Publications

2024

Exploring Cannabis-Associated Presentations to Canadian Pediatric Emergency Departments: A Cross-Sectional Study Cannabis, 01 November 2024

Objective: Recent studies found that recreational legalization of cannabis consumption for Canadian adults has increased presentation to the emergency department (ED) among children. In this descriptive study, our objectives were to (1) understand Canadian pediatric emergency medicine (PEM) providers’ training and knowledge of clinical presentations associated with cannabis exposure in children and (2) describe pediatric ED presentations related to cannabis exposure across Canada following legalization in 2018.

Method: In 2021, following ethics board approval, 230 Pediatric Emergency Research Canada (PERC) network pediatric emergency medicine (PEM) physicians were invited to share about their knowledge, training, and experience with patients presenting with cannabis-associated emergencies using an anonymized survey administered through REDCap.

Results: In total, 84/230 (36.5%) invited physicians completed the survey. Almost 70% of the PEM physicians reported an increase in the number of cannabis-associated ED presentations they have seen since legalization, while only 15% reported no increase in presentations. More than 90% of the respondents reported an average or higher level of knowledge of cannabis-associated pediatric emergencies. More than half (n = 48, 57%) were interested in pursuing further training, preferring formal training opportunities. The main presentations to the ED were decreased level of consciousness, known unintentional (accidental) ingestion and vomiting. Significantly more tests were ordered when cannabis consumption was unknown at the beginning of the assessment, compared to when it was known, however, treatment plans were the same (mainly supportive measures).

Conclusions: Most PEM providers are managing an increasing number of cannabis-associated ED presentations. PEM providers should improve communication with caregivers around household cannabis use. When caregivers feel comfortable disclosing cannabis presence at home, it can help prevent unnecessary tests and interventions for their children if they present to the ED.

A multi-centre, tolerability study of a cannabidiol-enriched Cannabis Herbal Extract for chronic headaches in adolescents: The CAN-CHA protocol PLOS One, 20 September 2024

Introduction Cannabis products have been used in the management of headaches in adults and may play a role in pediatric chronic pain. Canadian pediatricians report increasing use of cannabis for the management of chronic headaches, despite no well-controlled studies to inform its dosing, safety, and effectiveness. The aim of our clinical trial is to determine the dosing and safety of a Cannabidiol (CBD)-enriched Cannabis Herbal Extract (CHE) for the treatment of chronic headaches in adolescents.

Methods and analysis Youth, parents, and an expert steering committee co-designed this tolerability study. Twenty adolescents (aged 14 to 17 years), with a chronic migraine diagnosis for more than 6 months that has not responded to other therapies will be enrolled into an open label, dose escalation study across three Canadian sites. Study participants will receive escalating doses of a CBD-enriched CHE (MPL-001 with a THC:CBD of 1:25), starting at 0.2–0.4 mg/kg of CBD per day and escalating monthly up to 0.8–1.0 mg/kg of CBD per day. The primary objective of this study is to determine the safety and tolerability of CBD-enriched CHE in adolescents with chronic migraine. Secondary objectives of this study will inform the development of subsequent randomized controlled trials and include investigating the relationship between the dose escalation and change in the frequency of headache, impact and intensity of pain, changes in sleep, mood, function, and quality of life. Exploratory outcomes include investigating steady-state trough plasma levels of bioactive cannabinoids and investigating how pharmacogenetic profiles affect cannabinoid metabolism among adolescents receiving CBD-enriched CHE.

Discussion This protocol was co-designed with youth and describes a tolerability clinical trial of CBD-enriched CHE in adolescents with chronic headaches that have not responded to conventional therapies. This study is the first clinical trial on cannabis products in adolescents with chronic headaches and will inform the development of future comparative effectiveness clinical trials.

Trial registration CAN-CHA trial is registered with ClinicalTrials.gov with a number of register NCT05337033.

Cannabinoids Used for Medical Purposes in Children and Adolescents: A Systematic Review and Meta-Analysis JAMA Pediatrics, 16 September 2024

Importance Cannabinoids are increasingly used for medical purposes in children. Evidence of the safety of cannabinoids in this context is sparse, creating a need for reliable information to close this knowledge gap.

Objective To study the adverse event profile of cannabinoids used for medical purposes in children and adolescents.

