Dr. Tina Wismer (Senior Director of the ASPCA Animal Poison Control Center) and Dr. Andy Roark discuss the rising rates of Maijuana toxicity in dogs, the cause, and the staples of effective treatment.
LINKS
PRACTICE OWNER SUMMIT: www.unchartedvet.com/pos2021
Uncharted Podcast on iTunes: podcasts.apple.com/us/podcast/the-…st/id1449897688
Charming the Angry Client On-Demand Staff Training: drandyroark.com/on-demand-staff-training/
What’s on my Scrubs?! Card Game: drandyroark.com/training-tools/
Dr. Andy Roark Swag: drandyroark.com/shop
All Links: linktr.ee/DrAndyRoark
ABOUT OUR GUEST
Tina Wismer, DVM, MS, DABVT, DABT, is the Senior Director of the ASPCA Animal Poison Control Center. She earned her undergraduate degree from Ohio’s University of Findlay and received her DVM from Purdue University. Dr. Wismer worked in both small animal and emergency practice before joining the ASPCA Animal Poison Control Center in 1998. Dr. Wismer is a Diplomate of the American Board of Toxicology and the American Board of Veterinary Toxicology. She is an adjunct instructor at the University of Illinois, a visiting professor at St. Matthews University (Grand Cayman), a consultant for VIN (Veterinary Information Network) and a Master Gardener.
Editor: Dustin Bays
www.baysbrass.com
@Bays4Bays Twitter/Instagram
SHOW TRANSCRIPT
Dr. Andy Roark:
Welcome, welcome, welcome to The Cone of Shame Veterinary Podcast. I am your host, Dr. Andy Roark. I am back today with my friend, Dr. Tina Wismer. She is the senior director of the ASPCA Animal Poison Control Center. We talk about rising rates of marijuana toxicity. I saw one of these last week. The numbers are up, and that’s tied to legalization of marijuana, and just an increased prevalence in it, in daily life of many people. And we want to run through it, and then get into the staples of therapies. Make sure you’re up to date on everything you need, what to expect, what to tell people if they’re calling and asking about it, and just generally, what do you need to know, in a short little bite sized bundle. That’s what we got. Let’s get into this episode.
Kelsey Beth Carpenter:
[Singing] This is your show. We’re glad you’re here. We want to help you in your veterinary career. Welcome to The Cone of Shame with Dr. Andy Roark.
Dr. Andy Roark:
Welcome Dr. Tina Wismer, thanks for being here again.
Dr. Tina Wismer:
Thanks for inviting me.
Dr. Andy Roark:
Oh, it’s always my pleasure, I love to have you. You are the senior director of toxicology at ASPCA Animal Poison Control, for those who don’t know. You’ve been a regular guest on The Cone of Shame. I think this is our fourth episode together, out of a hundred, basically. We have a hundred and a couple, so you’re 4% of the podcast history.
Dr. Tina Wismer:
Woo hoo.
Dr. Andy Roark:
Right here.
Dr. Andy Roark:
Well, I wanted to jump on and talk to you today about, I was always looking at trends and what’s common. What are we seeing in the exam rooms today? And that’s what I’d like to bring you in and talk about on the podcast. Let’s talk a bit about legalization of marijuana across the country, and this has sort of been weird state by state creep. But I wanted to talk to you, as it becomes more normalized and legal, and we’vve got CBD dispensaries and things like that. Are we seeing fall outs of that, from a toxin basis, from an emergency medicine basis?
Dr. Tina Wismer:
Certainly. We have seen an increase in marijuana cases, just about every year, since legalization started. And I can tell you like between 2018 and 2020, the number of cases reported to animal poison control has more than doubled.
Dr. Andy Roark:
Okay.
Dr. Tina Wismer:
And we certainly don’t get all of them that are reported. I think part of it has to do with it being legal, and people are more likely to admit it. Yep, my dog got into marijuana. Right, there’s less of a stigma.
