Little is known about the relative harms of edible and inhalable cannabis products.
To describe and compare adult emergency department (ED) visits related to edible and inhaled cannabis exposure.
Chart review of ED visits between 1 January 2012 and 31 December 2016.
A large urban academic hospital in Colorado.
Adults with ED visits with a cannabis-related International Classification of Diseases, Ninth or 10th Revision, Clinical Modification (ICD-9-CM or ICD-10-CM), code.
Patient demographic characteristics, route of exposure, dose, symptoms, length of stay, disposition, discharge diagnoses, and attribution of visit to cannabis.
There were 9973 visits with an ICD-9-CM or ICD-10-CM code for cannabis use. Of these, 2567 (25.7%) visits were at least partially attributable to cannabis, and 238 of those (9.3%) were related to edible cannabis. Visits attributable to inhaled cannabis were more likely to be for cannabinoid hyperemesis syndrome (18.0% vs. 8.4%), and visits attributable to edible cannabis were more likely to be due to acute psychiatric symptoms (18.0% vs. 10.9%), intoxication (48% vs. 28%), and cardiovascular symptoms (8.0% vs. 3.1%). Edible products accounted for 10.7% of cannabis-attributable visits between 2014 and 2016 but represented only 0.32% of total cannabis sales in Colorado (in kilograms of tetrahydrocannabinol) during that period.
Retrospective study design, single academic center, self-reported exposure data, and limited availability of dose data.
Visits attributable to inhaled cannabis are more frequent than those attributable to edible cannabis, although the latter is associated with more acute psychiatric visits and more ED visits than expected.
Primary Funding Source:
Colorado Department of Public Health and Environment.
- 1. Ogden DW. Investigations and Prosecutions in States Authorizing the Medical Use of Marijuana [Memorandum]. Accessed at http://blogs.justice.gov/main/archives/192 on 18 August 2014. Google Scholar
- 2. Colo. Const. amend. LXIV. Google Scholar
Zhu H, Wu LT. Trends and correlates of cannabis-involved emergency department visits: 2004 to 2011. J Addict Med. 2016;10:429-36. [PMID: 27574753] CrossrefMedlineGoogle Scholar
- 4. Colorado Department of Revenue. Marijuana Sales Reports. Denver: Colorado Department of Revenue; 2018. Accessed at www.colorado.gov/pacific/revenue/colorado-marijuana-sales-reports on 9 July 2018. Google Scholar
- 5. Colorado Department of Public Health and Environment. Behavioral Risk Factor Surveillance System and Child Health Survey. Denver: Colorado Department of Public Health and Environment; 2018. Accessed at www.colorado.gov/pacific/cdphe/behaviorsurvey on 7 February 2019. Google Scholar
Cao D, Srisuma S, Bronstein AC, Hoyte CO. Characterization of edible marijuana product exposures reported to United States poison centers. Clin Toxicol (Phila). 2016;54:840-6. [PMID: 27418198] CrossrefMedlineGoogle Scholar
- 7. Dowd M. Don't harsh our mellow, dude. The New York Times. 3 June 2014. Accessed at www.nytimes.com/2014/06/04/opinion/dowd-dont-harsh-our-mellow-dude.html on 7 February 2019. Google Scholar
Giombi KC, Kosa KM, Rains C, Cates SC. Consumers' perceptions of edible marijuana products for recreational use: likes, dislikes, and reasons for use. Subst Use Misuse. 2018;53:541-7. [PMID: 28910182] doi:10.1080/10826084.2017.1343353 CrossrefMedlineGoogle Scholar
Lamy FR, Daniulaityte R, Sheth A, Nahhas RW, Martins SS, Boyer EW, et al. “Those edibles hit hard”: exploration of Twitter data on cannabis edibles in the U.S. Drug Alcohol Depend. 2016;164:64-70. [PMID: 27185160] doi:10.1016/j.drugalcdep.2016.04.029 CrossrefMedlineGoogle Scholar