Data Sources For this systematic review and meta-analysis, MEDLINE, Embase, PsycINFO, and the Cochrane Library were searched for randomized clinical trials published from database inception to March 1, 2024, for subject terms and keywords focused on cannabis and children and adolescents. Search results were restricted to human studies in French or English.

Study Selection Two reviewers independently performed the title, abstract, and full-text review, data extraction, and quality assessment. Included studies enrolled at least 1 individual 18 years or younger, had a natural or pharmaceutical cannabinoid used as an intervention to manage any medical condition, and had an active comparator or placebo.

Data Extraction and Synthesis Two reviewers performed data extraction and quality assessment independently. The Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guideline and PRISMA-S guideline were used. Data were pooled using a random-effects model.

Main Outcomes and Measures The primary outcome was the incidence of withdrawals, withdrawals due to adverse events, overall adverse events, and serious adverse events in the cannabinoid and control arms. Secondary outcomes were the incidence of specific serious adverse events and adverse events based on organ system involvement.

Results Of 39 175 citations, 23 RCTs with 3612 participants were included (635 [17.6%] female and 2071 [57.3%] male; data not available from 2 trials); 11 trials (47.8%) included children and adolescents only, and the other 12 trials (52.2%) included children, adolescents, and adults. Interventions included purified cannabidiol (11 [47.8%]), nabilone (4 [17.4%]), tetrahydrocannabinol (3 [13.0%]), cannabis herbal extract (3 [13.0%]), and dexanabinol (2 [8.7%]). The most common indications were epilepsy (9 [39.1%]) and chemotherapy-induced nausea and vomiting (7 [30.4%]). Compared with the control, cannabinoids were associated with an overall increased risk of adverse events (risk ratio [RR], 1.09; 95% CI, 1.02-1.16; I2 = 54%; 12 trials), withdrawals due to adverse events (RR, 3.07; 95% CI, 1.73-5.43; I2 = 0%; 14 trials), and serious adverse events (RR, 1.81; 95% CI, 1.21-2.71; I2 = 59%; 11 trials). Cannabinoid-associated adverse events with higher RRs were diarrhea (RR, 1.82; 95% CI, 1.30-2.54; I2 = 35%; 10 trials), increased serum levels of aspartate aminotransferase (RR, 5.69; 95% CI, 1.74-18.64; I2 = 0%; 5 trials) and alanine aminotransferase (RR, 5.67; 95% CI, 2.23-14.39; I2 = 0%; 6 trials), and somnolence (RR, 2.28; 95% CI, 1.83-2.85; I2 = 8%; 14 trials).

Conclusions and Relevance In this systematic review and meta-analysis, cannabinoids used for medical purposes in children and adolescents in RCTs were associated with an increased risk of adverse events. The findings suggest that long-term safety studies, including those exploring cannabinoid-related drug interactions and tools that improve adverse event reporting, are needed.

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Pharmacological and physiological effects of cannabidiol: a dose escalation, placebo washout study protocol BMC Neurology, 12 September 2024

Background: Cannabinoids such as cannabidiol (CBD) exhibit anti-inflammatory properties and have the potential to act as a therapeutic following mild traumatic brain injury. There is limited evidence available on the pharmacological, physiological and psychological effects of escalating CBD dosages in a healthy, male, university athlete population. Furthermore, no dosing regimen for CBD is available with implications of improving physiological function. This study will develop an optimal CBD dose based on the pharmacokinetic data in contact-sport athletes. The physiological and psychological data will be correlated to the pharmacokinetic data to understand the mechanism(s) associated with an escalating CBD dose.

Methods/design: Forty participants will receive escalating doses of CBD ranging from 5 mg CBD/kg/day to 30 mg CBD/kg/day. The CBD dose is escalated every two weeks in increments of 5 mg CBD/kg/day. Participants will provide blood for pharmacological assessments at each of the 10 visits. Participants will complete a physiological assessment at each of the visits, including assessments of cerebral hemodynamics, blood pressure, electrocardiogram, seismocardiogram, transcranial magnetic stimulation, and salivary analysis for genomic sequencing. Finally, participants will complete a psychological assessment consisting of sleep, anxiety, and pain-related questionnaires.

Discussion: This study will develop of an optimal CBD dose based on pharmacological, physiological, and psychological properties for future use during contact sport seasons to understand if CBD can help to reduce the frequency of mild traumatic injuries and enhance recovery.

Trial registration: Clinicaltrials.gov: NCT06204003.

