Medical marijuana is a smoking hot topic of our times (pun intended). It is on the lips and minds of many individuals in Trinidad and Tobago and across the globe. There are several countries that have legalised marijuana such as: Canada, Germany, Israel, Netherlands and some states in the US [1,4]. Some nations have legalised both recreational and medical usage whilst others have opted to only legalise the medical use of marijuana. In the UK, for example, it is legal for only certain medical conditions [2,4].
There has been a lot of hype surrounding its use in children, especially in cases of epilepsy, as can be seen by its "success stories" shared by parents online [7]. Recently, I was privileged to attend a research conference organised by the Trinidad and Tobago Medical Association in conjunction with the Paediatric Society of Trinidad and Tobago, and it was not a surprise that one of the presentations focused on medical marijuana in children. Today, I will share briefly some information that exists on this topic.
Before I begin, I must preface this discussion with the fact that marijuana is still illegal in Trinidad and Tobago, both for recreational and medical use, and the purpose of this article is not to agitate for or against its legalisation, but to look at what are the conditions in which it is being used for in children.
The world is a small village and with the ease of communication and transportation it is possible that this treatment will be sought by parents, in places where it is legal to access. Therefore, physicians should be aware of what is the current climate of this drug in the paediatric world.
The way how marijuana works is not completely understood. We know about certain receptors in the central nervous system that are affected by marijuana, but it's full mechanism of action is not known. The marijuana plant can produce up to 144 chemicals [4]. However, there are 2 primary components of marijuana which are widely studied in the literature. These are: tetrahydrocannabinol (THC) and cannabidiol (CBD). THC is considered to have the euphoric and psychotropic (mind-altering) effect whilst the CBD component does not have such feelings of being "high". CBD is the one currently being used in children medically.
Because of our limited evidence of marijuana usage in paediatrics [1], CBD usage is highly restricted at the moment. The current indications for medical marijuana in children are for severe intractable seizures (seizures that do not respond to any treatment) or as an adjunctive therapy in patients with drug resistant epilepsy (DRE).
According to the International League Against Epilepsy, DRE refers to failure of adequate trials of two tolerated, appropriately chosen and used anti-epileptic drug schedules to achieve seizure freedom [2].
The 2 main conditions in which Epidiolex (which is a highly purified CBD component) is studied and FDA approved as of June 2018 in children over the age of 2 years, are [3,4]:
1. Dravet Syndrome
2. Lennox Gastaut Syndrome
It is important to note that both these conditions are very rare (between 1 in 20 000 to 1 in 40 000 for Dravet Syndrome [8]). These patients suffer from several dozens of different type seizures and are usually unresponsive to typical first line anti-epileptic therapy[8,9]. They need constant supervision due to seizure risk and can have developmental delays. As a result, it is understandable why a parent would seek any form of treatment available that they think will help reduce their child's seizures.
At the same time, it must be borne in mind that CBD is not the panacea for DRE. The current evidence estimates that the number of people needed to be treated with CBD for one person to achieve a 50% reduction in seizures is eight [1]. Put another way, for every 8 children who meets the criteria to receive CBD and is treated with CBD, only one shall achieve more than 50% reduction in seizures. Parents and caregivers need to appreciate this.
More importantly, parents must not feel that CBD is their only option in these "hard-to-treat" epilepsy syndromes.
Parents and caregivers must not feel that CBD is their only option in "hard-to-treat" epilepsy syndromes. There are other treatment option available such as: ketogenic diets, epilepsy brain surgery and vagal nerve stimulation (VNS) [2]. In fact, the British Paediatric Neurology Association issued a statement in October 2018 [5] that CBD should only be used as a last resort after other modalities have been tried. The BPNA states:
"Prescription of a non‐licensed cannabis‐based product for medicinal use should be used as a treatment of last resort for children who meet the following three criteria:
1. Have an epilepsy that has proven intractable to treatment with conventional licensed anti‐epileptic drugs given at therapeutic doses.
2. Have not responded to the ketogenic diet or for whom the diet is inappropriate.
3. Are not candidates for epilepsy surgery ."
Having looked at its uses, we should have a view of its harms. Medical marijuana is not risk-free. There are potential side effects and drug interactions. Some of the documented side effects of CBD in the studies done on children with Dravet Syndrome include [1]: somnolence (36%), diarrhea (31%), decreased appetite (28%), fatigue (20%), vomiting (15%), fever (15%), lethargy (13%), upper respiratory tract infection (11%), convulsion (11%), elevated liver aminotransferase enzymes (20%) and status epilepticus (4.9%). Additionally, CBD can interact negatively with other anti-epileptic drugs such as valproic acid and clobazam [5].
Another negativity to consider is the rise in marijuana toxicity and addiction in children living in places that have legalised both recreational and medical marijuana [6]. Whilst we know that chronic recreational use of THC can affect the developing adolescent brain and mental health [5], we await long term studies on the effects of chronic CBD usage in medical conditions.
Medical marijuana and its use in children is certainly a topic that will not go away. At the present moment, CBD has its potential uses in children with Dravet Syndrome and Lennox Gastaut Syndrome. At the same time, CBD is not the panacea for these conditions. It has documented side effects and there are other alternatives to be explored.
In the next 20 year I reckon we would have much more evidence to make informed decisions. As for now, it is our job as physicians, parents and paediatricians to follow the developments and keep up to date, as the use of it will likely progress as the evidence base becomes stronger.
Dr. Zafir W. Latchan
BMedSci, MB.BS,
PGDip. Paediatric Emergency Medicine (Edin)
MRCPCH (Lon)
Disclaimer: This article is for educational purposes only. In no way is this article intended to diagnose or treat you or your child. If you are concerned about your health or the health of your child, please speak to a qualified and trained health care professional.
References:
[1] Stockings E, Zagic D, Campbell G, et al. Evidence for cannabis and cannabinoids for epilepsy: a systematic review of controlled and observational evidence. Journal of Neurology, Neurosurgery & Psychiatry 2018;89:741-753. https://jnnp.bmj.com/content/89/7/741
[2] Harijan P, Seal AK, Prasad M, et al. Fifteen-minute consultation: When medicines don't work- the child with poorly controlled seizures. Arch Dis Child Educ Pract Ed 2019;104:135-140.
[3] Mary Beth Nierengarten. Medical marijuana for children. Contemporary Pediatrics. July 3, 2019. https://www.contemporarypediatrics.com/pediatrics/medical-marijuana-children
[4] Freeman Tom P, Hindocha Chandni, GreenSebastian F, Bloomfield Michael A P. Medicinal use of cannabis based products and cannabinoids. BMJ 2019; 365 :l1141. https://www.bmj.com/content/365/bmj.l1141
[5] British Paediatric Neurology Association. BPNA Guidance on the use of cannabis- based products for the medicinal use in children and young people with epilepsy. https://www.bpna.org.uk/userfiles/BPNA_CBPM_Guidance_Oct2018.pdf
[6] CBS NEWS. The unintended consequences of more potent pot. August 10, 2019, 1:37pm. https://www.cbsnews.com/news/marijuana-the-unintended-consequences-of-more-potent-pot/
[7] Alexandra Thompson. Senior Health Reporter for Mail Online. Girl, nine, who endured up to 300 seizures EVERY DAY and had one of the worst cases of epilepsy doctors have even seen is nearly seizure-free thanks to cannabis oil.
[8] Dravet Syndrome. https://www.epilepsy.com/learn/types-epilepsy-syndromes/dravet-syndrome
[9] Lennox-Gastaut Syndrome https://www.epilepsy.com/learn/types-epilepsy-syndromes/lennox-gastaut-syndrome-lgs
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