- 10. Phillips N. Trial for Richard Kirk in Observatory Park slaying set for March 2017. The Denver Post. 29 September 2016. Accessed at www.denverpost.com/2016/09/29/richard-kirk-observatory-park-marijuana-killing-wife-insanity-plea/2016 on 7 February 2019. Google Scholar
- 11. Ingold J. Denver coroner: Man fell to death after eating marijuana cookies. The Denver Post. 2 April 2014. Accessed at www.denverpost.com/2014/04/02/denver-coroner-man-fell-to-death-after-eating-marijuana-cookies/2014 on 7 February 2019. Google Scholar
- 12. Third Death in Colorado Linked to Marijuana Edibles. Food Safety News. 27 March 2015. Accessed at www.foodsafetynews.com/2015/03/third-death-in-colorado-linked-to-edible-marijuana/#.WzKfui2ZOjQ on 24 June 2018. Google Scholar
Monte AA, Zane RD, Heard KJ. The implications of marijuana legalization in Colorado. JAMA. 2015;313:241-2. [PMID: 25486283] doi:10.1001/jama.2014.17057 CrossrefMedlineGoogle Scholar
Wang GS, Hall K, Vigil D, Banerji S, Monte A, VanDyke M. Marijuana and acute health care contacts in Colorado. Prev Med. 2017;104:24-30. [PMID: 28365373] doi:10.1016/j.ypmed.2017.03.022 CrossrefMedlineGoogle Scholar
Wang GS, LeLait MC, Deakyne SJ, Bronstein AC, Bajaj L, Roosevelt G. Unintentional pediatric exposures to marijuana in Colorado, 2009–2015. JAMA Pediatr. 2016;170:e160971. [PMID: 27454910] doi:10.1001/jamapediatrics.2016.0971 CrossrefMedlineGoogle Scholar
Wang GS, Roosevelt G, Heard K. Pediatric marijuana exposures in a medical marijuana state. JAMA Pediatr. 2013;167:630-3. [PMID: 23712626] doi:10.1001/jamapediatrics.2013.140 CrossrefMedlineGoogle Scholar
Wang GS, Roosevelt G, Le Lait MC, Martinez EM, Bucher-Bartelson B, Bronstein AC, et al. Association of unintentional pediatric exposures with decriminalization of marijuana in the United States. Ann Emerg Med. 2014;63:684-9. [PMID: 24507243] doi:10.1016/j.annemergmed.2014.01.017 CrossrefMedlineGoogle Scholar
Hudak M, Severn D, Nordstrom K. Edible cannabis-induced psychosis: intoxication and beyond [Letter]. Am J Psychiatry. 2015;172:911-2. [PMID: 26324307] doi:10.1176/appi.ajp.2015.15030358 CrossrefMedlineGoogle Scholar
Hall KE, Monte AA, Chang T, Fox J, Brevik C, Vigil DI, et al. Mental health-related emergency department visits associated with cannabis in Colorado. Acad Emerg Med. 2018;25:526-37. [PMID: 29476688] doi:10.1111/acem.13393 CrossrefMedlineGoogle Scholar
D'Souza DC, Perry E, MacDougall L, Ammerman Y, Cooper T, Wu YT, et al. The psychotomimetic effects of intravenous delta-9-tetrahydrocannabinol in healthy individuals: implications for psychosis. Neuropsychopharmacology. 2004;29:1558-72. [PMID: 15173844] CrossrefMedlineGoogle Scholar
Desai R, Shamim S, Patel K, Sadolikar A, Kaur VP, Bhivandkar S, et al. Primary causes of hospitalizations and procedures, predictors of in-hospital mortality, and trends in cardiovascular and cerebrovascular events among recreational marijuana users: a five-year nationwide inpatient assessment in the United States. Cureus. 2018;10:e3195. [PMID: 30402363] doi:10.7759/cureus.3195 CrossrefMedlineGoogle Scholar
Grotenhermen F. Pharmacokinetics and pharmacodynamics of cannabinoids. Clin Pharmacokinet. 2003;42:327-60. [PMID: 12648025] CrossrefMedlineGoogle Scholar
Di Forti M, Marconi A, Carra E, Fraietta S, Trotta A, Bonomo M, et al. Proportion of patients in South London with first-episode psychosis attributable to use of high potency cannabis: a case-control study. Lancet Psychiatry. 2015;2:233-8. [PMID: 26359901] doi:10.1016/S2215-0366(14)00117-5 CrossrefMedlineGoogle Scholar