2023

Medical cannabis for children: Evidence and recommendations Canadian Paediatric Society, 19 October 2023

Interest in using cannabis products for a medical purpose in children under the age of 18 years is increasing. There are many medical cannabis products available that can include cannabidiol (CBD) or delta-9-tetrahydrocannabinol (THC), or both cannabinoids. Despite many therapeutic claims, there are few rigorous studies to inform the dosing, safety, and efficacy of medical cannabis used in paediatric clinical practice. This statement reviews the current evidence and provides recommendations for using medical cannabis in children. Longer term (2-year) reports support the sustained tolerability and efficacy of cannabidiol therapy for patients with Lennox-Gastaut and Dravet syndromes. CBD-enriched cannabis extracts containing small amounts of THC have been evaluated in a small number of paediatric patients, and further research is needed to inform clinical practice guidelines. Given the widespread use of medical cannabis in Canada, paediatricians should be prepared to engage in open, ongoing discussions with families about its potential benefits and risks, and develop individualized plans that monitor efficacy, reduce harms, and mitigate drug−drug interactions.

Keywords: Cannabinoids; CBD; Children; delta-9-tetrahydrocannabinol; Medical cannabis; Pharmacotherapy

Cannabinoids for symptom management in children with cancer: A systematic review and meta-analysis Cancer, 28 August 2023

Background: Despite the widespread use of medical cannabis, little is known regarding the safety, efficacy, and dosing of cannabis products in children with cancer. The objective of this study was to systematically appraise the existing published literature for the use of cannabis products in children with cancer.

Methods: This systematic review, registered with the International Prospective Register of Systematic Reviews (CRD42020187433), searched four databases: MEDLINE, Embase, PsycINFO, and the Cochrane Library. Abstracts and full texts were screened in duplicate. Data on types of cannabis products, doses, formulations, frequencies, routes of administration, indications, and clinical and demographic details as well as reported efficacy outcomes were extracted. Data on cannabinoid-related adverse events were also summarized.

Results: Out of 34,611 identified citations, 19 unique studies with a total of 1927 participants with cancer were included: eight retrospective chart reviews, seven randomized controlled trials, two open-label studies, and two case reports. The included studies reported the use of various cannabis products for the management of symptoms. Cannabinoids were commonly used for the management of chemotherapy-induced nausea and vomiting (11 of 19 [58%]). In controlled studies, somnolence, dizziness, dry mouth, and withdrawal due to adverse events were more commonly associated with the use of cannabinoids. Across all included studies, no serious cannabis-related adverse events were reported.

Conclusions: Although there is evidence to support the use of cannabis for symptom management, in children with cancer, there is a lack of rigorous evidence to inform the dosing, safety, and efficacy of cannabinoids. Because of the increasing interest in using cannabis, there is an urgent need for more research on medical cannabis in children with cancer.

Co-designing clinical trials alongside youth with chronic pain Paediatrics & Neonatal Pain, 8 May 2023

Youth have a right to participate in research that will inform the care that they receive. Engagement with children and young people has been shown to improve rates of enrollment and retention in clinical trials as well as reduce research waste. The aim of the study is to gain practical insight on the design of trials specifically on (1) recruitment and retention preferences, (2) potential barriers to research, and (3) study design optimization. Based on this youth engagement, we will co-design two clinical trials in headaches with youth. Two recruitment strategies were used to recruit 16 youth from across Canada (aged 15–18 years) from an existing youth group, the KidsCan Young Persons' Research Advisory Group (YPRAG) and a new youth group in collaboration with Solutions for Kids in Pain (SKIP). Four virtual, semi-structured discussion groups were held between April and December 2020, which included pre-circulated materials and utilized two distinct upcoming planned trials as examples for specific methods feedback. Individual engagement evaluations were completed following the final group session using the Public and Patient Engagement Evaluation Tool. Descriptive results were shared with participants prior to publication to ensure appropriate interpretation. The discussion was centred around three themes: recruitment and retention preferences, potential barriers to participation, and study design optimization. Youth indicated that they would prefer to be contacted for a potential study directly by their physician (not over social media), that they would like to develop rapport with study staff, and that one of the barriers to participation is the time commitment. The youth also provided feedback on the design of the clinical trial including outcome measurement tools, data collection, and engagement methods. Feedback on the virtual format of the engagement events indicated that participants appreciated the ease of the online discussion and that the open-ended discussion allowed for easy exchange of ideas. They felt that despite a gender imbalance (towards females) it was an overall inclusive environment. All participants reported believing that their engagement will make a difference to the work of the research team in designing the clinical trials. Perspectives from a diverse group of youth meaningfully improved the design and conduct of two clinical trials for headaches in children. This study provides a framework for future researchers to engage youth in the co-design of clinical trials using online engagement sessions.

