Marijuana: A Multifaceted Movement
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In 1996, California became the first state to pass legislation condoning the use of marijuana for medicinal purposes, and since the onset of that law, a powerful trend was set. Over 33 other states, including the District of Columbia, have now adopted various statutes for the permittance of recreational and medicinal marijuana. Although many government entities have sided that the benefits of the cannabis plant outweigh the risks, others are anxious that the ease of accessibility may cause an influx of misleading notions regarding the plant. Its exposure to vulnerable populations, including adolescents, those pregnant, or individuals suffering from preexisting psychiatric disorders continues to be a significant concern among communities.
The Impact of Legalization on Local Communities
In a cross-sectional marijuana dispensary density study from 2001-2012 in California, associations between marijuana abuse/dependence hospitalizations disclosed that an additional one dispensary per square mile was associated with a 6.8% increase in the number of marijuana hospitalizations. The study’s findings concluded that increased availability of marijuana in zip codes with a higher density of dispensaries continues to be a probable correlation to the increased hospitalizations in dispensary-dense areas.1
Despite this study and others, a recent CBS News Poll found that support for marijuana legalization has risen among groups that have historically opposed it. More than half of Republicans (56 percent) now think marijuana use should be legal due to reasons such as marijuana being less harmful than alcohol and believing it is less harmful than other drugs.2 However, increases in marijuana potency is triggering a valid fear that the levels of THC in today’s plants are more toxic than therapeutic.
Increased Potency, Increased Risks
As highly potent cannabis increases in availability, scientists who study marijuana and the effects it has to the human body are becoming disturbed with the increasingly high rates of potency in delta-9-tetrahydrocannabinol (THC)–the main compound responsible for the drug’s psychoactive effects. According to a U.S. Drug Enforcement Administration seize, the potency of marijuana has increased from about 4% THC in 1995 to about 12% in 2014. By 2017 marijuana samples were up to 17.1% THC, totaling an increase of more than 300% from 1995-2017. Concentrated cannabis products known as hash and hash oil are also reaching potency levels as high as 80-90% THC.3
Nora Volkow, Director of the National Institute on Drug Abuse (NIDA) states, “The notion that it is a completely safe drug is incorrect when you start to address the consequences of this very high content of Delta-9-THC.”
The levels of THC within cannabis is imperative when factoring the effects it can have on the body when consumed. Low THC levels have been known to have less adverse effects compared to high THC levels.
Low THC Content:
- Decreases Anxiety
- Treats Nausea
High THC Content:
- Panic Attacks
- Cannabinoid Hyperemesis Syndrome3
The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) of the American Psychiatric Association now includes Cannabis Use Disorder (CUD) as a substance use disorder (SUD) diagnosis. Not all cannabis users develop CUD, however it is becoming more common than we think and can be serious. Normalizing use and reducing perception of harm can increase the development of CUD.4
DSM-5 Cannabis Withdrawal Symptoms:
- Anxiety, restlessness
- Depression, irritability
- Insomnia/odd dreams
- Physical symptoms, e.g.Tremors
- Decreased appetite4
In a longitudinal study published in Addiction, CUD was found to be significantly associated with psychotic and depressive symptoms.5
The Association Between Cannabis Use and Psychiatric Comorbidity
Cannabis use is recognized as a contributing factor for developing a psychotic disorder, children and teens with a family history of psychosis are most vulnerable.4
In a long-term prospective study, 1265 children born in Christchurch, New Zealand in 1977 were assessed repeatedly for psychosis symptoms due to daily exposure of cannabis in utero, which contributed to psychotic symptoms portrayed in these children at between the ages of 18-25. There was a significant correlation between cannabis use and later development of psychosis.4
A study conducted by Lancet Psychiatry found that three European cities–London, Paris, and Amsterdam, where high-potency weed is most prevalent, also have the highest rates of new cases of psychosis. The study indicates that daily pot users are three times more likely to endure a psychotic episode compared to an individual who has abstained from the substance.4
High potency forms of marijuana known as wax, butane hash oil, dabs, or shatter are growing in popularity and are more likely to induce psychotic states. The principal psychoactive component of cannabis is THC, which binds to cannabinoid-1 (CB-1) receptors found throughout the central nervous system. Studies specify that pure THC and CB1 agonists can produce psychotic symptoms including suspiciousness, paranoia, thought disorganization, and derealization.7
