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
• Relaxation³

High THC Content:

• Panic Attacks
• Psychosis
• Paranoia
• 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 14^th 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.

References:

1. 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/
2. “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/
3. 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
4. Hasin, D. S. (2018, January). “US Epidemiology of Cannabis Use and Associated Problems.” Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5719106/
5. 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/
6. 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
7. 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
8. Jones, J. (2018).“Medical Marijuana Laws and Maternal Marijuana Use.” Des Plaines, IL: Archives of Women Health and Care.
9. “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
10. 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
11. 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
12. 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

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.

Neonatal Drug Withdrawal

By Freepik© Studio

Maternal Nonnarcotic Drugs that cause neonatal psychomotor behavior consistent with withdrawal.

The Onset of Newborn Withdrawal Symptoms is Highly Variable

 – Click here to download the pdf.

Read an excerpt from the article Neonatal Drug Withdrawal below:

Signs characteristic of neonatal withdrawal have been attributed to intrauterine exposure to a variety of drugs. Other drugs cause signs in neonates because of acute toxicity. Chronic in utero exposure to a drug (eg, alcohol) can lead to permanent phenotypical and/or neurodevelopmental-behavioral abnormalities consistent with drug effect. Signs and symptoms of withdrawal worsen as drug levels decrease, whereas signs and symptoms of acute toxicity abate with drug elimination. Clinically important neonatal withdrawal most commonly results from intrauterine opioid exposure. The constellation of clinical findings associated with opioid withdrawal has been termed the neonatal abstinence syndrome (NAS). Among neonates exposed to opioids in utero, withdrawal signs will develop in 55% to 94%.^1,2 Neonatal withdrawal signs have also been described in infants exposed antenatally to benzodiazepines,^3,4 barbiturates,^5,6 and alcohol.^7,8
— Neonatal Drug Withdrawal https://doi.org/10.1542/peds.2011-3212

References:

1. Harper RG, Solish GI, Purow HM, Sang E, Panepinto WC.  The effect of a methadone treatment program upon pregnant heroin addicts and their newborn infants.  Pediatrics.  1974 ; 54 (3): 300–305 [PubMed]
2. Ostrea EM, Chavez CJ, Strauss ME. A study of factors that influence the severity of neonatal narcotic withdrawal. J Pediatr. 1976; 88 (4 pt 1): 642–645 [PubMed]
3. Rementería JL, Bhatt K. Withdrawal symptoms in neonates from intrauterine exposure to diazepam. J Pediatr. 1977; 90 (1): 123–126 [PubMed] 
4. Athinarayanan P, Piero SH, Nigam SK, Glass L. Chloriazepoxide withdrawal in the neonate. Am J Obstet Gynecol. 1976; 124 (2): 212–213 [PubMed]
5. Bleyer WA, Marshall RE. Barbiturate withdrawal syndrome in a passively addicted infant. JAMA. 1972; 221 (2): 185–186 [PubMed]
6. Desmond MM, Schwanecke RP, Wilson GS, Yasunaga S, Burgdorff I. Maternal barbiturate utilization and neonatal withdrawal symptomatology. J Pediatr. 1972; 80 (2): 190–197 [PubMed]
7. Pierog S, Chandavasu O, Wexler I. Withdrawal symptoms in infants with the fetal alcohol syndrome. J Pediatr. 1977; 90 (4): 630–633 [PubMed]
8. Nichols MM. Acute alcohol withdrawal syndrome in a newborn. Am J Dis Child. 1967; 113 (6): 714–715 [PubMed]

What You Need To Know: Testing for Drug Exposure vs. Ingestion

Testing for environmental exposure to illicit drugs is a powerful tool for protecting the welfare of children. Exposure testing is different from typical drug testing, and when properly done, has the potential to reduce the risk of harm to children.

No Metabolite Does NOT Mean No Exposure

Testing labs often apply government workplace testing guidelines to child exposure testing samples. Under workplace guidelines, negative results are reported when drug metabolites are absent in the testing sample, even if the native drug is present.

Child hair and nail samples for exposure testing often do not contain drug metabolites because the child has not ingested illicit substances. Adhering to workplace guidelines can result in false negative reporting for drug exposure, especially when children are involved.

Environmental Exposure

Environmental Exposure testing is most effective in alternative sample types, such as hair and fingernails. For example, hair testing is 3.5x more likely to detect methamphetamine exposure than urine testing. Typical drug testing samples are washed to remove drug biomarkers resulting from exposure. Environmental exposure testing eliminates this step.

 – Click here to download the pdf.

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.

References

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.

The need for opiate and drug testing has grown in the last three decades. 2.4 million people in the United States abused opioid pain relievers in 1985, the year before President Ronald Reagan announced his Federal Drug-Free Workplace Program.1 That number swelled to 4.9 million – a 104% increase – by 2012.2 During that same time, the population of the United States grew only 32%.

The original opiate testing panel created in 1986 is an incomplete tool for today’s drug testing needs. No other category of drugs has evolved as much as opiates and opioids. Addiction to high strength pain relievers and newer opioid compounds has eclipsed codeine, morphine, and heroin addiction addressed by the original 1986 five-panel drug test.

Based on the most recent data on emergency department visits related to illicit substance abuse, it is clear that opiate and opioid abuse has shifted dramatically. Screening for opiate abuse using only 1986 drug testing guidelines for the opiate drug class misses the past 30 years of pharmaceutical and drug testing advancements.3

References:

1. United States Department of Health and Human Services. National Institutes of Health. National Institute on Drug Abuse. National Household Survey on Drug Abuse, 1985. ICPSR06844-v3. Ann Arbor, MI: Inter-university Consortium for Political and Social Research [distributor], 2013-06-19.

2. Substance Abuse and Mental Health Services Administration, Results from the 2012 National Survey on Drug Use and Health: Summary of National Findings, NSDUH Series H-46, HHS Publication No. (SMA) 13-4795. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2013.

3. Substance Abuse and Mental Health Services Administration, Drug Abuse Warning Network, 2011: National Estimates of Drug-Related Emergency Department Visits. HHS Publication No. (SMA) 13-4760 Series D-39. Rockville, MD: Substance Abuse and Mental Health Services Admin., 2013.

When a child is exposed to illegal substance abuse they often also face other coexisting obstacles to a normal life – neglect, abuse, violence, and other vulnerabilities. Substance abuse is a disease, one that often prevents adults from doing what is in a child’s best interests. Our environmental exposure test for children can help.

Our hair environmental exposure test is the only drug test designed to detect passive exposure to drugs and detect both native drugs and drug metabolites in the hair specimen. Drug metabolites are produced in the body only if drugs have been ingested. Children in drug exposed environments are most often not drug users themselves, so drug metabolites are typically absent in child specimens. However, the hair, like a sponge, can absorb non-metabolized drug (native drug) if it is exposed through things such as touching or being in contact with drugs or drug users.

Standard hair tests with other labs will only report a positive exposure result if drug metabolites are detected, even when the native drug is in the child’s hair specimen. Our hair environmental exposure test reports a positive result if either native drugs or drug metabolites are detected.

A hair exposure test can provide evidence of drugs in a child’s environment for the past 3 months. A positive test result suggests that the child has experienced one or more of the following: passive inhalation of drug smoke, contact with drug smoke, contact with sweat or sebum (skin oil) of a drug user, contact with the actual drug, or accidental or intentional ingestion of illegal drugs.

ChildGuard^®is the only child hair test designed to detect exposure to native drugs and drug metabolites.