accessing cannabis without medical authorization, and safe storage troubleshooting and maintenance requirements.

Due to the many complexities of tracking and studying medical cannabis use, it is not known how many children and youth access cannabis for medical purposes in Canada at this time. Similarly, challenges with consistent documentation and identification of patients using medical cannabis limits the ability to have a comprehensive view of how many patients may be using medical cannabis in our settings at any given time. Ongoing work seeks to improve ordering practices in order to facilitate communication and data collection, enhance documentation practices when cannabis storage is required and formalize principles to inform discussion when unauthorized cannabis use may be occurring for medical purposes.

SUMMARY AND RECOMMENDATIONS

As outlined in this commentary, there is complexity in understanding how children and teens use or may be exposed to both recreational and medical cannabis and the challenges these may pose for health care providers. Given that patient care programs can be siloed within health care institutions there is a need to develop ways to support mutual learning to promote understanding of the differences between recreational and medical cannabis use and formulations, identify the needs of individual patients and their families, and promote practices that support access to appropriate and safe resources.

Based on our experience and the emerging literature, we have identified a number of key considerations for paediatric health care institutions that build from the identification of, and collaboration amongst, institutional internal resources and experts, along with clinicians, educators, researchers, and leaders in order to:

• Develop an organizational framework for the approach to the identification, assessment and care of patients with cannabis-related health issues and:

• Address the ongoing learning needs of the health care professionals and trainees relating to cannabis and health

• Create data-collection methods to monitor various patient populations for whom cannabis-related issues are part of care (e.g., palliative care, acute intoxication, acute, and chronic adolescent use)

• Advocate for additional and ongoing research, scholarship and knowledge mobilization in this area.

As frontline health care providers, educators and researchers, we have both an obligation and the opportunity to play key roles in the development, sharing, and application of knowledge and understanding about how cannabis impacts the health of children and adolescents in Canada and beyond.

Funding: There are no funders to report for this submission.

Potential Conflicts of Interest: All authors: No reported conflicts of interest. All authors have submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Conflicts that the editors consider relevant to the content of the manuscript have been disclosed.

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