Medical cannabis in schools: The experiences of caregivers Paediatrics & Child Health, 4 May 2023

Objectives: Implementing medical cannabis (MC) into a child’s daily routine can be challenging and there is a lack of guidance for its therapeutic use in schools in Canada. Our objective was to learn about the experiences of caregivers of school-aged children who require MC.

Methods: Qualitative description was used and caregivers were interviewed about MC in schools and in general. The transcripts were entered into Dedoose software for qualitative analysis and content analysis was performed. Sentences and statements were ascribed line by line into meaning units and labelled with codes, and organized according to categories and subcategories.

Results: Twelve caregivers of school-aged children who take MC participated. The most common reasons for treatment were drug-resistant epilepsy (DRE), autism, or other developmental disorders. Approximately half of the participants’ children (n = 6) took MC during the school day and most (5/6) perceived their experiences to be positive or neutral but reported a lack of knowledge about MC. While data saturation was not reached regarding MC in schools, rich dialogues were garnered about MC in general and three categories were identified: challenges (subcategories stigma, finding an authorizer, cost, dosing, and supply); parents as advocates (subcategories required knowledge, attitudes, skills, and sources of information); and caregiver relief for positive outcomes.

Conclusions: Caregivers demonstrate remarkable tenacity despite the many challenges associated with MC use. Education and practice change are needed to ensure that children using MC can benefit from or continue to experience its positive outcomes within the school environment and beyond.

Removing barriers to accessing medical cannabis for paediatric patients Paediatrics & Child Health, 31 March 2023

Medical cannabis (MC) may offer therapeutic benefits for children with complex neurological conditions and chronic diseases. In Canada, parents, and caregivers frequently report encountering barriers when accessing MC for their children. These include negative preconceived notions about risks and benefits, challenges connecting with a knowledgeable healthcare provider (HCP), the high cost of MC products, and navigating MC product shortages. In this manuscript, we explore several of these barriers and provide recommendations to decision-makers to enable a family-centered and evidence-based approach to MC medicine and research for children.

2022

Medical Cannabis in Canadian Schools: A Scoping Review of Existing Policies Cannabis and Cannabinoid Research, 05 December 2022

Objective: An increasing number of children and youth in Canada are taking medical cannabis for complex medical conditions. While they deserve safe and consistent access to pharmacotherapy throughout the day, administrative policies on cannabis use in schools are inconsistent. A scoping review identified policies and publications associated with medical cannabis in Canadian schools.

Methods: Five databases (Scopus, PubMed, CINAHL, EMBASE, and Web of Science) were searched to identify scientific literature. Legislation in each province and territory and Ministry of Education webpages were reviewed for pertinent laws and policies regarding cannabis use in schools.

Results: The scientific search resulted in 1289 articles. The five included articles pertain to implications for school nurses in the United States, which are not relevant to the Canadian context. A search of Ministry of Education websites identified only one policy with information regarding medical cannabis in schools (from Ontario). Federal legislation (the Cannabis Act) does not specifically address medical cannabis in schools, and there is a lack of consistency in terminology and clarity within provincial and territorial laws. All provinces and territories prohibit smoking and vaping of cannabis on school property and some provinces prohibit any method of cannabis consumption.

Conclusions: In Canada, there is a lack of guidance for medical cannabis administration, storage, and disposal in schools, with some policies explicitly prohibiting this type of treatment. This shifts the burden to families to individually create plans school by school. A federally harmonized approach to supporting children who take cannabis for medical purposes ought to be explored.

Medical cannabis in schools: A qualitative study on the experiences of clinicians Paediatrics & Child Health, 12 November 2022

Objectives: Guidance is lacking for medical cannabis use in Canadian schools in both legislation and approach; the impact of ambiguous policy on patient care is unknown. A qualitative study was undertaken to explore the experiences of clinicians who care for school-aged children who take medical cannabis.

Methods: Semi-structured interviews were recorded and transcribed verbatim. Qualitative content analysis performed using the Dedoose qualitative software ascribed meaning units and codes, which were further consolidated into categories and subcategories.

