Wednesday, August 29, 2018

PRO/AH/EDR> Cannabis overdoses - Canada: dramatic rise

A ProMED-mail post
ProMED-mail is a program of the
International Society for Infectious Diseases

Date: Tue 28 Aug 2018 4:00 AM ET
Source: CBC (Canadian Broadcasting Corporation) News [edited]

It was early evening at a popular downtown Toronto jazz bar, the band
playing for an older crowd more into Ella Fitzgerald than Rihanna's
"Umbrella". Part way through the set, a man in his late 50s stood and
then promptly collapsed, face-first, onto the floor.

The bar's supervisor [NM], watched in horror from behind the bar. "You
see this scene and you're like, 'Oh God. OK, instantly 911,'" he

[NM] assumed it was a stroke or a heart attack, but as paramedics
arrived, he learned it was something quite different. "He had eaten a
[cannabis] edible and just couldn't handle it," [NM] said.

Cannabis overdoses are something he said he's personally witnessed at
the bar 3 times in the past year.

That mirrors a trend happening across the country -- as the 17 Oct
2018 date for legalization of recreational pot looms, CBC News has
learned that cannabis-related emergency room visits have spiked.

Data from the Canadian Institute for Health Information (CIHI) shows
over the past 3 years the number of emergency room visits because of
cannabis overdoses in Ontario has almost tripled -- from 449 in
2013-14, to nearly 1,500 in 2017-18.

In Alberta, the number has nearly doubled over the same timeframe,
from 431 to 832.

Symptoms of cannabis overdose -- or more precisely, THC
[tetrahydrocannabinol] poisoning, THC being the main psychoactive
chemical in pot -- include elevated heart rate and blood pressure,
anxiety, vomiting and in some cases psychosis, possibly necessitating

Outside of Alberta and Ontario, the statistics on cannabis overdoses
are sparse. But the CIHI figures that are available for other
reporting jurisdictions, which include small samples from health
centres in Nova Scotia, Prince Edward Island, Yukon, Manitoba, and
Saskatchewan, show Canadians in some regions are being sent to a
hospital because of pot at 4 times the rate they were in 2013.

"That's just the tip of the iceberg," said Heather Hudson at the
Ontario Poison Centre at SickKids children's hospital in Toronto,
pointing to a rise in the number of cases involving children and

"We are certainly getting more calls about children who are being
exposed unintentionally," she said.

While the CIHI data doesn't break down what kind of cannabis the
patients used, Toronto University Health Network emergency room
physician Dr Michael Szabo said edibles are a big factor in ER

"We're seeing a lot of people out there who are accidentally ingesting
huge amounts of cannabis. They're not realizing that what they're
taking, it is excessive," Dr Szabo said.

"Nothing's labelled properly. The serving size is not clearly marked
so they're eating a whole brownie, not realizing they're only supposed
to eat 1/8th of that brownie."

Szabo said patients who have overdosed on cannabis often present as
agitated, with rapid breathing, high heart rates, and elevated blood
pressure. "They have, often, symptoms like anxiety. It can progress to
paranoia and actually frank psychosis, where they become detached from
reality," Dr. Szabo said.

Depending on the severity of the case, he said patients can spend up
to 20 hours in the ER coming down from the unintentional high. He
added they are often exposed to unnecessary radiation from CT scans,
because they initially show possible stroke symptoms.

"It's a huge burden. They're occupying beds. They're occupying nursing
time, physician time," Szabo said.

Although Health Canada doesn't have plans to make edibles legal for
another year, they are already widely available and Szabo said many
consumers don't understand how they work. One problem is that people
sometimes eat more of a cannabis product when they don't feel an
immediate strong effect.

"When you ingest something edible it's going to peak in 2 to 4 hours
after you take it in," he said. "So you should not increase the amount
you're taking until the 4-hour mark."

In the video clip, [at the source URL above], Szabo describes a recent
cannabis overdose case he dealt with in Toronto:

Szabo said he looks forward to when cannabis edibles are legalized,
because at least then there will be some clear regulation governing
them. Until then, he said he expects to see more patients who have
eaten one gummy too many clogging up the emergency room.

Szabo blames a lack of public health messaging, and he's not alone.

"I would have liked to have seen public health messaging starting as
soon as the bill passed, if not sooner than that," said Ian Culbert of
the Canadian Public Health Association.

"We've known that this was coming -- at the federal level the Liberals
have a majority, we knew that it was going to pass," Culbert said.
"That [public health] information should have started immediately."

CBC News contacted the departments of health in several provinces for
details on their public education plans around the legalization of
- The Ontario ministry said, "We see public education efforts as
critical in the lead up to the legalization," but did not provide any
specific details about a plan, including how and when it might be
- Alberta Health Services said it will be launching a public awareness
campaign aimed primarily at "our target audience of those aged about
25 years," with a focus on the health risks associated with cannabis.
It gave no launch date. [Given this article opened with a person much
older than 25 having effects, perhaps these message should target all
peoples. - Mod.TG]
- The British Columbia government said it is "involved in
cross-government efforts to identify key areas of focus for public
education activities that will most effectively reach our most
vulnerable populations."
- Manitoba officials told CBC News the province is working on a
public education campaign that is expected to "touch on a number of
areas, including health," adding that "the campaign is in the planning

Culbert is alarmed at the scarcity of harm-reduction messaging out
there for consumers, especially when it comes to unregulated edibles.
He fears the number of pot-related emergency room visits will go up
even more after cannabis is legalized in October.

