By some accounts, the legalization of recreational marijuana in California has coincided with a spike in the number of people seeking medical help for cannabis-related incidents. But the severity of the problem, if it exists, is an open question, as not every expert is seeing the same trend and data on cannabis-related health emergencies is only now starting to be collected.
On one hand, officials from some hospitals and the states poison control center are treating more people complaining of cannabis-related side-effects, such as hallucinations and extreme paranoia, than in previous years.
“There has been a huge surge since the beginning of this year in patients coming to the emergency room with acute cannabis intoxication,” said Dr. Ashraf Ismail, medical director of the psychiatry department at St. Joseph Hospital in Orange.
But other experts say theyve seen little or no increase in patients suffering symptoms from consuming too much marijuana.
“I was actually very fearful with marijuana being legalized that wed see a huge increase in car accidents and kids showing up high in the ER and huge numbers of people getting hurt,” Dr. Sam Torbati, medical director of the Emergency Department at Cedars-Sinai in Los Angeles. “Were not really seeing that.”
Neither hospital could offer much in the way of statistics, however. And comparing the number of cannabis-related hospital visits over time statewide isnt possible because the data hasnt been tracked previously.
That makes it tough to answer a question that was a key part of the debate prior to Californias vote on Proposition 64: Does legalizing marijuana harm public health?
Data hard to come by
Many hospitals arent monitoring that question beyond their mandate to provide the state with coded data on all patient visits. So a number of facilities contacted for this story — such as UCLA Medical Center and Hoag Health Network, with hospitals in Irvine and Newport — couldnt provide information on marijuana-related visits.
“Unfortunately, we dont have great metrics,” Tobarti said.
County health departments generally arent tracking the information, either.
“There was no funding provided in Prop. 64 that I am aware of to fund surveillance efforts specific to marijuana,” said David Souleles, deputy agency director for Orange County Public Health Services.
The Office of Statewide Health Planning and Development is keeping tabs on marijuana-related hospital visits. And during the first year after the passage of Prop. 64 — which allowed adults 21 and older to legally possess up to an ounce of marijuana and grow up to six plants per home as of Nov. 9, 2016 — the agency reports the number of hospital visits for “cannabis poisoning” rose 28 percent to 6,887 visits in 2017.
But data for the first three months of 2018, since recreational cannabis sales became legal in California on Jan. 1, isnt due out until this summer, agency spokesman Andrew DiLuccia said.
More crucially, theres no marijuana-specific statewide data before 2016, DiLuccia said. Up to that point, hospital visits for cannabis were lumped in with all hallucinogens.
The same problem existed in Colorado after residents there voted to legalize marijuana in 2012. Thats why studies there — which were cited by Prop. 64 opponents since they indicated increases in hospital visits by young people who accidentally ingested marijuana-infused edibles and tourists who got too high from newly potent products — relied on data from individual hospitals.
One factor such reports cant take into account is comfort. Its possible that cannabis users are more willing to seek medical help now that the drug is legal.
But with no comparative statewide data from earlier years, and 2018 data still weeks away, the limited anecdotal evidence from area doctors and hospitals offers the only glimpse of how the issue is unfolding in California.
Hospitals report mixed results
Two years ago, Ismail from St. Joseph Hospital in Orange said hed see maybe one or two patients a week who tested positive for cannabis alone when they came in for help with some type of psychotic episode.
Now, Ismail says thats up to three or four patients a week. And when he counts people who test positive for cannabis and other drugs, the number jumps to seven, eight or nine.
Drawing a direct correlation is problematic, though, Tobarti noted, because marijuana can stay in the system for weeks. So just because a patient tests positive for cannabis when they get to the hospital doesnt mean theyre still feeling the effects of consumption, making it tough to know whether marijuana is to blame or if the patient suffers from an an underlying psychiatric condition.
But Ismail said the symptoms these patients exhibit also are getting worse, with cannabis consumers experiencing severe paranoia, panic and hallucinations. Sometimes, he said, these patients are being brought to the ER by law enforcement.
Such cases almost never happen with marijuana smokers, Ismail says. Instead, he said, patients experiencing psychotic symptoms typically have eaten cannabis-infused edibles, which are tricky to dose because they can take up to two hours to fully kick in. Or theyve used products such as waxes or oils, which can have up to 90 percent concentrations of the psychoactive compound THC.
Similar results are reported at St. Joseph Healths facilities in Los Angeles County, according to spokeswoman Lisa ONeill Hill.