Results: Thirteen physicians were interviewed virtually, representing seven provinces in Canada. The physicians provided care for between five and hundreds of school-aged children who took medical cannabis. The most common indications were refractory seizure disorders and autism. The interviews provided rich descriptions on perceptions of medical cannabis in schools, and in general. Five overarching categories were identified across both domains including variability, challenges (subcategories: lack of knowledge, stigma, lack of policy, and pragmatic challenges), potential solutions (subcategories: treat it like other medications, communication, education, and family support), positive experiences and improvements over time.

Conclusion: In Canada, cannabis-based medicine use in schools still faces important challenges. Effective education, communication, family support and policy refinements that allow cannabis to be treated like other prescription medications are recommended to improve the status quo. These findings will guide the C4T Medical Cannabis in Schools Working Group’s future priorities and initiatives.

Neither the “devil’s lettuce” nor a “miracle cure:” the use of medical cannabis in the care of children and youth Neuroethics, 03 February 2022

Lack of guidance and regulation for authorizing medical cannabis for conditions involving the health and neurodevelopment of children is ethically problematic as it promulgates access inequities, risk-benefit inconsistencies, and inadequate consent mechanisms. In two virtual sessions using participatory action research and consensus-building methods, we obtained perspectives of stakeholders on ethics and medical cannabis for children and youth. The sessions focused on the scientific and regulatory landscape of medical cannabis, surrogate decision-making and assent, and the social and political culture of medical cannabis. We found that evidence-gathering and data dissemination, pressures on clinical relationships, and the lack of integration of culturally diverse perspectives and Indigenous knowledges were key areas of concern. Participants emphasized the importance of utilizing adaptive study designs, highlighted the importance of trust-building between clinicians, patients and caregivers, and discussed barriers including historical and ongoing stigmatization of medical cannabis. We conclude that continued public consultation and strength-based research that integrate diverse perspectives are critical steps forward.

Clinician views on and ethics priorities for authorizing medical cannabis in the care of children and youth in Canada: a qualitative study CMAJ, 01 January 2022

Background: The use of cannabis for medical purposes by pediatric patients is expanding across Canada; however, supporting evidence, federal regulations and treatment guidelines are lacking. To understand factors affecting treatment decisions in this landscape, we sought to delineate clinician perspectives, ethics priorities and values for cannabis authorization.

Methods: We sampled participants purposefully through Canadian Childhood Cannabinoid Clinical Trials listservs, which include the majority of pediatric oncologists and palliative care physicians practising in Canada, among many other pediatric physicians and clinicians. Inclusion criteria were being a practising clinician in Canada, involvement in the care of children and willingness to be interviewed regardless of stance on medical cannabis. In November and December 2020, we conducted semistructured interviews focusing on principles, values and priorities, including medical, professional, regulatory, evidentiary and social considerations, for authorizing medical cannabis to children. Interviews were recorded, transcribed and analyzed by means of deductive and inductive thematic methods.

Results: We conducted 18 interviews with a diverse group of clinicians representing a range of specialties within pediatric care, including neurology, palliative care, oncology, family medicine and pharmacology. The interviews yielded 4 themes and 12 subthemes related to a priori (medical, professional, regulatory, evidentiary and social themes) and emergent themes. The 4 themes of access, relationships and relational autonomy (autonomy within relationships), medically appropriate use and research priorities were grounded in principles of harm reduction. Participants described problematic authorization procedures that negatively affect patient use. Principles associated with relational autonomy were highlighted as a feature of open clinical communication. Benefits of appropriate medical uses weighed positively over risks, even in the context of potential effects on neurodevelopment. Participants expressed that more research is essential to align medical cannabis with biomedical standards.

Interpretation: Clinicians reported pursuing ethical use of medical cannabis for pediatric patients and prioritizing their safety under principles of harm reduction. There is a need for evidence about neurodevelopmental risks, support for research, treatment guidelines and greater knowledge about stakeholder perspectives to alleviate burdens related to use of medical cannabis for pediatric patients in Canada.

