Melatonin vs. Cannabis Poisoning Incidents
Are sweetened edible gummies driving both problems?
(Note: this post should be considered a First Draft. Its conclusions are preliminary. I’ve done my best to get the math right, and draw my conclusions from the evidence presented in the studies I’ve accessed. I’ll be continuing my research to access more studies on this topic. Despite the fact that I consider this post incomplete, it offers a lot more detail than the stories I’ve found in major news media outlets. That accounts for why I’m publishing it publicly so early on. I will definitely have some additions and corrections. I don’t anticipate changing any of the conclusions I’ve presented. If that becomes necessary, I’ll print a retraction and apology, along with detailing the information that prompted it.)
Press reports on “marijuana poisoning” incidents have increased markedly in recent years, with particular emphasis on increases in the aftermath of commercial legalization in U.S. States like Washington, Colorado, and California. These increases are typically cited in terms of increases in percentage, without much other information provided. This post is intended to supply some of the most relevant details required to place the phenomenon of cannabis poisoning in a wider context, in order to obtain an accurate perspective on the problem. The metrics include the number and percentage of cannabis-associated incidents that were considered severe enough to require hospitalization; the number that were associated with death or lasting after-effects; and an overview of annual reports for all causes of poisoning.
Currently, even in states with commercial legalization, reports of cannabis poisoning do not feature significantly in annual poisoning reports. Other substances are much more common. Most of the reported incidents are handled with phone advice, with no need for a visit to a hospital or clinic. More than half of them involve unintentional ingestion, mostly by children.
It’s notable that most of the reported increases in cannabis poisoning incidents result from the ingestion of cannabis edibles, which are commonly marketed as confections, including the popular sugar candy known as “gummies.” Gummies are not by any means reserved for cannabis edibles, of course. Not only are they a popular candy, in recent years they’ve become widely used for vitamins and supplements. The “drug delivery system” of chewable sweets has also become a prominent feature in pediatric poisoning incidents.
For the purpose of comparison with recent reports on pediatric cannabis poisoning, I’ve chosen the supplement melatonin: in 2020, melatonin “became the most frequently ingested substance among children reported to national poison control centers.” The use of both cannabis edibles (especially in the legal states,but not exclusively) and melatonin (which is of course available OTC in all 50 states, and DC) has skyrocketed in recent years. The phenomenon of pediatric poisoning resulting from melatonin overdose hasn’t achieved the same headline prominence as the post-legalization rise in cannabis poisoning, but it has been widely reported in various press outlets. I’m using the same study that provided the basis for those mews articles for my comparison.
Both cannabis and melatonin are known to have mildly toxic physical side effects when consumed in excess by adults. The toxic effects are occasionally more serious when overdoses are consumed by children under age 6. Significantly, both cannabis edibles and melatonin are commonly marketed in the form of gummy candies, a feature that tends to make them relatively more attractive for ingestion and overconsumption, particularly overdose due to accidental ingestion by children. Neither substance features prominently in terms of producing severe poisoning or lethality, but both have seen dramatic year-to-year increases as far as being specifically identified in reports to poisoning centers and emergency room visits.
This overview has a number of the usual problems related to statistical comparisons between disparate studies of similar phenomena: the years of study often overlap but are not identical, and year-to-year totals are sometimes missing. One study relies on a 9-month time period, not a 12-month time period. The age group demographics are not subcategorized in the same way between studies. Detailed data on relationships between the tabulated severity of assessed outcomes and the associated age demographics is not presented. Detailed data on total annual numbers is sometimes not subdivided by age. As a result, I can only hazard rough estimates when offering comparisons between studies. I’m just trying to do my best with what I’ve been able to find.
(I understand that researchers are often making do with incomplete reports, and that their studies are often focusing on one central question without considering others. But how are we ever going to get to a reliable era of Big Data without studies that share a common basis of relevant metrics and parameters, with the details researched as thoroughly as possible?)
Screenshots of some of the tables and figures provided in the studies are found below.
My data summary, including estimates drawn from the data:
The number of poisonings recently reported for all cannabis products combined- flower, concentrates, edibles, etc.- is only a small fraction of the annual incidents of pediatric melatonin poisoning.
According to the study, 83.8% of cases between 2012 and 2021 involved children under the age of 6. In 2021, there were 52,563 cases of melatonin poisoning; using a rough estimate of 80%, that works out to 42,050 cases of children under 6 (age 0-5.)
In 2019, 1963 cases of cannabis poisoning by children under the age of 10 were reported to U.S. Poison Centers; there’s no detailed breakdown by year, but the ballpark average shown for the three studied years 2017-2019 is that 75% of them involved children under age 6: so 1472 cases.
The melatonin study lumps together “moderate” and “major” poisoning events as “more serious” outcomes; it also includes figures for hospitalization and ICU use, along with deaths attributed to melatonin poisoning (2). There are no annual breakdowns for the numbers of poisoning cases admitted to the hospital, or to the ICU. There are totals. Extrapolating from those figures to provide a rough estimate for the most recent year of the study, around 807 children were hospitalized in 2021, and 57 cases ended up in the ICU.