Dr. Andy Roark:
Well, let’s unpack that for a second. Do you think that these are new cases, meaning marijuana is more common and they’re more often getting it, or do you think that we’ve always been seeing marijuana toxicity cases, but people just didn’t admit it, and so we were having these kind of veiled conversations or veterinarians were treating unknown toxins. So yeah, help me with that a little bit.
Dr. Tina Wismer:
Sure. I think it’s a little bit of that. I definitely think that it’s more easily available. So as you said, there’s, dispensaries in, I shouldn’t say on every corner, but it seems like driving down the highway with all the billboards, that they’re on every corner.
Dr. Andy Roark:
Yeah.
Dr. Tina Wismer:
And I think that with less stigma, more people are willing to have it out in the open, and also that we’re dealing more with concentrated forms of THC now. A lot of the edibles have very high amounts of THC.
Dr. Andy Roark:
Okay, so let’s talk about that a little bit. It makes sense. Now that there’s dispensaries out in the open, and they’re selling a variety of products, hyper concentrated products, are they common? I mean, what percentage of toxin cases with marijuana do you think we’re seeing, that are this more processed, more potent version?
Dr. Tina Wismer:
So with cats, we’re still seeing a lot of plant material. Cats get into the baggie or cats eat the joints and become symptomatic. Dogs, it’s all about the edibles and especially because a lot of edibles contain chocolate, then we have to think about treating both chocolate and THC toxicosis.
Dr. Andy Roark:
So for those of us who are not in marijuana legal states, can you give us a quick breakdown of edibles, kind of what they are. Are these gummy products, chocolate products, anything that you can imagine? Are there trends and variables? Yeah. If you’re somewhere like South Carolina, it does not have legal marijuana. So yeah. I, I wonder if veterinarians there would be as familiar with the packaging of marijuana as in other states.
Dr. Tina Wismer:
Right? So you still can buy plant material, but you mentioned some of the things. You can get gummies, you can get brownies, you can get chocolate bars. You can get oil, which is a concentrated THC product. You can get wax, which is an even more concentrated THC product, and it does, it looks very waxy. All of these can be either ingested or smoked, and dogs seem to love them.
Dr. Andy Roark:
Well, I’m resisting their urge to drive this conversation more deeply into wax and how it’s used, because that’s not what we’re here for. I’m going to have to do some Googling after we get off the podcast. Okay.
Dr. Tina Wismer:
And one of the issues is that when people buy a brownie, or a chocolate bar, it’s considered to be multi dose. The typical THC dose for people is 10 milligrams, but a lot of these chocolate bars have like 180 milligrams. You’re just supposed to take a bite of it.
Dr. Andy Roark:
That’s terrible. Let’s let me jump in here for a second, that’s awful. The idea that I’m going to take a bite of a chocolate bar and stop, it’s not going to happen, makers of THC products, you need to be more responsible.
Dr. Tina Wismer:
Right, and dogs certainly don’t stop either. Right?
Dr. Andy Roark:
So what me and Labrador retrievers have in common is, we’re not stopping when we get a brownie, like we’re going to, we’re eating. The serving size is how big the pan is, and everybody should be open about that.
Dr. Andy Roark:
Hey guys, I just want to jump in real quick with some housekeeping wanted to let you know what’s going on. The big thing is December 2nd through the 4th in Greenville, South Carolina, in person, the practice owner summit is going on. This is uncharted practice owner summit. It is a gathering of practice owners. It is only open to practice owners. That’s not business owners, that’s practice owners. It is going to be a summit, which means there is going to be some workshops. There are going to be some hands on working groups, and it’s going to be a lot of discussion. It’s going to be a lot of collaborative problem solving and talking about your practice and working on your practice. So if you want to get re-energized, if you want to get re-motivated, if you want to connect with other people who are practice owners, talk about a real benefit.