"We know people want to use this product. We know a quarter of 15- to
24-year-olds in Canada are currently using it in the illegal market.
So it's really important they have the information they need to make
healthy choices," Culbert said.

And, he added, it's not just younger users who need to be educated.

"Cannabis is a very different product than it was 20, 30 years ago. So
everybody needs a bit of a refresher on how do you consume the product
and limit their consumption," Culbert said.

While official public health messaging remains thin, some in the
burgeoning cannabis industry are taking the responsibility upon
themselves to educate people about the safe and responsible use of

In her Toronto kitchen, chef [CL] uses a special machine to diffuse
cannabis strains into fats and oils so she can control the dosing. She
caters cannabis-themed events and helps people learn to cook safely
with cannabis products.

"I highly recommend starting light. There's no need to overindulge.
It's meant to be gentle," said [CL], who started experimenting with
cannabis menus in lieu of alcohol as a way to unwind.

"I was looking for some alternatives to sort of relax, take off some
of the pain from working as a chef. You know, I'm on my feet all the
time, I'm running around carrying heavy things. It's a very demanding
job," she said.

A self-described wimp when it comes to drug use, [CL] advocates
"micro-dosing," working very small doses of cannabis into recipes.

She also warns that people need to do their homework before cooking
with cannabis. "When it comes to dosing, you really have to know where
the strains are coming from, where they're being sourced, how they're
grown, whether it's CBD [cannabidiol] or THC. [CBD] is the relaxing
version, like a muscle-relaxing sort of anxiety relieving, versus the
THC which is a bit more of a heady, higher-energy sort of scenario,"
[CL] said. "Then ease your way into trying small quantities."

Back at the Toronto bar, [NM] is frustrated at both the lack of public
education about cannabis, and of guidelines for the industry to
safeguard against over-serving in a world where recreational pot will
be legal and as commonplace as having a beer.

Even with all the education around responsible drinking, alcohol is a
significant factor in hospitalizations, sending about 77 000 Canadians
for medical treatment in 2015-16, according to CIHI figures. Still,
[NM] said he believes public health messaging around responsible
drinking works, and it also helps servers reduce overuse.

"I'd like to see a little bit of support from the agencies telling us
to manage alcohol and manage people's experience with substances.
[I'd] like to see them reiterate there is a responsibility of the
patron to, you know, to take care of themselves," [NM] said.

Smart Serve Ontario, the provincial program that trains restaurant and
bar staff on responsible alcohol practices, told CBC News servers will
need to "re-align their thinking when it comes to the signs of
intoxication once pot is legalized." It said it has been in talks with
the Ontario government about its role in cannabis education.

In the meantime, [NM] says he believes people are going to continue to
learn the hard way, like the gentleman he watched pass out at the bar.
"That's an eye opener for that guy, you know, he's probably going to
think twice about it. I hope," [NM] said.

[Byline: Katie Nicholson]

Communicated by:
Karyn L Bischoff

[There is a huge difference between THC and CBD. Education on which
form of cannabis to use to achieve specific results is desperately
needed. The physiological effects of smoking vs eating cannabis
products are very different. Instead of a euphoric high or a mild
relaxation, mistakes of overdoses from edibles can easily result in

Owners especially need to refrain from feeding their pets cannabis
edibles. These edibles, even in small doses can have extremely
detrimental effects, including death to your pet.

While work with the various cannabis products has found beneficial
effects with some diseases such as Parkinson's, and some seizure
maladies, there remains more work to understand appropriate cannabis
doses and expected results.

Work is ongoing, especially at Colorado State University Veterinary
School in the US, to understand appropriate uses and doses for seizure
disorders in dogs.

Inappropriate doses in both human beings and pets can have very
serious consequences. Education must accompany, and should begin well
before, the legalization. This product has the ability to do
incredible good but also to cause incredible harm.

Perhaps the by-word should be "know what you smoke and know what you
eat" before you do it. - Mod.TG

HealthMap/ProMED-mail map of Canada:

[See Also:
Marijuana, canine - USA: (OR)
Marijuana, canine - Canada (02) (AB)
Marijuana, canine - Canada: (AB)
Mucormycosis - USA: (CA) fatal, lung, raw marijuana susp,
immunocomprom. patient
Contaminated marijuana - USA: (OR) pesticide
Marijuana, water - USA: (CO)
Poisoning, marijuana - USA: (CO) children
Foodborne illness - Canada: (BC) marijuana infused food
Marijuana candy - USA: (RI)
Cannabis toxicity - Albania
Marijuana, canine - USA (CO)]
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