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Pet Poison Helpline ©20173600 Amer i can B l vd . W. , #725 B loom in g ton , MN 55431www.pe tpo i sonhe lp l i n e . com
Pot and Pets:Updates on Marijuana Intoxication in
Dogs and Cats
Ahna Brutlag, DVM, MS, DABT, DABVTAssociate Director of Veterinary Services & Sr. Veterinary ToxicologistPet Poison [email protected]&Adjunct Assistant ProfessorDept. Veterinary Biomedical SciencesCollege of Vet. Med., University of Minnesota
September 19, 2017
Speaker IntroductionAhna G. Brutlag, DVM,
MS, DABT, DABVT
Associate Director of Veterinary Services
&
Senior Veterinary Toxicologist
Pet Poison Helpline
Minneapolis, Minnesota
&Adjunct Assistant Professor
College of Veterinary Medicine University of Minnesota
What is Pet Poison Helpline?• 24/7 animal poison control center
• Veterinary & human expertise
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Email us for info!
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Pet Poison Helpline® and Nationwide®
September, 2017
Nationwide® & PET POISON HELPLINE® working together
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Shared mission in highlighting the importance of preparing for accidents and poisonings in small animals
Addressing the cost of veterinary careNationwide® covers the $59 Pet Poison Helpline® fee when an insured pet is brought in to your hospital for care
Enabling best medicinePet owners with Nationwide®
spend twice as much on their pets than those without pet insurance
Nationwide® pet insurance claims in 2016
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Incidence rate of “poisonings of plant origin”
1230 pets affected
Average claim amount $562
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Nationwide’s Whole Pet® with Wellness!
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It’s serious coverage—which means serious business for you.
Coverage Highlights:
• One annual deductible—not per incident• 90% reimbursement on veterinary expenses• All veterinary exams including specialty and emergency visits• All hospitalization and surgeries including preventive and elective procedures• All injuries, illnesses, and cancer including hereditary and congenital conditions• All diagnostic testing including xrays, MRIs, CAT scans and ultrasounds• All prescribed medications, nutritional supplements and therapeutic diets• All preventive care including vaccinations, teeth cleaning and spay/neuter
90% reimbursement with $250 annual deductible
PET POISON HELPLINE
Objectives
• Marijuana poisoning in dogs & cats
– Sources
– Pharmacology/physiology
– Clinical signs
– Treatment
• CBD vs THC
• FDA perspective
Audience Poll
PET POISON HELPLINE
Historical medical use
• Medical use first 2700 BCE
• First legit medical use in U.S., 1851
• Marihuana Tax Act 1937
• Removed from USP in 1942
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PET POISON HELPLINE
Case #1
• “Max”: Vomited at home. Extreme sedation, HR 80‐90 with normal pulses but heart is “beating hard”
• “Scruff”: ataxic, dribbling urine, head bobbing
• Dogs alone all day, present ~4 pm
• Owner denies “toxin” exposure
“Max”, 4 yo, 70 lb, MN Labradoodle “Scruff”, 5 yo, 20 lb, MN
mixed breed
PET POISON HELPLINE
PET POISON HELPLINE
Marijuana chocolate chip cookies!
3 dozen cookies total, ~2 dozen missing
1 ounce medical marijuana
10 ounces of Nestle chocolate chips
PET POISON HELPLINE
PET POISON HELPLINE
Marijuana Trends at PPH
• 448% increase in cases over 6 yrs
PET POISON HELPLINE
Food
Plant
MedicalUnknown
SOURCE
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PET POISON HELPLINE
“Medibles”
• #1 source
• 70% involve chocolate
• Top sources– Brownies & cookies
– Chocolate bars/choc covered fruit
– Gummi bears
– Butter/coconut oil
• Risk– High concentration THC
– Better bioavailability (butter/oil)
– Co‐ingestants
PET POISON HELPLINE
PET POISON HELPLINE
Dried plants
• #2 source
• Not your parent’s plants…
– Up to 30% THC
– Joint = 15‐30 mg THC
• Vomiting common
Mature plant, courtesy of Minnesota Medical Solutions
PET POISON HELPLINE
PET POISON HELPLINE
What is “medical cannabis”?
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PET POISON HELPLINE
THC Concentrates
• 50‐90% THC
• Smoked or vaped
• High risk to pets
http://honestmarijuana.com/trichomes/
PET POISON HELPLINE
PET POISON HELPLINE
Marijuana alternatives
• “K2” & “Spice”
• Smoked
• In 2010 became popular in US as “legal highs”– Sold in gas stations, online, head shops, etc.