The most detailed cannabis study- for reported incidents reported to poison control centers in the US nationwide- provides the numbers for both “moderate” and “major” outcomes, but the numbers are aggregated for 2017-2019. The total number of events for children under age 10 (0-9) between 2017 and 2019 was 4172; the total number of “major” cannabis poisoning events in the three years between 2017 and 2019 was 57, or around 1.36% of 4172. Applied to the 2019 figure of 1963 cases, that indicates a total of 27 in the year 2019.
This nationwide study is notable for its focus on the role of edibles in pediatric cannabis overdose; it includes a separate category for edibles ingestion. The referenced melatonin study does not include that level of detail, which I think is an unfortunate oversight. I think it’s likely that sweetened chewables play a prominent role in both cannabis poisoning and melatonin cannabis poisoning- and also various other vitamins and supplements- in cases of toxic ingestions by small children. I view this as a fixable problem; there’s no need for that form of substance delivery for any of those products. The overdose problem would probably diminish markedly if they were banned from sale.
I’m old enough to remember getting “candy cigarettes” as Halloween candy. I also remember when were banned. The only rationale for their banning was their kinda-sorta resemblance to actual cigarettes- they were white cylinders dyed tan at one end, to resemble a cigarette filter. They were also much smaller than actual tobacco cigarettes, and no one would mistake one for the other. But that resemblance was enough to have the candies banned, on the basis that they were “grooming” children to view cigarettes as harmless, and possibly conditioning them in the direction of consumption. Compared to the current problem of child poisonings resulting from chewable sweets as a delivery method for compounds that are toxic when consumed in overdose, I think that ban is silly. But nobody ever complained that candy cigarettes were taken off the shelves, because it would have been even sillier to complain about it.
I think the situation of “active substance containing” chewable candies is much more serious; it rises to the level of being an Attractive Nuisance for children. It’s arguably even an attractive nuisance for adults; as an occasional melatonin sleep aid user (it works well, for me), I used to pop two or three chewables at once, before I found out that more than one was completely unnecessary. I was mostly prompted to eat more than one as, well, a bedtime snack…and then I had to brush my teeth, when I was done chewing them. (Or else, hmm? I learned about cavities the hard way.)
What’s up with that? This whole infantilization of adults, as if we won’t take our vitamins unless they’re formulated with sugar. 21st century modernity. A digression for another time, perhaps. I need to get back to my point: if it’s possible to cut incidents of toxic pediatric ingestion of cannabis, melatonin, and other supplements and vitamins- which number in the thousands (at minimum), annually- by 50% or more, simply by banning their compounding as chewable sweets and other candies, wouldn’t that be a good idea?
I think this is an especially important question in terms of the ramifications of cannabis legalization. Presently, pediatric cannabis overdoses are only a fraction of those resulting from melatonin. But melatonin is legally available in all 50 states, often huge jars of it with no childproofing. If cannabis becomes legalized nationwide, the number of pediatric overdoses is likely to rise considerably if THC products are sold as confections. It doesn’t matter if 85% of the poisoning incidents can be handled with a phone call. The other 15% present more serious problems- and the most severe of those cases have the potential to lead to tragic outcomes. It’s the numbers that are important here, not the percentages. Cannabis is renowned for its lack of toxicity, historically. But that long history preceded the advent of the potential for a toddler to eat a bag of THC gummies. Some of those cases have ended up in the ICU.
That’s Bad News, to be avoided. I would hope that even the cannabis industry can comprehend the liabilities of the resulting Bad Publicity. The industry needs to pay serious attention to this. If legal cannabis is associated with a death toll from pediatric poisoning, it’s no good hand-waving it with whataboutist statistical comparisons to aspirin and acetaminophen. The natural plant provides its own check on THC poisoning; raw cannabis is not an attractive edible. (I do get that toddlers can choke on anything, which means that attentive parents don’t keep pot buds within easy reach of tiny hands.) But the more THC is concentrated and the easier it is to swallow, the more problems are likely to arise, whether for children or adults. In my view, the across-the-counter commercial market should not be streamlining the process.
Cannabis consumers also need to think about this. If you’re that found of gummies, why not make your own? Does everything have to be consumer convenience, instant gratification, fast food nation? How invertebrate is that?
Sources
Some of the data I’ve found on melatonin and cannabis poisoning incident reports: I’m adding bold and italics for the information that I find to be most significant.
Melatonin, 2012-2021
Melatonin is an endogenous neurohormone that regulates the sleep-wake cycle (1). It is used therapeutically for insomnia in adults and for primary sleep disorders in children (2). Melatonin is regulated by the Food and Drug Administration (FDA) as a dietary supplement. Various synthetic melatonin preparations are widely available over the counter (OTC) in the United States with sales increasing from $285 million in 2016 to $821 million in 2020 (3). Children are at increased risk for melatonin exposure because of the supplement's widespread use and growing popularity as a sleep aid. In 2020, melatonin became the most frequently ingested substance among children reported to national poison control centers (4); however, more research is needed to describe the toxicity and outcomes associated with melatonin ingestions in children.