2021

Efficacy and safety of medical cannabinoids in children: a systematic review and meta-analysis Scientific Reports, 06 December 2021

Improving the regulation of medical cannabis in Canada to better serve pediatric patients CMAJ, 18 October 2021

Key points:

Children with chronic debilitating illness and pain are increasingly using cannabis for medical purposes, particularly when conventional treatment options have limited benefit or substantial adverse effects.
Better processes and regulation are needed in Canada to ensure adequate research into the effectiveness and adverse effects of cannabis products for medical conditions in children and adolescents.
Refinement of authorization and prescribing processes and mandated adverse effect reporting are needed to enhance patient safety.
Innovative mechanisms for adequate research funding that is independent of industry influence are required to support research that can strengthen the evidence base on the indications, dosage, efficacy and potential toxicity of medical cannabis for pediatric patients.

Pharmacokinetics and perceptions of children and young adults using cannabis for attention-deficit/hyperactivity disorder and oppositional defiant disorder: protocol for a mixed methods proof-of-concept study JMIR Research Protocols, 18 October 2021

Background: Despite the lack of evidence on the use of cannabis for the treatment of attention-deficit/hyperactivity disorder (ADHD), the growing perception that cannabis is safe has led more patients and caregivers to self-medicate. Some psychiatrists now authorize medicinal cannabis for patients with ADHD with features of oppositional defiant disorder (ODD) to curtail the unregulated (ie, self-medicated) use of recreational cannabis or to offer a therapeutic option to those who continue to experience symptoms after exhausting all other treatment options.

Objective: This protocol aims to explore the perceived effectiveness and pharmacokinetics of cannabis in youth and young adults, who are currently taking it as part of their treatment plan for ADHD with features of ODD, under the supervision of a psychiatrist.

Methods: Patients between the ages of 12 and 25 years with a diagnosis of ADHD and features of ODD, who are currently taking cannabis herbal extract (at a Δ 9 -tetrahydrocannabinol [THC]:cannabidiol [CBD] ratio of 1:20) as a treatment adjunct to stimulant pharmacotherapy will be recruited. A sample size of 10-20 individuals is estimated. The study interview will consist of (1) validated symptom rating scales (Swanson, Nolan, and Pelham-IV Questionnaire [SNAP-IV], 90-item; Patient Health Questionnaire, 9-item [PHQ-9]; and Screen for Child Anxiety Related Emotional Disorders [SCARED] tool to measure symptoms of ADHD and ODD, depression, and anxiety, respectively); (2) a semistructured interview to probe the experiences of using cannabis; and (3) a cannabis side effects survey. A cannabis product sample as well as 2 blood samples (a trough level and 2-hour postdose level) will be collected to measure plasma concentrations of cannabinoids and relevant metabolites (THC, CBD, 11-hydroxy-THC, 7-hydroxy-CBD, cannabichromene, and 11-nor-9-carboxy-THB) using liquid chromatography–tandem mass spectrometry (LC–MS/MS). Self-report rating scales (SNAP-IV, SCARED, and PHQ-9) will be scored in accordance with standard protocols and compared to retrospective scores obtained from the participant’s chart. Demographic variables (age, weight, and race), symptom scores, and blood levels (peaks and troughs) of THC, CBD, cannabichromene (CBC), and metabolites will be summarized using descriptive statistics. Relationships between plasma concentrations and symptom scores will be determined using analysis of variance, and multiple regression analysis will be performed to determine associations between plasma concentrations and demographic variables (age, weight, and ethnicity). The qualitative data will be audio-recorded and transcribed and organized into themes.

Results: The protocol was approved by the Biomedical Research Ethics Board at the University of Saskatchewan (protocol #1726), and recruitment began in May 2021.

Conclusions: This proof-of-concept study will explore the potential treatment effectiveness of medical cannabis in participants with ADHD and ODD through a mixed methods approach to inform future research in this area

Keywords: attention-deficit/hyperactivity disorder; ADHD; oppositional defiant disorder; cannabis; cannabidiol; young adults; youths; pharmacokinetics; marijuana

Perspectives of pediatric oncologists and palliative care physicians on the therapeutic use of cannabis in children with cancer Cancer Reports, 23 August 2021

Background: Children with cancer are increasingly using cannabis therapeutically.

Aim: The purpose of this study was to determine the perspectives and practices of pediatric oncologists and palliative care physicians regarding the use of cannabis for medical purposes among children with cancer.

Methods: A self-administered, voluntary, cross-sectional, deidentified online survey was sent to all pediatric oncologists and palliative care physicians in Canada between June and August 2020. Survey domains included education, knowledge, and concerns about cannabis, views on its effectiveness, and the importance of cannabis-related research. Data were analyzed using descriptive statistics.

