Pediatrics

New Study Finds Cannabis May Be “Unsafe” For Pregnant Women

https://www.wbur.org/commonhealth/2019/06/18/cannabis-unsafe-pregnant-women

In a study of 661, 617 pregnant women, researchers found that cannabis use was significantly associated with an increased risk of preterm birth. But these findings may be limited due to other risk factors like tobacco, alcohol, and opioid use. 

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Benjamin Caplan, MDNew Study Finds Cannabis May Be “Unsafe” For Pregnant Women
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Adolescent Executive Dysfunction in Daily Life: Relationships to Risks, Brain Structure and Substance Use

Researchers assessed 817 youth (aged 12 to 21) who previously participated in the National Consortium on Alcohol and Neurodevelopment in Adolescence study. They found that 123 subjects (15.2%) had used cannabis in the past year, and that cannabis use impaired inhibitory control, emotional control, and task planning.

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Benjamin Caplan, MDAdolescent Executive Dysfunction in Daily Life: Relationships to Risks, Brain Structure and Substance Use
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Medical Marijuana and Treatment of Pediatric Epilepsy Patients

Medical Marijuana in the Pediatric Population With Epilepsy—What You Should Know

A recent review has discussed the known benefits of treating children who are suffering from epilepsy with cannabis-based medicine. Medical marijuana (MM) is a viable option for treating this population that comes with risks due to the high that comes from THC and its legal status as a Schedule 1 drug. The legal status is currently preventing larger scale research to be done so that physicians can better educate parents on how to care for a child taking MM.

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Benjamin Caplan, MDMedical Marijuana and Treatment of Pediatric Epilepsy Patients
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Cannabidiol as a suggested candidate for treatment of Autism Spectrum Disorder

This 2018 review summarizes the available data regarding the safety and effectiveness of medical cannabis in young ASD patients. Here’s our video adaptation:

  • Autism spectrum disorder (ASD) defines a group of neurodevelopmental disorders that are frequently associated with general cognitive deficits
    • DSM-5 criteria of ASD include:
      • A. Persistent deficits in social communication and social interaction
      • B. Restricted, repetitive patterns of behavior, interests, or activities
      • C. Symptoms must be present in the early developmental period
      • D. Symptoms cause clinically significant impairment in social, occupational, or other important areas of current functioning.
      • E. These disturbances are not better explained by intellectual disability or global developmental delay
    • ASD is frequently accompanied by co-morbidities:
      • sleep disorders
      • attention-deficit/hyperactivity disorder (ADHD)
      • Psychosis
      • Anxiety
      • mood and cognitive disorders
      • epilepsy
    • Despite it being one of the most severe chronic childhood disorders with relatively high prevalence, morbidity and impact on the society, no effective treatment for the core symptoms of ASD is available yet.
    • There is increasing interest in cannabinoids, especially cannabidiol (CBD), as monotherapy or add-on treatment for the core symptoms and co-morbidities of ASD.
  • CBD Use for Epilepsy
    • 20-30% of people with ASD also suffer from epilepsy
    • Surveys conducted among parents of children suffering from epilepsy suggest improvement following treatment with CBD-enriched cannabis extracts. These results however, do not necessarily apply when it comes to treating adults with epilepsy (Alexander et al., 2009).
    • Still, in a retrospective study that examined the effect of CBD enriched medical cannabis oil on children with intractable epilepsy, the treatment caused a reduction in seizure frequency in 89% of patients (Tzadok et al., 2016).
  • CBD Use in Psychiatry
    • CBD in Psychosis
      • In some cases, psychosis can be a comorbidity of ASD, with the simultaneous onset of schizophrenia at adolescence or early adulthood (Sagar et al., 2013).
      • Ineffective
        • A 2006 study that investigated the influence of CBD as monotherapy in treatment-resistant schizophrenia found that it was ineffective (Zuardi et al., 2006).
      • Effective
        • But a 2018 study showed that, in patients with schizophrenia, adding CBD to ongoing antipsychotic treatment resulted in greater antipsychotic activity and beneficial effects, as compared to placebo add-on (Mcguire et al., 2018).
    • CBD and Anxiety
      • Many ASD patients suffer from anxiety disorders that harm their quality of life (Gu, 2017; Haan et al., 2008; Perrin, 2011).
      • CBD may possess anxiolytic effects both in animals and humans (Bergamaschi et al., 2011).
      • When tested in humans, CBD showed an anxiolytic effect in patients that suffer from social anxiety disorder (SAD), contrary to THC that may induce anxiety (Devinsky et al., 2014).
    • CBD, mood and cognitive disorders
      • It was previously shown that a variety of psychiatric co-morbidities may occur in ASD patients, the most common one being mood disorders (Ghaziddin and Zafar, 2008).
      • Risks of THC
        • THC use may be associated with onset or aggravation of depression, bipolar disorder, mania and psychosis (Rong et al., 2017).
        • THC administration may also result in memory impairment (Ranganathan and Souza, 2006; Rong et al., 2017).
      • Benefits of CBD
        • On the other hand, CBD possesses agonistic activity at the 5-HT1A serotonin receptor and shares similar mechanisms with lithium. These pharmacological properties may indicate its potential role in the treatment of mood disorders (Rong et al., 2017).
        • Therapeutic CBD properties were investigated for cognitive deficits as well. In a preclinical study that tested the effect of CBD on cognition in an Alzheimer’s Disease mouse model (APPxPS1), chronic CBD treatment reversed the cognitive deficits without affecting anxiety-related behaviors (Cheng et al., 2014).
    • CBD and sleep disorders
      • Sleep disorders are highly prevalent among children with ASD.
      • In the general population insomnia is the most common sleep complaint, and treatment with medical cannabis may be effective, especially when the insomnia is associated with pain (Gates et al., 2014).
      • It has been claimed that long term use of cannabis may induce sleep disturbances (Gates et al., 2014). however, a case series indicated that CBD treatment may actually improve the quality of sleep in Parkinson’s disease (Chagas et al., 2014).
    • CBD and ADHD
      • ADHD is one of the most common psychiatric co-morbidities in young ASD patients (Ghaziddin and Zafar, 2008), with comorbidity rates in the range of 40-70% (Antshel et al., 2016).
      • In a pilot randomized placebo-controlled experimental study of a cannabinoid medication (an oral spray containing 1:1 ratio of THC:CBD) in adults who suffer from ADHD, there was no significant improvement in the cognitive performance, but there was a significant improvement in the hyperactivity, impulsivity and inhibition measures after the treatment with the medical cannabis (Cooper et al., 2017).
    • The role of cannabis use for social behavior
      • Risks
        • Some studies show that THC administration may lead as well to a reduction in social interaction in rats, while co-administration of CBD seems to attenuate this effect (Malone et al., 2009).
      • Benefits
        • On the other hand, in a study that tested the influence of marijuana smoking on healthy human volunteers, subjects reported retrospectively that while smoking marijuana they were happier, friendlier and calmer, responded more warmly to others, seemed to have a better understanding of their peers’ state of mind and were less likely to respond angrily or defensively. However, they had a harder time focusing and paying attention to what others said (Galanter et al., 1974).
        • CBD Use for Children
    • The administration of cannabinoids for children and adolescents suffering from ASD is a controversial legal and ethical issue (Khalil, 2012).
      • Risks
        • Those who oppose the use of medical cannabis in pediatrics claim that this treatment might harm young children and adolescents’ brain development.
      • Benefits
        • In the field of pediatric mental illnesses, CBD is sometimes used as a treatment for anxiety disorders. In a case report describing a 10-year-old girl who suffered from PTSD after being sexually abused, it was reported that CBD treatment reduced her anxiety and improved her sleep (Shannon, 2016).
  • Conclusions
    • The use of cannabinoids in general and CBD in particular in the treatment of numerous medical and mental conditions, including ASD, is growing rapidly.
    • There certainly is a big gap in the field and such studies are needed before drawing any conclusions on the potential therapeutic applications of cannabinoids in ASD.
    • Further pre-clinical and clinical studies are needed in order to examine the pros and cons of CBD and other cannabinoids in ASD, before they are established as a treatment for ASD symptoms and co-morbidities.

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Benjamin Caplan, MDCannabidiol as a suggested candidate for treatment of Autism Spectrum Disorder
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How to prevent inappropriate teen use?