This study assessed isolated melatonin ingestions among the pediatric population (defined here as children, adolescents, and young adults aged ≤19 years) during January 1, 2012–December 31, 2021, using the American Association of Poison Control Centers’ National Poison Data System (NPDS). During the 10-year study period, 260,435 pediatric melatonin ingestions were reported to NPDS, and the annual number of ingestions increased 530%. In addition, pediatric melatonin ingestions accounted for 4.9% of all pediatric ingestions reported to poison control centers in 2021 compared with 0.6% in 2012. Pediatric hospitalizations and more serious outcomes due to melatonin ingestions increased during the study period, primarily related to an increase in unintentional ingestions among children aged ≤5 years. Five children required mechanical ventilation, and two died.
During 2012–2021, a total of 260,435 pediatric melatonin ingestions were reported to poison control centers, representing 2.25% of all pediatric ingestions reported during the same period. The majority of ingestions were unintentional (94.3%), involved males aged ≤5 years [no percentage given. ed.], occurred in the home (99.0%), and were managed on-site (88.3%) (Table). Most children (82.8%) were asymptomatic. Among those with reported symptoms, most involved the gastrointestinal, cardiovascular, or central nervous systems. Among 27,795 patients who received care at a health care facility, 19,892 (71.6%) were discharged, 4,097 (14.7%) were hospitalized, and 287 (1.0%) required intensive care. Among all melatonin ingestions, 4,555 (1.6%) resulted in more serious outcomes. [“More serious”- what exactly does that mean? ed.] Five children required mechanical ventilation, and two died. Both deaths occurred in children aged <2 years (3 months and 13 months) and occurred in the home. One ingestion involved intentional medication misuse; the reason for the other is unknown.
The number of pediatric melatonin ingestions increased 530% from 8,337 in 2012 to 52,563 in 2021, with the largest yearly increase (37.9%) occurring from 2019 to 2020 [excuse me. what is that? numerically, I mean. ed.] In 2021, pediatric melatonin ingestions accounted for 4.9% of all pediatric ingestions compared with 0.6% in 2012. The annual rate of ingestions per 100,000 U.S. population increased during the 10-year study period (Figure 1). This resulted largely from an increase in unintentional ingestions among children aged ≤5 years. There was also an increase in the number of ingestions requiring hospitalization and in those resulting in more serious outcomes (Figure 2). Most hospitalized patients were teenagers with intentional ingestions, whereas the largest increase in hospitalization occurred among children aged ≤5 years with unintentional ingestions…
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9169525/
addition and correction, with charts https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9290379/
[My grade of this study: D. Too many relevant metrics are missing. ed.]
Cannabis
Nationwide U.S. reported cannabis exposures, children 0-9 years 2017-2019
There were 4172 cannabis exposure cases among children aged 0 to 9 years during the study period, of which 45.7% (n = 1906) were associated with edible cannabis products (Table 1). (See below. ed.)
Children aged 3 to 5 years experienced the highest proportion of all exposures (43.1%). Most cases were exposed by ingestion (72.0%). A small proportion experienced major (1.4%) or moderate (15.4%) medical outcomes. In 2019, areas with legal adult cannabis use reported greater pediatric cannabis exposures compared with states without this policy: 975 exposures (8.9 per 100 000 population) versus 972 exposures (3.4 per 100 000 population). The proportion of calls due to edible cannabis product exposures was greater in legal states than in states without this policy: 62% vs 46% (P < .001).
Colorado 2021
incidents reported to Rocky Mountain Poison and Drug Safety (RMPDS)
total, all ages: 310
5 years and younger: 151
unintentional poisoning: 179
ingestion of edibles: 175
Washington State
Jan.1-Sept. 30, 2020
total, all ages 424
5 years and younger 122
[my grade of this study: B+. ed.]
https://marijuanahealthreport.colorado.gov/health-data/poison-center-data
[my grade of this study: A. ed.]
Washington State
https://www.wapc.org/data/data-reports/cannabis-data-report/
[my grade of this study: B. ed.]
Canada, 1/2016- 3/2021 (my full analysis has not yet been done. Study excerpt is below.)
Unintentional Pediatric Cannabis Exposures After Legalization of Recreational Cannabis in Canada
A similar phenomenon has been happening in Canada. A study published in JAMA Network Open examined all cannabis-related emergency department visits and hospitalizations in Ontario among children 9 and under between January 2016 and March 2021. The researchers found that after marijuana edibles became available in early 2020, a greater proportion of kids were hospitalized. Overall, 19 of the children, or 3.6 percent, were admitted to intensive care…
https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2787715
U.S. National Poison Control Call Statistics, 2021 (in the interest of context)
National Poison Control Call Statistics, 2021
https://www.poison.org/poison-statistics-national