Toxicology & Ortho 2 (September 2016)
Research:
For a Review Article
- How has reading the article changed your practice?
- What information had you believed in previously that were debunked by reading this article?
- What new information did you learn from reading this article?
- What are current areas of uncertainty on this topic that can be potential areas for research?
For an Original Research Article
- What are some strengths of the study?
- What are the limitations?
- What are the main outcomes of the study?
- Does reading this article change your practice? If so, how?
18 comments
Kim and Monte, “Colorado Cannabis Legalization and Its Effect on Emergency Care.”
Strengths: Takes advantage of the natural experiment of the Colorado experience of legalization of medical marijauna and subsequently recreational marijuana use to look at broad trends in ED utilization — particularly relevant given so many states have referendums on this issue this November.
Limitations: As the article acknowledges, stigma around marijuana use, particularly in the pre-legalization phase, may limit the accuracy of some of the data d/t patient non-disclosure (not to mention heightened physician awareness in the post-legalization phase). Also, Colorado is just one state, and though it does seem like there is some preliminary data suggesting that other states that have legalized marijuana are seeing similar trends, it is impossible to say from this study. The generalizability of the Colorado experience is not at all clear to me. I also think the overall public opinion about marijuana is evolving simultaneously with its legalization, and so I’m not sure that you can point to changes in laws as being the sole factor contributing to increased use since those changes are necessarily borne out of increased public acceptance of marijuana use.
What are the main outcomes of the study? Marijuana legalization (first medical then recreational) significantly increased marijuana use as well as marijuana related ED visits (including pedi ED visits and hyperemesis visits).
Does reading this article change your practice? If so, how? No.
Interesting point about ingested MJ being more potent in smoked. I guess pot brownies aren’t got amateurs.
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Make sure you get out and vote this year. Legalization of recreational MJ will be on a ballot question. The impact of doing so in MA will likely be similar to that of CO.
I guess pot brownies aren’t for amateurs I mean.
While the chance of seeing these category A bioterrorism agents is low. It’s good to be prepared.
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Plus, some forms of these agents can be seen in the ED outside of a terrorist attack, such as wound botulism.
1. What are some strengths of the study?
The study material is relevant, especially given recent changes in legislation and upcoming decisions regarding the legalization of MJ.
2. What are the limitations?
Limited Pt population, since they only studied Colorado which may not be generalizable to other US populations. Also low overall incidences for some of the conditions they studied (hyperemesis, pediatric exposures). Additionally, Pts can be reluctant to report illegal drug use, so it’s difficult to tell whether findings are due to increased MJ use vs increased reporting by Pts.
3. What are the main outcomes of the study?
MJ-related ED visits appeared to increase after legalization of recreational use in Colorado.
4. Does reading this article change your practice? If so, how?
Not particularly, although I hadn’t even thought about pediatric ingestion prior to this, so after reading this article I will keep it in mind. Same with MJ-related hyperemesis…didn’t know it was a thing, so now I do.
Strengths: Retrospective analysis of Colorado Hospital Association data on call volume as well as ED visits pre- and post-legalization of medical/recreational marijuana. Essentially, the authors have a large sample size to work with and a clear intervention around which to draw conclusions.
Limitations: The conclusions made about increased MJ-related ED visits following MJ legalization are sound. It is likely there is a negative reporting bias on the patient side given prior stigma about MJ use, and the authors themselves have (rightfully) advocated against urine toxicology testing in these patients. While the data presented clearly shows an increased in MJ associated ED visits, the actual number of associated visits is likely much higher. Regarding generalization of the conclusions presented here – I expect similar trends will arise around the country if MJ becomes more broadly legalized.
Main Outcomes: Increased MJ related ED visits post-MJ legalization for recreational use in Colorado
Will it change my practice? Possibly. I found the discussion on treatment choices to be interesting and informing. It seems obvious to prioritize symptomatic control in these patients, and the recommendations for IVF, zofran, and low dose benzodiazepines fall in line. What surprised me was the recommendation for low dose haloperidol in MJ associated emesis if first line agents fail. I’ll remember that – I would imagine it would be a decent tool for the synthetic cannabinoids which we see from time to time.
Colorado Cannabis Legalization
Strengths: This study had a fairly large sample size and used data from pre- and post-legalization. The authors were careful not to draw too many conclusions based on the data available- for example, they acknowledge that pre-legalization self-reporting of MJ use may have been limited since use was previously illegal. This was a good overview of types of use and possible complications.
Limitations: There is no information about the frequency of use, dosing, or chief complaints of people seen in the ED for MJ-related illnesses. Because complications seem to be dependent on the frequency of use and dose, more research needs to be done. It’s also not clear what the criteria was to define “hospitalization for marijuana exposure”.