Results: In total, 122/259 (47.1%) physicians completed the survey. Although 62.2% of the physicians completed some form of training about medical cannabis, nearly all (95.8%) desired to know more about the dosing, side effects, and safety of cannabis. Physicians identified a potential role of cannabis in the management of nausea and vomiting (85.7%), chronic pain (72.3%), cachexia/poor appetite (67.2%), and anxiety or depression (42.9%). Only four (0.3%) physicians recognized cannabis to be potentially useful as an anticancer agent. Nearly all physicians reported that cannabis-related research for symptom relief is essential (91.5%) in pediatric oncology, whereas 51.7% expressed that future studies are necessary to determine the anticancer effects of cannabis. Conclusions: Our findings indicate that most pediatric oncologists and palliative care physicians recognize a potential role for cannabis in symptom control in children with cancer. Well-conducted studies are required to create evidence for cannabis use and promote shared decision making with pediatric oncology patients and their caregivers.

Keywords: cancer, cannabidiol, cannabis, pediatrics, symptom control, tetrahydrocannabinol

Medicinal cannabis in children and adolescents with autism spectrum disorder: a scoping review Child: Care, Health and Development, 17 August 2021

Background: Autism spectrum disorder (ASD) is a neurodevelopmental condition estimated to affect 1 in 66 children in Canada and 1 in 270 individuals worldwide. As effective therapies for the management of ASD core and associated symptoms are limited, parents are increasingly turning to clinicians for advice regarding the use of medicinal cannabis to manage behavioural disturbances.

Objective: The objective of this scoping review was to identify and map symptoms, outcomes and adverse events related to medicinal cannabis treatment for ASD-related behaviours.

Methods: Ovid MEDLINE, Embase, CINAHL, PsycInfo, Web of Science Core Collection, Google Scholar and grey literature sources were searched up to 5 January 2020 for studies. Included studies met the following criteria: (1) investigate the use of medicinal cannabis, (2) at least 50% participants had ASD, (3) at least 50% of the study population was 0–18 years old and (4) any study design (published or unpublished).

Results: We identified eight completed and five ongoing studies meeting the inclusion criteria. All studies reported substantial behaviour and symptom improvement on medicinal cannabis, with 61% to 93% of subjects showing benefit. In the three studies reporting on concomitant psychotropic medication usage and with cannabis use, up to 80% of participants observed a reduction in concurrent medication use. Adverse events related to cannabis use were reported in up to 27% of participants related, and two participants had psychotic events.

Conclusions: Early reports regarding medicinal cannabis in paediatric ASD symptom management are presented as positive; the evidence, however, is limited to very few retrospective cohort and observational studies. Evidence of safety and efficacy from prospective clinical trials is needed.

Coverage of medical cannabis by Canadian news media: Ethics, access, and policy International Journal of Drug Policy, 10 July 2021

Background: The use of recreational cannabis by adults was legalized in Canada in 2018 (The Cannabis Act, 17 October 2018). This change in drug policy indirectly opened the doors to broader uses, including those for health-related conditions. As a first step towards understanding ethical, legal, and social shifts on this landscape, we examined messaging surrounding medical cannabis and health in Canadian news media before and after legalization.

Methods: We retrieved news articles about medical cannabis and health from Canadian sources (2010–2020). Deductive and inductive content analytic approaches were applied to code eligible articles for both a priori ethical, legal, social, and issues, and emergent themes. Wilcoxon-Mann-Whitney U tests were used to test for thematic changes pre- and post-legalization.

Results: Two hundred and sixteen (216) articles met inclusion criteria. Analysis yielded three themes and eight subthemes, comprising 4931 coded references. The a priori theme of Ethical, Legal and Social Issues (access, benefits/risks of medical cannabis, public engagement, and conflicts of interest) dominated news media coverage across the decade (coded in 99% of articles). The emergent theme of Medical Applications (therapeutic use of cannabis, consumption considerations, comparisons to other drug and treatment options) was coded in 86% of articles; Resource Issues (research and education) in 50%. We found little discourse on ethics issues specific to exceptional populations. Coverage on aspects of access declined significantly post-legalization.