van Os J, Bak M, Hanssen M, Bijl RV, de Graaf R, Verdoux H. Cannabis use and psychosis: a longitudinal population-based study. Am J Epidemiol. 2002;156:319-27. [PMID: 12181101] CrossrefMedlineGoogle Scholar
Volkow ND, Baler RD, Compton WM, Weiss SR. Adverse health effects of marijuana use. N Engl J Med. 2014;370:2219-27. [PMID: 24897085] doi:10.1056/NEJMra1402309 CrossrefMedlineGoogle Scholar
Kylie Lee KS, Sukavatvibul K, Conigrave KM. Cannabis use and violence in three remote Aboriginal Australian communities: analysis of clinic presentations. Transcult Psychiatry. 2015;52:827-39. [PMID: 26045571] doi:10.1177/1363461515589047 CrossrefMedlineGoogle Scholar
Norström T, Rossow I. Cannabis use and violence: is there a link? Scand J Public Health. 2014;42:358-63. [PMID: 24608093] doi:10.1177/1403494814525003 CrossrefMedlineGoogle Scholar
Jouanjus E, Lapeyre-Mestre M, Micallef J; French Association of the Regional Abuse and Dependence Monitoring Centres (CEIP-A) Working Group on Cannabis Complications. Cannabis use: signal of increasing risk of serious cardiovascular disorders. J Am Heart Assoc. 2014;3:e000638. [PMID: 24760961] doi:10.1161/JAHA.113.000638 CrossrefMedlineGoogle Scholar
Kalla A, Krishnamoorthy PM, Gopalakrishnan A, Figueredo VM. Cannabis use predicts risks of heart failure and cerebrovascular accidents: results from the National Inpatient Sample. J Cardiovasc Med (Hagerstown). 2018;19:480-4. [PMID: 29879084] doi:10.2459/JCM.0000000000000681 CrossrefMedlineGoogle Scholar
- 30. Colorado Department of Public Health and Environment. Monitoring Health Concerns Related to Marijuana in Colorado. Denver: Colorado Department of Public Health and Environment; 2014. Accessed at www.colorado.gov/pacific/cdphe/retail-marijuana-public-health-advisory-committee on 7 February 2019. Google Scholar
Kim HS, Anderson JD, Saghafi O, Heard KJ, Monte AA. Cyclic vomiting presentations following marijuana liberalization in Colorado. Acad Emerg Med. 2015;22:694-9. [PMID: 25903855] doi:10.1111/acem.12655 CrossrefMedlineGoogle Scholar
Kim HS, Hall KE, Genco EK, Van Dyke M, Barker E, Monte AA. Marijuana tourism and emergency department visits in Colorado [Letter]. N Engl J Med. 2016;374:797-8. [PMID: 26933869] doi:10.1056/NEJMc1515009 CrossrefMedlineGoogle Scholar
Vandrey R, Raber JC, Raber ME, Douglass B, Miller C, Bonn-Miller MO. Cannabinoid dose and label accuracy in edible medical cannabis products. JAMA. 2015;313:2491-3. [PMID: 26103034] doi:10.1001/jama.2015.6613 CrossrefMedlineGoogle Scholar
Newmeyer MN, Swortwood MJ, Taylor ME, Abulseoud OA, Woodward TH, Huestis MA. Evaluation of divided attention psychophysical task performance and effects on pupil sizes following smoked, vaporized and oral cannabis administration. J Appl Toxicol. 2017;37:922-32. [PMID: 28138971] doi:10.1002/jat.3440 CrossrefMedlineGoogle Scholar
Allen JA, Davis KC, Duke JC, Nonnemaker JM, Bradfield BR, Farrelly MC. New product trial, use of edibles, and unexpected highs among marijuana and hashish users in Colorado. Drug Alcohol Depend. 2017;176:44-7. [PMID: 28514695] doi:10.1016/j.drugalcdep.2017.03.006 CrossrefMedlineGoogle Scholar
MacCoun RJ, Mello MM. Half-baked—the retail promotion of marijuana edibles. N Engl J Med. 2015;372:989-91. [PMID: 25760351] doi:10.1056/NEJMp1416014 CrossrefMedlineGoogle Scholar
Benjamin DM, Fossler MJ. Edible cannabis products: it is time for FDA oversight. J Clin Pharmacol. 2016;56:1045-7. [PMID: 27270959] doi:10.1002/jcph.778 CrossrefMedlineGoogle Scholar
Author, Article, and Disclosure Information
Andrew A. Monte,
University of Colorado School of Medicine, Aurora, Colorado, and Rocky Mountain Poison & Drug Center, Denver Health and Hospital Authority, Denver, Colorado (A.A.M.)