Marta Di Forti, lead author from the Institute of Psychiatry, Psychology, and Neuroscience at King’s College London says, “As the legal status of cannabis change in many countries and states, and as we consider the medicinal properties of some types of cannabis, it is of vital public health importance that we also consider the potential adverse effects that are associated with daily cannabis use, especially high potency varieties.”6
Maternal Marijuana Use
The adverse effects of marijuana can become extremely dangerous when the substance is used among those pregnant. According to the National Survey on Drug Use and Health, nearly 4% of pregnant women in 2007 and 2012 used marijuana in the past 30 days. Long-term neurobehavioral studies have shown that negative consequences have been found in children exposed to marijuana in utero such as altered neural functioning, behavioral deficits, emotional deficits, low academic achievement, and increased risk of adolescent substance use initiation.8
The uptick of marijuana legalization has generated a significant concern among obstetricians, gynecologists, and neonatal practitioners who are combating misleading claims that marijuana use during pregnancy is safe. According to the Center for Disease Control and Prevention (CDC), about 1 in 25 women in the U.S. report using marijuana while pregnant, despite the fact that marijuana use during pregnancy may increase the baby’s risk of developmental problems and low birth weight.9 The American College of Obstetricians and Gynecologists (ACOG) recommends that obstetrician-gynecologists counsel women against using marijuana while trying to get pregnant, during pregnancy, and while breastfeeding.10 Studies have found that cannabinoid receptors appear in the fetal brain around the 14th week of gestation and are located in areas where cognitive and behavioral functioning develop.11
According to a qualitative study, women reported that although they were consistently seeking prenatal care throughout their pregnancy, information and resources regarding maternal marijuana use was either not helpful or non-existent, resulting in the assumption that marijuana did not pose a significant threat to a developing fetus.12 The study concludes that absenteeism of perinatal marijuana education can lead to an increase of use among pregnant women.12
Testing for Abuse
Cannabis is not a harmless substance. It has been found to have addictive properties, which can lead to impairments and cause serious health risks. Our tests are designed to identify the detection of short-term and long-term marijuana usage. Each available specimen type provides a unique window of detection.
- Hair: Up to approximately 3 months prior to collection.
- Nail: Up to approximately 3-6 months prior to collection.
- Umbilical Cord: Up to approximately 20 weeks prior to birth.
- Meconium: Up to approximately 20 weeks prior to birth.
- Urine: Up to approximately 2-3 days prior to collection.
We believe that to remain at the forefront of toxicology, it is imperative to offer testing services for all substances that may pose an increased risk for abuse and dependence. Our continued investment in developing and implementing testing for drug ingestion and exposure helps us address substances that most concern you.
- Mair, C., Freisthler, B., Ponicki, W. R., & Gaidus, A. (2015, September 01). “The impacts of marijuana dispensary density and neighborhood ecology on marijuana abuse and dependence.” Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4536157/
- “Support for marijuana legalization hits new high, CBS News poll finds.” (n.d.). Retrieved from https://www.cbsnews.com/news/support-for-marijuana-legalization-hits-new-high-cbs-news-poll-finds/
- Chatterjee, R. (2019, May 15). “Highly Potent Weed Has Swept The Market, Raising Concerns About Health Risks.” Retrieved from https://www.npr.org/sections/health-shots/2019/05/15/723656629/highly-potent-weed-has-swept-the-market-raising-concerns-about-health-risks
- Hasin, D. S. (2018, January). “US Epidemiology of Cannabis Use and Associated Problems.” Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5719106/
- Pond, E. (2019, January 28). “Cannabis Use, Cannabis Use Disorder Linked to Psychotic, Depressive Symptoms.” Retrieved from https://www.psychiatryadvisor.com/home/topics/addiction/cannabis-use-cannabis-use-disorder-linked-to-psychotic-depressive-symptoms/
- Robinson, J. (2019, March 20). “Daily use of high-potency cannabis increases risk of psychosis by four times, study finds.” Retrieved from https://www.pharmaceutical-journal.com/news-and-analysis/news/daily-use-of-high-potency-cannabis-increases-risk-of-psychosis-by-four-times-study-finds/20206308.article?firstPass=false
- Corey J. Keller, Evan C. Chen, Kimberly Brodsky & Jong H. Yoon(2016)“A case of butane hash oil (marijuana wax)–induced psychosis, Substance Abuse”, 37:3, 384-386, DOI: 10.1080/08897077.2016.1141153
- Jones, J. (2018).“Medical Marijuana Laws and Maternal Marijuana Use.” Des Plaines, IL: Archives of Women Health and Care.