Hill added that L.A. area doctors have also seen an increase in marijuana consumers who are suffering from cyclical vomiting. Thats the main symptom of cannabinoid hyperemesis syndrome, a recently recognized condition thats plaguing some chronic cannabis consumers.
Other physicians note that cannabis has been so common in California, for so long, that year-to-year differences arent easy to note.
“There are no changes that Im aware of,” said Dr. Richard Clark, director of the Division of Medical Toxicology at UC San Diego Health. He added that he spends far more time treating patients whove had too much alcohol or other drugs, such as methamphetamine, than he spends treating patients suffering from too much cannabis.
Poison center calls
Some of those hospital visits start with a call to the California Poison Control System.
The state-funded system didnt report any notable changes in the volume of cannabis-related calls in 2017 or in January of this year, according to Stuart Heard, executive director of the Berkeley-based service.
But February saw calls jump to an all-time high of 129, compared with a 2017 high of 122 calls (in November), and the monthly totals have remained high since then even as the numbers of calls for other types of poisonings have held flat. So far this year, marijuana-related calls have averaged about 113 a month, compared with about 100 calls a month in 2017.
Heard said the the poison center actually expected a bigger jump this year. But he noted that the roll-out of Californias legal recreational market has been slower than expected. Tax revenues are down and the number of licensed shops is low, with most cities still blocking all businesses. As these things pick up, and as prices come down, Heard believes the center will start getting more marijuana-related calls.
“The area that we do have concern about is edibles, particularly with children,” Heard said.
He noted one cautionary tale that actually occurred just before Californias new marijuana laws passed. In August 2016, Heard recounted how 19 people attending a quinceanera in San Francisco, including 13 who were under age, got sick after unknowingly ingesting cannabis-infused gummy candies. The party-goers experienced rapid heart rates, dizziness, confusion and more, but Heard said they all recovered.
One trend that popped up in Colorado — a spike in the number of tourists ending up in hospitals after consuming too much cannabis too quickly — doesnt yet seem to have materialized in California.
But Heard noted that the California Poison Control System numbers likely dont account for tourists because if theyre calling from their cell phone, the system will likely use their area code to automatically reroute their call to the poison control center in their home state.
How are cases handled?
Most of the poison centers marijuana-related calls are for minor incidents, Heard said.
Since there are no reported incidents of anyone dying from too much marijuana alone, and since time is the only thing that helps most people who are too high, Heard said experts typically advise callers to keep the patient at home. Then theyll follow up with a call to make sure everything is OK.
But if there are children involved, or if the person has other health conditions, Heard said theyll often advise them to go to a hospital to be safe.
Anyone experiencing psychotic symptoms, such as hearing voices, should always go to an emergency room, Ismail said, since they could hurt themselves or someone else.
“It can become life-threatening, especially when hallucinations kick in,” he said.
If cannabis consumers come to the hospital with severe paranoia or hallucinations, Ismail said theyll often given them anti-psychotic drugs to calm them down.
If severe vomiting is an issue, Clark said they may get intravenous fluids to keep them hydrated.
Beyond that, both Ismail and Clark said all they can really do is observe the patient until their symptoms subside. For new consumers, Ismail said that typically happens within a few hours. For chronic users, he said it can take a full day or even two for them to feel normal again.
Fewer than one in five patients who went to California emergency rooms for cannabis poisoning in 2016 and 2017 were admitted to the hospital, OSHPD data shows. A majority of patients were treated and released, likely leaving with only memories of their “bad trip” and a fat hospital bill.
Better data coming?
We will likely never be able to compare marijuana hospital visits before and after legalization. But theres hope that better data on this issue, and others related to cannabis, is coming.
Souleles, with Orange County Public Health, said there has been “considerable conversation statewide among public health officials” about the need to monitor emergency room visits for cannabis.
Prop. 64 also designates some tax revenue for research related to public health.
That includes $10 million annually for 11 years for public universities in California to study impacts of legalization, including health issues. And, starting in the 2019-2020 fiscal year, a portion of remaining tax revenue should fund grants to local public health programs in communities that welcome the industry.
But since cannabis is so tricky to measure and most symptoms it causes are temporary, Torbati said hes just not sure if theres a will to dedicate the resources needed to carefully track hospital visits going forward.
“Its not one where the public health issue is as grave, where you need to really measure so you can create a public health platform,” he said.
“Maybe in the next 10 years well have more information, but its still too early.”