– Potency varies dramatically
• Contain– Synthetic cannabinoids (hundreds of options)
• CB1 and CB2 agonists
• +/‐ NMDA
– Variety (10+) herbs
PET POISON HELPLINE
Clinical Signs in Dogs/Cats• Common
• CNS depression • Ataxia• Bradycardia (occasional tachycardia) • Urinary incontinence• ~25% develop agitation• Glazed expression
• Less common• Vocalizing, vomiting, diarrhea, hypothermia, hypersalivation, mydriasis, hyperesthesia, seizure (?), coma
PET POISON HELPLINE
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PET POISON HELPLINE
Marijuana Intoxication in Pets
PET POISON HELPLINE
Diagnostics
• Signs + history
• Any tests?– CBC/chem/UA typically normal
– Human urine drug test?
– Best: Vet diagnostic lab• GI contents
• Urine/serum
• Liver/kidney
PET POISON HELPLINE
Teitler JB. Evaluation of a human on‐site urine multidrug test for emergency use with dogs. J Am Animal Hosp Assoc. 2009
PET POISON HELPLINE
Marijuana—Testing
• Dogs: Often false negative on OTC urine test
• False positives in humans caused by
– Ibuprofen
– Naproxen
– Pets too?
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PET POISON HELPLINE
Marijuana–Treatment
• Decontaminate– Emesis—may be – difficult– Activated charcoal
• Supportive care!– No antidote– Monitor body temp– IV crystalloids for perfusion
• Agitation/seizures – Diazepam– Acepromazine
• Monitor
– Temp
– Heart rate
– Blood pressure
• Lipid therapy?
– Fat soluble agent
– 20% intravenous lipid emulsion
PET POISON HELPLINE
DEA Drug Schedules
• Schedule I– No medical value. High potential for abuse.– Heroin, LSD, ecstasy
• Schedule II– Medical value. High potential for abuse.– Cocaine, hydromorphone, methamphetamine, Adderall, Ritalin
• Schedule III– Moderate to low potential for abuse. – Ketamine, testosterone, anabolic steroids
• Schedule IV– Low potential for abuse/low risk of dependence– Tramadol, diazepam, alprazolam (Xanax)
• Schedule V– Lower potential for abuse than IV, sold in limited quantities– Robitussin AC (codeine), Lomotil, Lyrica
Audience Poll
PET POISON HELPLINE
PHARMACOLOGY & PHYSIOLOGY
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PET POISON HELPLINE
Endocannabinoids
• Naturally‐occurring substances that act within the same signaling system as exogenous cannabinoids
• Two main “endocannabinoids”– Anandamide = N‐arachidonoylethanolamine = AEA
– 2‐arachidonoylglycerol = 2‐AG
PET POISON HELPLINE
Endocannabinoids
• Produced on‐demand in response to stress
• Largely inhibit neurotransmitter release
PET POISON HELPLINE
Cannabinoid receptors
CB1
• Primarily in CNS
• Also in smaller concentrations other cells such as lymphocytes, retinal and endocrine cells.
• Activation = psychoactive effects
CB2
• Concentrated in the immune system and the non‐nerve cells that support the CNS
• Primary effect is anti‐inflammatory and immunosuppressive
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PET POISON HELPLINE
Exogenous Phytocannabinoids
THC
• Psychoactive
• “Ideal” drug– Lethal dose = 1000x effective
dose
– Fatalities are rare
– Death seen 3‐9 gm/kg (dog)
• Binds both CB1 & CB2
• Indications same as for people??