- “What You Need to Know About Marijuana Use and Pregnancy” | Fact Sheets | CDC. (n.d.). Retrieved from https://www.cdc.gov/marijuana/factsheets/pregnancy.htm
- National Institute on Drug Abuse. (n.d.).“Can marijuana use during and after pregnancy harm the baby?” Retrieved from https://www.drugabuse.gov/publications/research-reports/marijuana/can-marijuana-use-during-pregnancy-harm-baby
- Day, N. L., Goldschmidt, L., Day, R., Larkby, C., & Richardson, G. A. (2015, June). “Prenatal marijuana exposure, age of marijuana initiation, and the development of psychotic symptoms in young adults.” Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/25534593
- Jarlenski, M., Tarr, J. A., Holland, C. L., Farrell, D., & Chang, J. C. (2016). “Pregnant Women’s Access to Information About Perinatal Marijuana Use: A Qualitative Study.” Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/27131908
There are many variables regarding the analyses of substance abuse testing. Clients will often ask about specifics pertaining to the determination of time, dose and frequency when detecting substance(s) of abuse.
When testing a reservoir matrix- a material or substance which can accumulate and retain drug and alcohol biomarkers (eg., urine, blood, hair, nail, umbilical cord, or meconium, etc.), the reported quantitation of a drug or its metabolite cannot be used to determine when/if a specific substance was used, how much of a substance was used or how often a substance was used. Test results show only if a substance was detected or not detected.
A specimen’s window of detection provides an estimated timeframe for detecting substance(s) of abuse. Based on extensive research studies, the generally accepted windows of detection for specimens used in our testing are as follows:
- Scalp Hair- Up to approximately 3 months prior to collection.
- Fingernail- Up to approximately 3-6 months prior to collection.
- Umbilical Cord- Up to approximately 20 weeks prior to birth.
- Meconium- Up to approximately 20 weeks prior to birth.
- Urine- Up to approximately 2-3 days prior to collection.
- Blood (PEth)-May be up to approximately 2-4 weeks prior to collection.
It is important to know that the interpretation of drug testing results may be determined by a Medical Review Officer (MRO). A Medical Review Officer is a licensed physician (MD or DO) who has knowledge of substance abuse disorders and has the appropriate medical training to interpret and evaluate an individual’s positive test result together with his or her medical history and any other relevant biomedical information.1This is an incredibly important aspect of drug testing. A laboratory can detect substances, but an MRO may be used to interpret what that detection means.
1. Journal of Occupational and Environmental Medicine: (January 2003-Volume 45-Issue 1-p 102-103) Qualifications of Medical Review Officers (MRO’s) in Regulated and Nonregulated Drug Testing. Departments: ACOEM Consensus Opinion Statementhttps://www.usdtl.com/blog/limits-of-interpreting-a-drug-test
To view larger image, please click here.https://www.usdtl.com/blog/drug-guide-for-parents-learn-the-facts-to-keep-your-teen-safe
What you need to know about meconium collection.
by Michelle Lach, MSIMC
Meconium is the first stool of a newborn infant. It is produced in utero and consists of materials such as epithelial cells, bile, mucous, and more. In most newborns, meconium is generally passed in the first day or so of life, has no odor, and appears as a very dark, tar-like substance. This helps distinguish meconium from the next phase of passage called transitional stool.
Transitional stool will start to have an odor and present with a more brown, green, or yellow color as the newborn starts digesting milk. When drug testing the meconium of a newborn, it is important to note this difference since only meconium is created during gestation and transitional stool is created after birth. Collection of any stool other than meconium for drug testing purposes may result in a rejected specimen.
Unlike umbilical cord tissue, drugs are not distributed uniformly throughout the meconium specimen (see Figure 1). Because of this, the collection of the entire mass of meconium is highly encouraged to assure that there will be enough specimen to test, and that the maximum window of drug detection is achieved. It can take multiple passages of meconium before the newborn begins the transitional stool phase.
We require a minimum of 3 grams of meconium to be able to properly run our tests, so collecting the entire passage of meconium from newborns that have been exposed to substances of abuse is highly critical since they tend to have lower birth weights and create less specimen in the first place. If there is not enough specimen to run the test, the results are reported out as QNS. Quantity Not Sufficient (QNS) is a result of not having a sufficient quantity (volume) of specimen to test for the panels ordered.
