Editor's note: As an early adopter of marijuana legalization, Colorado is the epicenter of the marijuana debate. The hospital presented on the topic at the 2017 Quality and Safety in Children's Health Conference, and we share their strategies, originally published in the spring 2015 issue of Children's Hospitals Today.
As marijuana-laced candies, edibles and treats hit the market, child health and safety issues are emerging. Here’s how one children’s hospital is helping shape and influence the issue.
By Heidi Baskfield, J.D.
Colorado has long been world-renowned for its towering mountains, picturesque landscapes and recreational activities for residents and visitors. But the state has dominated the international news with a new reputation as the first in the country—and the world—to legalize recreational marijuana. What’s not as well-known is, for the most part, Colorado got legalization right.
While there is still much work to do, policymakers have adhered to the will of voters while protecting public safety, responsibly regulating a new industry, and ensuring children aren’t harmed by these new laws.
While this was not Colorado’s first venture with marijuana—voters legalized its use for medicinal purposes in 2000—Children’s Hospital Colorado (Children’s Colorado) became increasingly engaged with state lawmakers and regulators in the implementation of subsequent marijuana policies.
As the state began to set up one of the world’s first legal retail marijuana markets, the urgent need to get marijuana policy right the first time demanded the hospital’s involvement to help protect kids’ health and safety.
Across the country, attitudes and opinions about marijuana legislation are changing, and over the last few years, national opinion has swung in favor of legalizing marijuana. According to a 2014 Gallup Poll, 51 percent of Americans support marijuana legalization, and of that, 64 percent of respondents ages 18 to 34 support legalization.
In Colorado, Jan. 1, 2015, marked the official one-year anniversary since recreational marijuana became legal. To date, 23 states and the District of Columbia have legalized medical marijuana. Four states (Colorado, Washington, Oregon and Alaska) and the District of Columbia have legalized recreational marijuana for adults 21 years of age and older.
As additional states contemplate their own ballot initiatives, this presents a likely child health and safety issue other children’s hospitals will face. As one of the first children’s hospitals to lend pediatric expertise to the topic, here’s a look at what Children’s Colorado experienced.
Advocating for children
In Colorado, for supporters and opponents alike, legal marijuana is the new reality. That reality has arrived with a staggering array of rapid-fire policy challenges. Aside from the changes to criminal law, legalization has implications for school safety policies, child abuse and neglect statutes, child care center regulation, advertising restrictions, substance abuse programs, employment law, traffic offenses, banking, state revenue, ports of entry and federalism, among many others.
These policy challenges have far-reaching implications, few have been easy to resolve, and most have drawn time and resources away from other policy areas. But most stakeholders have approached each issue with good faith and an earnest determination to find solutions that gain broad support.
Public safety advocates accept legalization as the law of the land in the state, and marijuana industry representatives know it will come to a quick end if responsible regulation fails and the federal government is forced to intervene.
Children’s hospitals play a key role in advocacy and public safety. And because advocacy is a central tenet of Children’s Colorado’s mission, the core message of keeping children and youth healthy and safe through evidence-based strategies has resonated with policymakers. As a result, legislators have called on the hospital’s experts frequently to serve on task forces, testify at hearings, and even help craft legislative and regulatory policy.
Like many children’s hospitals across the U.S., Children’s Colorado has the pediatric toxicologists, neurologists, public health specialists, adolescent medicine and emergency medicine physicians, behavioral health specialists, and public policy and communications professionals to serve as child health advocates on this issue.
When there have been direct links to child health and safety issues, Children’s Colorado has worked to provide perspectives through public policy, advocacy, media engagement and clinical expertise. For example, the hospital worked with the state’s Marijuana Enforcement Division within the Department of Revenue and other state agencies like the Colorado Department of Public Health and Environment on a number of initiatives.
Tracking ED visits
One major concern the hospital’s emergency medicine physicians and medical staff members put into context has been the uptick in accidental ingestion cases since the new law went into effect. Accidental exposure to marijuana products in children in the state has increased in the last few years, based on the rate of emergency department visits and admissions at Children’s Colorado.
Between 2005 and 2009, before the medical marijuana boom and recreational legalization, the Children’s Colorado emergency departments saw no cases of accidental ingestion. In 2013, Children’s Colorado treated eight children (mostly ages 3 and under) who ingested edible marijuana. These are products that look like treats and are easily mistaken for a non-potent treat. This number increased to 14 children in 2014, which also was the first year of legalized retail marijuana.