Main Outcomes: Legalization of marijuana seems to be associated with an increase in ED visits for marijuana-related illnesses
Change in practice: Like others have said, I was really intrigued by the fact that haloperidol can be used to treat nausea in the setting of hyperemesis syndrome. This is good to remember if a pt presents with intractable nausea. I think I will also take marijuana intoxication more seriously, particularly as synthetic marijuana and edibles become more popular. A great differential diagnosis to keep in mind in the Peds ED.
This seemed like a review/descriptive article
How has reading the article changed your practice?
– Didn’t really change my practice but confirmed for me how great Haloperidol can be for hyperemesis. It works wonders! (check a QTc first)
What information had you believed in previously that were debunked by reading this article?
I did not have myths busted but I thought it was interesting that there was an episode of a suicide from MJ-induced psychosis. Crazy (literally)! I also found it interesting that the perception of MJ as “dangerous” went down after legalization.
What new information did you learn from reading this article?
The duration of action for edible MJ is so much longer than inhaled MJ.
What are current areas of uncertainty on this topic that can be potential areas for research?
I’d love to see more haloperidol/novel therapeutics for MJ associated N/V. It’s relatively new and I feel it is under diagnosed.
Bioterrorism article
◾How has reading the article changed your practice?
Not much changed, except to keep botulism on the back of my mind as it can be found in the environment.
◾What information had you believed in previously that were debunked by reading this article?
I did not think tularemia was a bioterrorism agent
◾What new information did you learn from reading this article?
That there are several significant risks with the traditional smallpox vaccine.
◾What are current areas of uncertainty on this topic that can be potential areas for research?
Safety and efficacy of the newer smallpox vaccines compared to the older FDA approved one.
Adalja, et al.
1. How has reading the article changed your practice?
Similar to what Dave mentioned, will keep anthrax (especially the classic cutaneous lesion) in the back of my mind as can occur in the environment.
2. What information had you believed in previously that were debunked by reading this article?
I thought all cases of anthrax had high mortality rate. However, cutaneous anthrax has a mortality rate of <1%.
3. What new information did you learn from reading this article?
Standard precautions are sufficient for infection control when caring for an anthrax patient.
4. What are current areas of uncertainty on this topic that can be potential areas for research?
Development and efficacy of a vaccine against Yersinia pestis.
Kim and Monte
1. How has reading the article changed your practice?
Would consider using haldol for cannabinoid hyperemesis syndrome
2. What information had you believed in previously that were debunked by reading this article?
N/A
3. What new information did you learn from reading this article?
Unintentional pediatric marijuana ingestions increased after state legalization.
4. What are current areas of uncertainty on this topic that can be potential areas for research?
Not for the field of emergency medicine, but long term effects of marijuana on pediatric brain development.
◾How has reading the article changed your practice?
not much, adds another article that supports Haldol to treat cyclic vomiting
◾What information had you believed in previously that were debunked by reading this article?
I did not know there have been cardiovascular events from weed
◾What new information did you learn from reading this article?
That the rate of ED visits for MJ and cases of cyclic vomiting have doubled in CO.
◾What are current areas of uncertainty on this topic that can be potential areas for research
How frequent are there re-visits for cyclic vomiting, potential patient outreach for prevention of further ED visits. I feel like we get a lot of return patients in our ED for this.
Colorado
How has reading the article changed your practice?
Asking about hot showers relieving symptoms and giving haldol if my clinical suspicion is high
What information had you believed in previously that were debunked by reading this article?
I had always thought of marijuana as a relatively “safe” drug, I didn’t realize that synthetic cannabinoids could precipitate seizures, renal failure, and death or that standard urine screens didn’t pick up these drugs
What new information did you learn from reading this article?
I didn’t know about using haldol for hyperemesis, nor did I know about the classic historical finding of hot showers relieving symptoms
What are current areas of uncertainty on this topic that can be potential areas for research?
RCT for hyperemesis syndrome treatment: haldol vs. placebo
Bioterrorism
How has reading the article changed your practice?
It has made me more vigilant regarding the red flags, workup, and treatment of these rare, but deadly diseases
What information had you believed in previously that were debunked by reading this article?
I had always assumed that these pathogens were contagious, which is what made them so well-suited for bioterrorism, but it turns out that isn’t universally true
What new information did you learn from reading this article?
I didn’t realize that the incubation period for anthrax could be up to 6+ weeks after exposure, this further complicates and already difficult diagnosis
What are current areas of uncertainty on this topic that can be potential areas for research?
It would be interesting to try to glean insights from the wildly successful small pox eradication campaign in order to address current public health crises (e.g. MDR-TB, HIV/AIDS, Ebola, perhaps even opioids)
Bioterrorism
How has reading the article changed your practice? I am now more afraid of bioterrorism.