Numerous studies have shown that meconium specimens are too often unavailable for substance exposure testing. Universal collection of umbilical cord specimens offers a solution.
By Joseph Salerno
Unable, despite her best efforts to shake her addiction, a woman exposes her unborn child to drugs in the womb. The baby is born, healthy and beautiful with all the promise the future holds. Three days later, the withdrawal symptoms kick in. The baby wails, flush with the pains of withdrawal and inconsolable, unable to sleep, experiencing seizures. The NICU physician wants to know what the baby has been exposed to, but now it’s too late. The meconium has already been passed and discarded, and the umbilical cord is gone, lost opportunities for concrete answers. Now it’s a guessing game.
This isn’t just a “what-if” scenario, unfortunately, but a potential reality in a surprisingly large number of newborn substance exposure cases. Withdrawal symptoms in substance exposed newborns can be delayed up to three, five, even seven days after the baby is born. Cases of in utero barbiturate exposure may not manifest withdrawal signs until 14 days post-delivery. By that time it’s too late to test any of the baby’s specimens for biomarkers of substance exposure, because the specimens are gone.
Universal collection of umbilical cord specimens offers a solution to avoid this dilemma. Umbilical cord is the only universally available specimen for substance exposure testing. Numerous studies have shown meconium is not available for testing in up to 27% of births. Meconium may be passed in utero. In some cases, there is not enough meconium volume to test even when it is able to be collected.
And again, meconium may have been passed by the newborn and discarded well before they begin to exhibit withdrawal symptoms. Unfortunately, this can also be a problem when the signs of in utero substance exposure emerge after the umbilical cord has been discarded. Newborn urine testing is not a viable option in these cases, because urine provides only a 1-3 day window of detection for substance exposure biomarkers, compared to the 20 week look-back of umbilical cord.
Universal collection of umbilical cord specimens for every birth ensures there are no lost opportunities should the need for substance exposure testing arise. Umbilical cord collection is extremely easy, requiring very little additional effort during post delivery procedures. Only six inches of the cord is required for substance testing, taking up very little storage space.
Umbilical cord tissue is a very stable and reliable specimen. Cord tissue is stable up to 1 week at room temperature, and up to 3 weeks when refrigerated, without jeopardizing the testing results. This is ample time for the emergence of newborn withdrawal symptoms, even in the most extreme cases. Enough time to avoid a missed opportunity for real answers. Only one donor and one collector are present during the umbilical cord collection – in contrast to the multiple collections and multiple collectors involved with meconium – greatly improving chain-of-custody integrity. Umbilical cord specimens are ready for transport just minutes after the birth, greatly improving turnaround time for results reporting. Meconium passages can be delayed for days before being sent to the lab.
1. Arendt, R., Singer, L., Minnes, S. and Salvator, A. (1999). Accuracy in detecting prenatal drug exposure. Journal of Drug Issues. 29(2), 203-214.
2. Ostrea, E., Knapp, D., Tannenbaum, L., Ostrea, A., Romero, A., Salari, V. and Ager, J. (2001). Estimates of illicit drug use during pregnancy by maternal interview, hair analysis, and meconium analysis. Pediatrics. 138, 344-348.
3. Lester, B., ElSohly, M., Wright, L., Smeriglio, V., Verter, J., Bauer, C., Shankaran, S., Bada, H., Walls, C., Huestis, M., Finnegan, L. and Maza, P. (2001). The maternal lifestyle study: Drug use by meconium toxicology and maternal self-report. Pediatrics. 107(2), 309-317.
4. Derauf, C., Katz, A. and Easa, D.. (2003). Agreement between Maternal Self-reported Ethanol Intake and Tobacco Use During Pregnancy and Meconium Assays for Fatty Acid Ethyl Esters and Cotinine. American Journal of Epidemiology. 158, 705–709.
5. Eylera, F., Behnkea, M., Wobiea, K., Garvanb, C. and Tebb, I. (2005). Relative ability of biologic specimens and interviews to detect prenatal cocaine use. Neurotoxicology and Teratology. 27, 677 – 687.https://www.usdtl.com/blog/lost-opportunities
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- Buprenorphine Misuse and Diversion
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- Ketamine: Current and Future Use
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- Poster Overview- Prenatal Exposure to Kratom