Especially in Colorado and Washington, people are taking note of teens’ use and access to potent marijuana, and many are concerned that there are not enough measures in place to prevent this. Newly legalized states should look into this before it becomes a national issue. https://wapo.st/2Fgmto9

Benjamin Caplan, MDHow to prevent inappropriate teen use?
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The Education of Dispensary Staff is Varied and Lacks Regulation

Training and Practices of Cannabis Dispensary Staff

How much medical training does your local budtender possess? An online survey sent to medical marijuana dispensary staff reported only 55% of staffers had any formal training for their position, with 20% reporting some background in medical/scientific training. The analysis reported that many among the dispensary staff are recommending cannabis choices that are consistent with current evidence, but some are recommending strains that are either ineffective or exacerbate a patient’s condition. The findings of this study stress the importance of consistent and well-regulated training of dispensary staff.

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Benjamin Caplan, MDThe Education of Dispensary Staff is Varied and Lacks Regulation
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Cannabinoids in Attention- Deficit/Hyperactivity Disorder: A randomized-controlled trial

In a placebo-controlled study of a cannabis oral spray in patients with ADHD, there was no significant improvement in cognitive performance, but there was a significant improvement in hyperactivity and impulsivity.

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This paper is also stored here:     http://bit.ly/31ykZiz    inside the CED Foundation Archive

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Benjamin Caplan, MDCannabinoids in Attention- Deficit/Hyperactivity Disorder: A randomized-controlled trial
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Multiple Health Risk Behaviors in Young Adult Smokers: Stages of Change and Stability over Time

Study finds that most young adult smokers engage in multiple other health risk behaviors. When placed in an intervention, participants were most ready to change their stress management and least ready to change their cannabis use.

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This paper is also stored here:  http://bit.ly/31mTqIM       inside the CED Foundation Archive

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Benjamin Caplan, MDMultiple Health Risk Behaviors in Young Adult Smokers: Stages of Change and Stability over Time
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Edibles: Tasty or Not Tasty?

Edibles are a popular way to consume cannabis because they can be tasty & easy, but maybe this is a problem? Should meds be made unappealing to children or pets? Although many people enjoy treatment via gummy bears, is this a bad path? The Brilliant Dr Peter Grinspoon’s take: http://bit.ly/2KygQov

The following is an interesting perspective from Julie Beck @ https://www.theatlantic.com/health/archive/2017/07/the-tastiest-medicine/533937/

Some interesting related points to consider:

Taste buds likely evolved to detect foods which have a positive (or negative) effect on the body. It seems logical to assume that good taste would prime good effects. Also, cannabis has an effect similar to hypnotizability and suggestibility. If it tastes good, it’s logical to suggest that good tastes would suggest a higher likelihood of improved effect, from a psychological standpoint too.

A counter-argument: “If it tastes good, people (especially kids) would take it all the time. It actually should taste unpleasant so that you only take it when the alternative is worse.”

1 – Better-tasting medications may enhance pediatric adherence to drug therapy, where that is appropriate. 

2 – Sugars, acids, salt, and other substances may reduce perceived unpleasant taste of cannabis With respect to children, in one study, more than 90% of pediatricians suggested that a drug’s taste and palatability were the biggest barriers to completing treatment. 

3 – The potential for taste stimuli to activate nongustatory sensory systems, including those of a visceroceptive nature in the cases where the taste solutions are swallowed, must be considered, particularly as bitter tastes (likely with cannabis) are governed by GPR protein receptors.

4 – Pleasant tasting products activate a conditioned response:  good taste = good effect (when can then generalized to all pleasant-tasting edibles.

5 – “The unpleasant taste of medicine is often a sensory expression of its pharmacological activity; in many cases, the more potent the drug, the more bitter it will be. The more bitter, the more likely the drug will be rejected. Better-tasting medications may go a long way toward enhancing the ability of pediatric patients to adhere to drug therapy, especially when failure to consume may do harm and, in some cases, be life-threatening.” 

6 – On the other hand, frequent use of sucrose-sweetened medicines has been linked to dental caries 

Benjamin Caplan, MDEdibles: Tasty or Not Tasty?
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