What information had you believed in previously that were debunked by reading this article? I thought you died if you were exposed to anthrax, and I thought it was contagious.
What new information did you learn from reading this article? Did not know that GI anthrax existed.
What are current areas of uncertainty on this topic that can be potential areas for research? I think the hardest thing with all of these is putting the diagnosis on your differential in the first place. Unless the clinician is aware of a possible exposure, these all seem like wildly unlikely things to consider. I wonder how else you can pick up sentinel cases.
Kim and Monte
1. How has reading the article changed your practice?
Everyone is jumping on the haloperidol train. I have to admit that I don’t often think of Haldol when considering anti-emetics. Articles like this help to broaden my scope with respect to medication options in certain clinical environments. I wonder if traditional anti-emetics work as well? Would HT3 antagonists or the dopamine antagonists work just as well? I suppose Haldol has the added benefit of settling a stoned and vomiting teenager down.
2. What information had you believed in previously that were debunked by reading this article?
I don’t believe that this article debunked any previously held beliefs. Many of the anecdotal observations from Colorado make were likely to be expected: i.e. uptick in use following legalization.
3. What new information did you learn from reading this article?
I was aware of a link between cyclic vomiting and marijuana ingestion but had forgotten about it. Thanks for reminding me.
4. What are current areas of uncertainty on this topic that can be potential areas for research?
The exact etiology of cyclic vomiting and its relation to THC/marijuana ingestion. I imagine its a complicated series of neurotransmitter activation/antagonism.
Bioterrorism article
Adalja et al.
◾How has reading the article changed your practice?
Bioweapons don’t usually pop into my head when approaching patients in the ED. I guess we should all, regrettably, be a bit more prepared. I doubt that it will change my practice other than being aware of the various agents that are out there. In the event of an invasion or a bomb going off around the corner I would probably dust off this article.
◾What information had you believed in previously that were debunked by reading this article?
I was unaware of IV anthrax although if it existed in so many other forms its no surprise that it can be transferred intravenously. I was unaware of the vaccine and routine for administration for anthrax.
◾What new information did you learn from reading this article?
I’m not sure if I ever knew that botulism causes a descending paralysis. I knew patients eventually developed a requirement for ventilation but was unaware of the progression towards that point.
◾What are current areas of uncertainty on this topic that can be potential areas for research?
There are two treatments for smallpox identified in this article which have not completed safety and effectiveness trials.
Cannabis Article
1) Strengths: I think it’s great that the authors attempted to provide data on the ever changing landscape of legalized marijuana. I also learned a few things (ie., edibles more potent than inhaling, pediatric cases more likely to present with CNS depression). It was also a good reminder that physicians should probably educate themselves on MJ as patients may begin to ask questions about the utility of MJ for certain d/o such as epilepsy and opioid use d/o.
2) Limitations: Similar to some of the info coming out of the Mass Med Society, I don’t think the authors do enough to highlight the limits of their research. While they certainly don’t state that the relationship b/w rising usage and legalization is causal, they could’ve plainly written that decreasing stigma could have played a role in increasing usage rates (in their defense, the authors state it just one time). Same goes for the increase in poison control calls, pediatric visits, etc. Lastly, generalizability is limited.
3) Main Outcomes: MJ usage and visits to ED are increasing. However, the way the data are presented you’d think the apocalypse is here with these large percentage changes. It should be noted that in whole numbers, MJ associated ED visits, etc still make up a very, very small piece of the pie.
4) Change in practice? I think I’m more likely to use Haldol w/ cyclical vomiting. I’ve seen a few attendings use it and it actually worked better than the typical anti-emetics. Additionally, I’ll likely have a lower threshold to get urine tox in peds pt who present with undifferentiated AMS.
Bioterrorism Article
1) Change in practice? Can’t say that a definite change in practice is in the works after reading the article. I will say that considering we’re physically located next to the National Infectious Emerging Disease Laboratory, it would behoove us to perhaps one day undergo a disaster type, bioterrorism simulation training…because frankly, I think I need a primer!
2) Debunked info? I thought these infectious agents largely didn’t discriminate. Apparently children and pregnant women may be at risk for more severe disease. I also didn’t realize how quick the onset of sxs is for botulism – 6 hours! I thought it was more sub-acute which makes it that much more scary.
3) New Info? Injectional anthrax exists. Would be interesting to know if the worsening opiate epidemic and IV use has had a role in injectional anthrax incidence. Also interesting to note that injectional anthrax use does not cause an eschar as does cutaneous. Additionally, I was unaware that anti-toxins were used for anthrax (and the debatable research when used with more typical antimicrobials). And remember, equine-derived anti-toxins for botulism outbreaks (and not human-derived)!
4) Research? Utility of antimicrobials w/ antitoxin tx, vaccine dosing. More evidenced based bioterrorism preparedness!