DENVER – A recent study published in the Annals of Internal Medicine reported harms associated with cannabis use as observed through hospital visits at University of Colorado Health Emergency Department (UCHED). While media was quick to point out the dangers of edibles dosing as a growing concern, what went unreported was that the data set represents less than 1 percent (.57 percent) of the total ER visits. The .57 percent number was informed by coding in a patient’s chart indicating partial attribution to cannabis. Of the ER visits partially attributed to cannabis, 62.7 percent were discharged, none were admitted to the intensive care unit, and none died. Consistent with other examinations on the issue, the majority of cases presented nominal health issues and patients went home.
“The phrase “partially attributed” is important because it means there was no way to establish direct causation, nor analysis about other potential contributing factors leading to hospitalization, such as the impacts of alcohol or other impairing substances, or preexisting conditions,” says Marijuana Industry Group (MIG) executive director Kristi Kelly. “It’s complicated to consider how such information fits into a larger evaluation of health impacts without understanding environmental context. Legal adult use was voted into Colorado’s constitution, and it is every adult’s right to safely access cannabis. MIG remains committed to helping to provide education to ensure that adults make responsible choices, and we take that role seriously.”
Consider the emerging social and legal environment during 2012-2016, the study’s evaluation period. The study points to a meaningful increase in ER visits during the assessment period. A lot changed, and the data set during that time period was consistently evolving. For most of 2012, Colorado was operating as a medical cannabis system, and the regulatory framework was being established and refined. At the end of 2012, Colorado voted to legalize adult use with the passage of Constitutional Amendment 64, which immediately allowed for home cultivation and adult use. Commercial sales at legal dispensaries didn’t begin until 2014. Intake data does not segment between regulated vs. unregulated sources of product, but product differences can be significant. Kelly believes it is logical that with these expanded benchmarks of legalization, there would be increased use among adults.
The research also raised concerns about prevalence of edibles hospitalizations, representing 10.7% of cannabis-attributable visits, or .32% of cannabis sales (based on kg of THC), which was translated by the media to be a 5-fold increase of ER visits. While edibles as a proportion of legal sales was not publicly available in 2016, a Marijuana Policy Group report commissioned by the Marijuana Enforcement Division using 2017 data from state databases attributes 13.7% of total retail sales coming from edibles. This is more in alignment with the stated proportion of edibles-attributed ER visits. The study’s measurement of kg/THC (an unconventional measurement) is based upon regulated cannabis products, and also does not account for the impacts of edibles sourced from unregulated markets that do not require adherence to serving sizes.
From 2014-2018, the state and industry focused on standardizing packaging, labeling and dosing. Colorado consumers started to see child-resistant packaging, consistent treatment of ingredient labels, dosing/serving sizes, testing results for potency, contaminants, and homogeneity. The category of product most positively impacted by these refined regulations? Edibles. In healthcare, as well as law enforcement, such attention led to increased education and better reporting of cannabis-related impacts. Colorado’s Department of Public Safety has consistently acknowledged the difficulty in quantifying how education and better reporting have contributed to upticks in cannabis data, or the best way to adjust for such variables.
Further, hospital reporting systems have room for improvement. Richard Pfeffer is a Colorado resident, industry business owner, and cannabis user. Pfeffer is the victim of two misdiagnoses for Cannabinoid Hyperemesis Syndrome (CHS) by two different ERs. CHS is one of the diagnoses included in the broad category of gastrointestinal symptoms, cited by the study as the most common reason for visits. His experience highlights the opportunity for error. “I was admitted into the ER for extreme nausea, and as a part of my intake, I was asked if I used cannabis. Upon my disclosure of frequent use, I received the diagnosis of cannabis hyperemesis syndrome. However, I did not have CHS. They ultimately determined through blood testing and ultrasound that I had gallstones and I was misdiagnosed by the simple act of disclosing my cannabis use. When I received my discharge paperwork in the mail, it listed marijuana overdose or something like that at the top of my diagnosis, even though by that time they knew marijuana had nothing to do with it. Upon searching the hospital’s database, I will falsely come up as a CHS patient. I ended up going to another ER when symptoms returned, and was again misdiagnosed with CHS because of my disclosure. I told them no, I had gallstones, which they later confirmed. Who knows how many other people are getting misdiagnosed and being coded in hospitals for cannabis issues that don’t truly exist?”
The study proposes that “user education about the adverse health effects” as having the greatest effect on public health. Increasing state funded from cannabis taxes have supported public education efforts on safe consumption. In FY17-18, Colorado Department of Public Health & Environment received $20.7M from the marijuana cash tax fund to support public awareness, substance abuse prevention, resources to monitor the ongoing impacts of retail marijuana and other public health priorities related to cannabis, according to the Joint Budget Committee State Budget Briefing (11/15/18).
Colorado Department of Public Health and Environment (CDPHE) also tracks cannabis-impacted hospitalizations statewide using Colorado Hospital Association data. For the same time period as the study (2016), cannabis-coded hospitalizations represent 0.01 percent (compared to .57 percent in the study) of ER visits statewide, and has remained stable for the current year.
The study was funded from a CDPHE grant for $97,500 as a part of marijuana public health research grants awarded in 2017. Of the grants provided, it is the only one with a proposal to study “adverse” effects, whereas other grants were awarded to projects with more research-neutral towards outcomes.
At the onset, this study proposed to identify harms – the original name of the grant was ‘The Adverse Effects of Edible Cannabis Products.” The study used data from the University of Colorado Health’s Emergency Department – located on the Anschutz campus, so named after a significant philanthropic contribution from Denver billionaire Philip Anschutz and his wife. Anschutz has also been credited for making generous contributions to Colorado anti-cannabis prohibitionist groups, as reported in 2018 by Variety. As a revered benefactor of the hospital system, it is not known whether Anschutz’s beliefs impacted the way that the study’s findings were presented.
About Marijuana Industry Group (MIG)
Marijuana Industry Group (MIG), the leading trade association for Colorado’s licensed business, was founded in 2010 by cannabis business owners to help craft Colorado’s earliest medical marijuana regulatory framework. Since participating in the development of the world’s first licensed, taxed and regulated model, MIG has cultivated strong relationships at the highest levels of state and local government, allowing for real-time education, access, and advancement of practical policy. As the oldest, largest and most diverse trade association in the state, MIG represents the interests of, and advocates on behalf of, the rapidly evolving needs of the leaders of regulated marijuana industry in Colorado.