CBD
• Not psychoactive
• No known LD50
• Hinder endocannabinoid breakdown (synergistic)– Augment natural
endocannabinoids
• Anecdotal dog dose = 0.02‐0.05 mg/kg twice daily
• Pediatric dose: 5‐25 mg/kg/day
PET POISON HELPLINE
Therapeutic Indications in People(non‐exclusive)
THC (CB1 & CB2 receptors)
• Weight loss/wasting
• Decreased appetite
• Nausea
• Anxiety
• Insomnia
• Pain
CBD (augment endocannabinoids)
• Seizures
• Pain
• Inflammation
• Immune mediated disease
PET POISON HELPLINE
Pet products with CBD
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PET POISON HELPLINE
PET POISON HELPLINE
Current Canine Research with CBD
• Colorado State University
– Safety, toxicity and pharmacokinetic study (in review)• 2016, 30 beagles
• CBD oil—capsule, tincture, transdermal cream
• Tincture showed most promise for safety
• Adverse effects = diarrhea and elevated liver enzymes
– Efficacy of CBD for canine osteoarthritis (enrolling)
– Efficacy of CBD for canine epilepsy (enrolling)
• University of Pennsylvania
– Unspecified trials with Therabis brands
http://www.thecannabist.co/2017/07/12/cbd‐pet‐products‐dogs‐cannabidiol‐research/83474/
PET POISON HELPLINE
DEA Drug Schedules
• Schedule I– No medical value. High potential for abuse.– Heroin, LSD, ecstasy
• Schedule II– Medical value. High potential for abuse.– Cocaine, hydromorphone, methamphetamine, Adderall, Ritalin
• Schedule III– Moderate to low potential for abuse. – Ketamine, testosterone, anabolic steroids
• Schedule IV– Low potential for abuse/low risk of dependence– Tramadol, diazepam, alprazolam (Xanax)
• Schedule V– Lower potential for abuse than IV, sold in limited quantities– Robitussin AC (codeine), Lomotil, Lyrica
Audience Poll
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PET POISON HELPLINE
Problems with CBD
• Poor oral bioavailability, 13‐19% dog
• P450 inhibition (2B in mice, 34A & 1A1 in humans)– Drug‐drug interactions similar to ketoconazole
• Decreased spermatogenesis (high doses)
• Rhesus macaque– 150 mg/kg IV = tremors, hypopnoea
– 200 mg/kg IV = resp arrest and cardiac failure
– 30‐300 mg/kg oral x 90 days• ↑liver, kidney, heart weights
• ↓tes cular size, ↓ spermatogenesis
Samara, et al. Pharmacokinetics of cannabidiol in dogs. Drug Metab Dispos. 1988Rosenkrantz et al. Toxicity of short‐term administration of cannabinoids to rhesus monkeys. Toxicology and applied pharmacology. 1981
PET POISON HELPLINE
PPH Experience with CBD
• #1 source = oil (topical or oral)
– Can be mixed with essential oils
• Signs: Variable
– Minor GI signs, ataxia, vomiting, “seizures”
• Treatment: Supportive
PET POISON HELPLINE
Summary
• Possible poisoning– Marijuana or THC
– High THC concentrates (butter‐based, medical)
– Co‐ingestants (e.g. chocolate)
• Less concerning– CBD alone in trustworthy products
• Treatment is primarily supportive
• Quality of products
• Legal status remains Schedule I
PET POISON HELPLINE
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Sign up for…Quarterly Newsletters Video Series
Tox Goodies!Free to order: [email protected]
Our iPhone appDetails 200+ toxins
$1.99
Blackwell’s Five‐Minute Veterinary Consult Clinical Companion:
Small Animal Toxicology 2nd Edition
Drs. Lynn Hovda, Ahna Brutlag, Robert Poppenga, Katherine Peterson
www.wiley.com/go/vet
Paperback | May 2016 | 960 pages | 978‐1‐119‐03654‐8 | $109.99 ∙ CAN $120.99
• Provides concise, bulleted information focused on the most important facts needed when treating a poisoned cat or dog
• Carefully organized for ease of use in an emergency, with important toxicants arranged alphabetically within categories
• Details clinically relevant information on the most common toxicants encountered by small animals
• Presents a wealth of color photographs to aid in plant identification
• Includes 14 new topics to this edition covering cyclosporine A, sleep aids, tacrolimus, bath salts, synthetic marijuana, poisonous lizards, imidacloprid, spring bulbs, and sodium monofluoroacetate
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PPH is hiring!
• Veterinary technician openings
• 22 states– Work from home!
• More info:petpoisonhelpline.com/veterinarians/job‐opportunities/
• Visit our booth:– Southwest Veterinary Conference (this week)
– The Wild West conference in Reno (October)
– Illinois State Conference (November)
– North Carolina State Conference (November)
Thank you for attending!
CE credit FAQs1. When will I get my CE certificate? We’ll email it to you by the end of the day tomorrow.
2. I attended the webinar but wasn’t the person who logged in. Can I still get interactive CE credit? Yes. Send your name and email address to [email protected] by 1pm central time on September 20, 2017 (strict deadline).
3. Can I watch the recorded webinar online for CE credit? Yes. You can receive non-interactive CE credit. Go to the “For Vets” page on our website, www.petpoisonhelpline.comfor more info.
Comments? Questions? Email us! [email protected]