Conclusion: Capturing the push of Canadian news coverage of medical cannabis is a powerful means of understanding how public opinions on the subject are shaped and then, by extension, inform public policy for well-being and healthcare. Continued examination of these issues, public consultation, engagement with diverse populations such as people with disabilities and neurologic and mental health conditions, and integration of diverse cultural views into the policy discourse are critical steps for future research and action.

Potential benefit of add-on Δ9-tetrahydrocannabinoil in pediatric drug-resistant epilepsy: a case series Canadian Journal of Neurological Sciences, 29 June 2021

We present five cases of pediatric drug-resistant epilepsy (DRE) that failed management using high cannabidiol (CBD) doses, but had significant reduction in seizure frequency with reintroduction or increasing doses of tetrahydrocannabinol (THC). There is growing evidence supporting the use of whole-plant CBD-rich extracts (containing THC and other cannabinoids) in the treatment of pediatric DRE. Based on our experiences and reports in the literature, we propose that, in patients who fail management with an initial trial of high-dose CBD-focused therapy, there may be a role for add-on THC-focused formulations.

Keywords: cannabis, THC, CBD, pediatric epilepsy

Family attitudes about and experiences with medical cannabis in children with cancer or epilepsy: an exploratory qualitative study CMAJ, 21 May 2021

Background: Cannabis is legal for recreational and medical use in Canada. Our aim was to explore family experiences using medical cannabis for children with severe conditions in the context of legalization.

Methods: We conducted a qualitative study using semistructured interviews between April and July 2019. Participants were parents of children attending BC Children’s Hospital oncology or palliative care clinics, recruited through posters, emails or referral. Participants were included if they spoke English and their child used any type of cannabis for medical purposes. Interviews included open-ended questions about the child’s cannabis use. Interviews were recorded and transcribed, and thematic analysis was performed using qualitative description.

Results: Ten interviews were completed with 9 mothers and 1 mother–father pair. The age range of the children was 22 months to 16 years. The primary reasons for cannabis use were epilepsy (6 children) or chemotherapy management (4 children). Five major themes were identified. 1) Child and family context, and cannabis as a last resort: children were seen as severely ill; parents sought cannabis out of desperation and responsibility to their child. 2) Varied information sources informed decision-making: parents lacked resources from health care providers and sought support from social media, industry and other families. 3) Cannabis as an ambiguous medicine: cannabis was viewed as both a serious drug that doctors should prescribe and as a natural alternative health product, safe to pursue alone. 4) Perceived effects: parents perceived medical benefits with few concerns about adverse effects. 5) Legal and financial challenges: parents were willing to obtain cannabis despite high costs and uncertain legality.

Interpretation: Parents of children with severe conditions pursued medical cannabis despite obstacles and needed unbiased information to access alone. Scientific investigation is needed to develop pediatric medical guidelines to inform decisions.

Medical cannabis in pediatric oncology: a survey of patients and caregivers Supportive Care in Cancer, 5 April 2021

Background: There are minimal data regarding the safety and efficacy of cannabis used as an anti-cancer agent or for symptom management in pediatric oncology. We aimed to characterize the prevalence and factors associated with the use of cannabis for the treatment of cancer and management of cancer-related symptoms in children during or after cancer treatment.

Methods: An anonymous 40 question paper survey was offered to patients/caregivers of children with cancer attending a pediatric oncology clinic in a provincially mandated cancer agency between October 2019 and March 2020.

Results: There were 64 respondents included in the analysis. Fourteen participants (N=14/64; 22%) reported use of cannabis, of which half used cannabis for either cancer treatment or symptom management, or both. Leukemia (n=9/14; 64%) was the most frequent diagnosis in children whose caregivers reported using cannabis and the majority of them were still receiving active cancer treatment (N= 5/9; 56%). All of the respondents using cannabis (14/14, 100%) experienced symptom improvement. Most of the caregivers procured cannabis from their friends (N=5/14; 36%), and oil was the most commonly used formulation (N=12/14; 86%). Cannabis-related information was received from another parent (N=4/14; 29%) or from a doctor (N=4/14; 29%). The reported monthly expenditure on cannabis varied widely from less than $50 CAD (N=4/14; 29%) to more than $500 CAD (N=3/14; 21%).

Conclusions: Our survey shows that cannabis, mostly oil products, was used by one-fifth of children with cancer during or after the completion of cancer treatment. These findings require validation in a larger nationwide survey.

Keywords: Cannabis, Medical marijuana, Pediatric oncology, Symptom management