While the total number of children admitted to the Children’s Colorado emergency department is low, especially relative to accidental ingestions of household products, it suggests an increase since 2005 in the risk of childhood exposure to marijuana products. And Colorado does not yet have data from all hospitals related to pediatric marijuana exposures, much less the total number of accidental exposures, most of which presumably do not result in a hospital visit.
When these children arrived at the emergency department, symptoms ranged from sleepiness to difficulty breathing, or they were comatose. Nearly half of the children required care in the intensive care unit and some needed intubation.
In an effort to prevent accidental ingestion, George Sam Wang, M.D., a pediatric emergency medicine physician and medical toxicologist at Children’s Colorado, helped the state craft legislation in 2014 that required child-safe packaging for marijuana products. For decades, child-resistant packaging has been a proven method for keeping kids out of unsafe products. Almost all pharmaceuticals and household products meet the standards.
Similarly, Children’s Colorado supported efforts to include warning labels on marijuana products that include messaging the pharmaceutical and toxic chemical industries use like, "Keep Out of Reach of Children."
The hospital worked with a state task force in the fall of 2014 to advocate for a standardized, imprinted symbol on items such as candies, pills and chocolates to indicate the product contained marijuana. Other efforts to reduce the likelihood emergency department visits include work to address potency limits in edible marijuana products, opaque packaging requirements so children are not drawn to marijuana products and labeling requirements.
Opportunities for research
In 2014, the state legislature authorized funds collected under the medical marijuana program to be used in a grant research program the state public health department oversees. The goal of the program is to advance scientific research regarding the efficacy and capacity of medical marijuana to provide therapeutic benefits. Lalit Bajaj, M.D., M.P.H., an emergency medicine provider and medical director of clinical effectiveness, served on the multidisciplinary group of reviewers the state health department convened to review the grants.
In December 2014, the state Board of Health approved eight applications, including four from primary investigators at Children’s Colorado. Physicians at the hospital will observationally study marijuana cannabinoids in epilepsy treatment. They also will study the use of marijuana in patients with inflammatory bowel disease and the use of marijuana in palliative care for patients with pediatric brain tumors.
On the horizon
All the parties involved have learned much in this inaugural year. Many individuals in this debate continue to share concerns about the gaps in available marijuana data in many areas, including behavioral health and substance abuse, public safety, schools and health care. The Office of Marijuana Coordination through Colorado Governor John Hickenlooper's office has established a list of areas where there is a clear need for improved data collection and coordination among entities in the state, and Children’s Colorado anticipates other hospitals will be engaged in the discussion regarding emergency department visits and hospitalizations related to marijuana use.
In addition to improving data collection, hospital teams are dealing with reporting challenges. For example, clinical and social work teams struggle to know when to contact law enforcement officials if a parent or guardian appears to be under the influence of marijuana. Providers also are conflicted with a Colorado law that dictates when a newborn tests positive for any Schedule 1 drug, including marijuana, the mother is subject to child dependency and neglect charges.
However, there are no such charges for fetal alcohol syndrome and no guidelines for pregnant moms who use marijuana. Schools have reported additional challenges because edible marijuana is difficult to detect in many circumstances, like when it’s infused in granola bars, energy drinks, cookies, candies or in vape pens or e-cigarettes.
The state legislature is facing its own challenges. As of publication of this article, legislators returned to the capitol for the 2015 legislative session and marijuana remains a hot topic. Legislators have proposed new measures to deal with concerns about potential abuse in the state’s medical marijuana program, marijuana revenue issues in local government, and proposals to include signage in marijuana shops warning pregnant women of the dangers of marijuana use. Experts at the hospital expect to continue efforts to address concerns around labeling and marking of edible marijuana products.
Despite the challenges and work that lies ahead, Children’s Colorado remains committed to participating in the evolving conversations and debates about marijuana to ensure the health and safety of the state’s children and youth. As other states contemplate legalizing marijuana, the hospital’s staff members encourage other children’s hospital colleagues to reach out about this issue. No matter what your state’s stance on marijuana, we all agree on one thing—child health and safety is an urgent matter.
Heidi Baskfield, J.D., is executive director of advocacy at Children’s Hospital Colorado.
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