Dr. Andy Roark:
We talk about knowledge is power and that’s true, but relationships are power as well. And, and the great thing about the uncharted, especially the summits, we really lean into the relationship. So come surround yourself with people who do what you do. Surround yourself with people who understand the struggles that you have, and get re inspired and re-motivated and reinvigorated. Get yourself a new lifeline or two, or three, or five, or twin, or 20 people who are there to help you and support you. That’s what we’re doing. Anyway, link in the show notes. I would love to see you there, registration closes on November the 15th. If you have friends who are practice owners, don’t let them miss out, put this on their radar. Be like, Hey, you need to look at this, it is really going to be awesome, and God, it’s going to feel good to get back together in person and see these smiling faces. Anyway, guys, take care and let’s get back into this episode.
Dr. Tina Wismer:
Our typical marijuana dog presents to you with the triad of classic signs. It is ataxic. It is hyper aesthetic ,and it’s dribbling urine, classic triad. Now we do have other dogs, about 25%, become a little more agitated, instead of lethargic.
Dr. Andy Roark:
Okay.
Dr. Tina Wismer:
But yeah, the classic triad.
Dr. Andy Roark:
It’s still a mixed bag. I’m assuming as far as what type of report you’re going to get from the pet owner. Yeah. So when marijuana’s legal, I’m sure you’re more likely to hear, yes. This is what happened. Are there common cover stories for nonlegal states that’s code for like my dog ate my stash.
Dr. Tina Wismer:
Right, typically its the neighbors threw it over the fence, and we’re like really. As one of my coworkers says, junkies don’t share. So it’s not uncommon that we’ll get, oh, it’s the neighbors marijuana. Okay, that’s fine. I don’t really care.
Dr. Andy Roark:
At this point, I jump in and help the high school kid out. I’m like, look, this happens all the time. Neighbors are always throwing marijuana into other people’s yards, and it just happens every day.
Dr. Tina Wismer:
Yes. Now, one of the weird things that does happen, so I have to mention it, and it’s kind of gross, is that people who do edibles, the metabolites that are passed in the stool are active. So we have dogs that will go to the park, or out hiking, and they eat human stool, and they get marijuana toxicosis.
Dr. Andy Roark:
That’s the case I would get, I would 100% get the hikers who come in with their dogs, stumbling around like I’m-. So like you’re a hiker, I’m sure that your nature interests extend to marijuana. And they would be like, no. I would only find out after the dog had thoroughly licked my face for like 10, that’s when I would make the discovery.
Dr. Tina Wismer:
Nice.
Dr. Andy Roark:
So, okay. Clinical science presentation, what’s my diagnostic workup on this dog?
Dr. Tina Wismer:
So we really don’t have any good diagnostic tools. The over the counter tests, the urine tests, really with dogs give false negatives, because dogs make different metabolites than people do. So typically we treat based on history and clinical signs.
Dr. Andy Roark:
So are you saying those tests are without value, meaning that they’re almost always going to be negative? Or do you mean that when there’s an error, it’s negative?
Dr. Tina Wismer:
They’re almost always negative.
Dr. Andy Roark:
All right.
Dr. Tina Wismer:
The time it can be positive is when they eat human stool, because that’s the metabolite that they’re testing for.
Dr. Andy Roark:
Okay, so that’s a test specifically for that type of ingestion, let’s write that down, you don’t know when you’re going to need that. That’s a pearl that maybe we’re going to need to break out.
Dr. Tina Wismer:
Definitely. So, we used to always joke about treating these guys with Pink Floyd and Doritos, that’s how you treat a [inaudible 00:11:21]. Forget about them in the back, don’t worry about it, but it’s changed with dogs that get into edibles,
Dr. Andy Roark:
Right.
Dr. Tina Wismer:
Because of the huge amount of THC, we can now see some of these dogs becoming severely hypotensive and comatose.
Dr. Andy Roark:
It seems like now, especially with being out in the open, is probably more likely that you can actually get some information about how much was consumed, in a way that you probably couldn’t in the past. Is that true, and how is that useful?
