Abstract

Support for legalizing the recreational use of marijuana has been steadily climbing. While there has been a decline in marijuana-related convictions and increase in state revenues, the impact on public health and safety is not clear. The nephrology community must be aware of the complications of chronic marijuana use, such as recurrent acute kidney injury secondary to hyperemesis.

Background

Marijuana is the most widely used illicit drug in the United States and in the world. About 44% of the US population aged 12 years and above have admitted to lifetime use of marijuana.1 The pro-marijuana legalization arguments include decriminalization of young people, higher arrest rate of ethnic minorities, difficulty in enforcing marijuana laws, apparent safety profile, and less addictive potential compared to alcohol and tobacco. State revenue generation is appealing, and tight regulation has been created to ensure that minors don’t get access to marijuana. The anti-marijuana legalization arguments include an increase in marijuana use among young adults, high potential for abuse, the potential rise in marijuana-related road traffic accidents, and use of marijuana as a “gateway drug” for more dangerous substances.

Recently, four additional states (California, Massachusetts, Maine, and Nevada) have voted to legalize the recreational use of marijuana, bringing the total to eight states and the District of Columbia. Oregon, Washington, Alaska, and Colorado have previously legalized recreational use of marijuana. Three of these states have given their first report on the impact of marijuana legalization. 2-4

Intoxication

The impact of marijuana legalization on road safety is not clear. In Oregon, 36% of frequent users reported driving within three hours of using marijuana.4 In Washington, 49% of young adults admitted to driving within three hours after using marijuana.2 Among people charged with driving under the influence of marijuana, 62% perceived no risk related to road safety under such conditions. There was a 122.2 % increase in the number of people with active THC in their blood in fatal driving accidents.

In Colorado, the number of drivers positive for tetrahydrocannabinol (THC) increased from 57% to 65% from 2012 to 2014. Of those positive for THC, detection of psychoactive component delta-9 THC at 2 ng/mL rose from 52% to 67%. 3 The fatalities in drivers positive for THC or THC-in-combination increased 44% from 2013 to 2014. However, the number of reported cases of driving under the influence of drugs (DUID) reduced by 18% from 2014 to 2015.

The number of marijuana-related calls to Washington State Poison Center increased by 79.27 % between 2010 and 2014, and almost half of these calls were from youngsters. The number of marijuana-related calls to the Poison Control Center in Oregon also increased substantially among all age groups in the second half of 2015. The number of marijuana-related calls to the Colorado state poison control centers tripled in two years.

Impact on kidney health

It is important that physicians are aware of the various complications of chronic marijuana use. Of note to nephrologists, chronic use can lead to recurrent acute kidney injury (AKI) from cannabinoid hyperemesis syndrome (CHS), which is often under-recognized. 5 CHS is frequently reported in the medical literature with several case reports published, but the number of emergency room visits for diagnosis remains high.

Chronic users of marijuana can initially have a prodrome, which is characterized by early morning nausea, aversion towards food, and weight loss. This is followed by the hyperemetic phase, which is paradoxical, considering the fact that medical marijuana is used as an anti-emetic.

A peculiar feature of this hyperemesis is the relief of nausea by taking hot showers. There have been reports of patients staying in the hot shower for days to relieve nausea. This becomes a learned and compulsive behavior. The recovery phase begins with marijuana cessation and is associated with recovery of appetite and eventual resolution of nausea. The syndrome recurs on later use of marijuana.

The hyperemetic phase can be complicated by recurrent AKI due to dehydration, mixed metabolic alkalosis, and elevated anion gap metabolic acidosis. Dehydration occurs because of vomiting and is greatly accentuated by taking scorching hot showers. One of our patients also had rhabdomyolysis as part of the clinical picture, which has previously been reported with the use of synthetic cannabinoids. Due to recurrent AKI, his serum creatinine levels remained elevated and returned to baseline only months after the cessation of marijuana smoking.

Treatment mainly consists of intravenous hydration, antiemetics, and marijuana cessation. Capsaicin cream, lorazepam, and haloperidol have been recently reported to relieve the hyperemesis and are areas of ongoing research. 6-8

Marijuana use and kidney transplantation

Marijuana use is not considered to be a contraindication for organ donation or transplantation, but it is regarded as a risk factor for medical complications, due to physical and behavioral components, albeit there is little evidence for this. 9 Areas of concern include susceptibility to fungal infections, possible interaction with the metabolism of immunosuppressants and co-existing behavioral disturbances. Previously, marijuana users were commonly denied kidney transplants, but physician attitudes towards this have been changing. Now experts have begun emphasizing behavioral assessment of these patients to rule out any negative influence of smoking marijuana on their socio-economic conditions. Seven states have disallowed physicians from rejecting potential transplant recipients solely on the basis of the use of medical marijuana. Transplant centers usually ask kidney donors to stop smoking tobacco and marijuana for 6-12 weeks prior to organ donation.

Summary

It is too early to make a social judgment on the impact of legalization of recreational use of marijuana. But with increased activity to the state poison call centers, the nephrology community must be aware of the potential complications of smoking marijuana, such as the risk of recurrent kidney injury from CHS. Behavioral issues must be taken into account while considering marijuana smokers as potential organ transplant recipients.

References

  1. National Survey on Drug Use and Health 2015. Substance Abuse and Mental Health Services Administration. US Department of Health and Human Services. Available from: https://nsduhweb.rti.org/respweb/homepage.cfm. Accessed on 22 Feb 2017.
  2. Washington State Marijuana Impact Report. Northwest High Intensity Drug Trafficking Area. March 2016.
  3. Marijuana Legalization in Colorado: Early Findings. A report pursuant to Senate Bill 13-283. March 2016
  4. Marijuana Report: Marijuana use, attitudes and health effects in Oregon. January 2016.
  5. Allen JH, de Moore GM, Heddle R, Twartz JC. Cannabinoid hyperemesis: cyclical hyperemesis in association with chronic cannabis abuse. Gut. 2004; 53:1566-70
  6. Roman F, Llorens P, Burillo-Putze G. Topical capsaicin cream in the treatment for cannabinoid hyperemesis syndrome. Medicina Clinica (Barc). 2016 Dec 2; 147(11):517-518.
  7. Witsil JC, Mycyk MB. Haloperidol, a novel treatment for cannabinoid hyperemesis syndrome. Am J Ther. 2017 Jan / Feb; 24 (1):e64-e67
  8. Cox B, Chhabra A, Adler M, Simmons J, Randlett D. Cannabinoid hyperemesis syndrome: case report of a paradoxical reaction with heavy marijuana use. Case reports in Medicine. 2012 (8):757696
  9. Pondrom S. Transplantaion and marijuana use. American Journal of Transplant. 2016 Jan; 16 (1):1