University of Colorado School of Medicine, Aurora, Colorado (S.K.S., E.M., J.S., A.H., B.S., M.D., T.C., J.F., C.B., K.W., D.A.)
Disclaimer: The contents of this work are the sole responsibility of the authors and do not necessarily represent the views of the National Institutes of Health (NIH) or the CDPHE.
Grant Support: By a grant entitled “The Adverse Health Effects of Edible Cannabis Products” from the CDPHE. Dr. Monte received support from NIH K23 GM110516, NIH CTSI UL1 TR001082, and CDPHE 17 FHHA 96950.
Disclosures: Dr. Monte reports grants from the Colorado Department of Public Health and Environment during the conduct of the study and also sits on the Colorado Retail Marijuana Public Health Advisory Committee, a group of clinicians and scientists tasked with reviewing the scientific literature related to the public health effects of cannabis use and exposure. Dr. Saben reports grants from the Colorado Department of Public Health and Environment during the conduct of the study. Authors not named here have disclosed no conflicts of interest. Disclosures can also be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M18-2809.
Editors' Disclosures: Christine Laine, MD, MPH, Editor in Chief, reports that her spouse has stock options/holdings with Targeted Diagnostics and Therapeutics. Darren B. Taichman, MD, PhD, Executive Editor, reports that he has no financial relationships or interests to disclose. Cynthia D. Mulrow, MD, MSc, Senior Deputy Editor, reports that she has no relationships or interests to disclose. Jaya K. Rao, MD, MHS, Deputy Editor, reports that she has stock holdings/options in Eli Lilly and Pfizer. Catharine B. Stack, PhD, MS, Deputy Editor for Statistics, reports that she has stock holdings in Pfizer, Johnson & Johnson, and Colgate-Palmolive. Christina C. Wee, MD, MPH, Deputy Editor, reports employment with Beth Israel Deaconess Medical Center. Sankey V. Williams, MD, Deputy Editor, reports that he has no financial relationships or interests to disclose. Yu-Xiao Yang, MD, MSCE, Deputy Editor, reports that he has no financial relationships or interest to disclose.
Reproducible Research Statement:Study protocol, statistical code, and data set: Available from Dr. Monte (e-mail, andrew.
Corresponding Author: Andrew A. Monte, MD, PhD, Department of Emergency Medicine, University of Colorado School of Medicine, 12401 East 17th Avenue, Aurora, CO 80045; e-mail, andrew.
Current Author Addresses: Drs. Monte, Chang, Brevik, and Abbott; Ms. Mills; Mr. Hopkinson; Mr. Devivo; and Mr. Fox: Department of Emergency Medicine, University of Colorado School of Medicine, 12401 East 17th Avenue, Aurora, CO 80045.
Ms. Shelton, Dr. Saben, and Mr. Sonn: University of Colorado, 12469 East 17th Place, Aurora, CO 80045.
Ms. Williamson: Colorado School of Public Health, University of Colorado, 13001 East 17th Place, Aurora, CO 80045.
Author Contributions: Conception and design: A.A. Monte.
Analysis and interpretation of the data: A.A. Monte, S.K. Shelton, E. Mills, J. Saben, K. Williamson, D. Abbott.
Drafting of the article: A.A. Monte, S.K. Shelton, J. Saben.
Critical revision of the article for important intellectual content: A.A. Monte, S.K. Shelton, J. Saben, D. Abbott.
Final approval of the article: A.A. Monte, S.K. Shelton, E. Mills, J. Saben, A. Hopkinson, B. Sonn, M. Devivo, T. Chang, J. Fox, C. Brevik, K. Williamson, D. Abbott.
Statistical expertise: A.A. Monte, K. Williamson, D. Abbott.
Obtaining of funding: A.A. Monte.
Administrative, technical, or logistic support: A.A. Monte, E. Mills, J. Saben, A. Hopkinson, B. Sonn.
Collection and assembly of data: A.A. Monte, S.K. Shelton, E. Mills, M. Devivo, T. Chang, J. Fox, C. Brevik.
This article was published at Annals.org on 26 March 2019.