Dr. Tina Wismer:
Yes. So people will tell you, oh, he ate a brownie that was four doses, or they ate a chocolate bar that was 16 doses. So you can at least get an idea of how much did they ingest? Yes, this is going to be a serious problem. Or, if it’s just one human dose, many times you can monitor them at home. If they can walk around, they respond to their name, they can eat, they can stay home, but if they can’t ambulate, they need to come in and see you.
Dr. Andy Roark:
Okay, all right. What kind of timeline are we talking about usually before we’re going to see significant clinical signs?
Dr. Tina Wismer:
Sure, so signs can start within about 30 to 60 minutes after ingestion, and one of the other differences with dogs that get into edibles, is that they can actually be symptomatic for up to three days, post ingestion.
Dr. Andy Roark:
Okay, that seems important for setting expectations.
Dr. Tina Wismer:
It does. Now, if the dog is recovering and it’s able to get up and it’s still just stumbling, then yeah, we can send it home. But the dogs that are comatose, we treat with lipids. So they get the intravenous lipid infusion.
Dr. Andy Roark:
Okay, talk to me more about that. I’ve never given a dog intravenous lipid infusion.
Dr. Tina Wismer:
Sure, so this is a 20% lipid solution that you can use for partial parental nutrition, and it’s been used in toxicology for fat soluble toxins. So THC is highly fat soluble, highly lipid soluble. So the thought is, that the lipids bind the THC so it can’t get to the receptors and the CNS, and then it’s metabolized and removed from the body. Dosing wise, it’s nice because with 20% solution, you can actually give it through a peripheral vein. You can use your cephalic vein. You don’t need a central line.
Dr. Andy Roark:
All right.
Dr. Tina Wismer:
You give an initial bolus, one and a half mills per kilo, followed by a constant rate infusion of 0.25 mills per kilo, per minute, for about 30 to 60 minutes, and then you stop it. You wait for about four to six hours. If the animal is still symptomatic, you draw a blood sample. If it’s like PMIC, you have to wait. But if the serum is clear, then you can go ahead and re dose your lipids.
Dr. Andy Roark:
Okay, given that dogs can show signs for three days, is there a window in which I would give this and not give it? So saying for example, the pet owner is like, hey, I work 12 hour shifts, and I’m pretty sure he ate it the moment I left the house and now it’s been 16 hours. Is there a window where you go, okay this window has closed.
Dr. Tina Wismer:
Yeah. So the dogs that need lipids are the ones that are comatose or hypotensive. If they don’t hit that point within the first 12 to 18 hours, they’re not going to. They’re just going to be sedated and wobbly and we can typically monitor those at home, but yeah, the other ones will come to you pretty quickly. You give them lipids, and then they recover.
Dr. Andy Roark:
Okay, are there any sort of side effects of lipid treatment that we should be aware of? Is this one of those supportive measures that may have its own sort of fall outs?
Dr. Tina Wismer:
It does, right, because as we know nothing we do as benign. With lipids, there is an increased risk of pancreatitis, and we can see some elevated liver values. The biggest risk is if you have given other medications to treat other clinical signs, if those medications are also lipid soluble, it could take them away. So not in this, in marijuana toxicosis typically, we’re not using any other additional medications, but let’s say you had a dog that got into amphetamines, it ate the child’s ADHD medication.
Dr. Andy Roark:
Okay.
Dr. Tina Wismer:
It’s very agitated. You give it acepromazine, calms it down. Well, if we gave lipids to animal, it would scoop up the acepromazine first and we would see our animal become agitated again from the amphetamines.
Dr. Andy Roark:
Gotcha, okay, any interactions that we tend to see with medications we’d use for supportive care of GI symptoms. So let’s say that we’ve got, our chocolate dogs, things like that, and we’re worried about having diarrhea, having vomiting. Are there medications that I might normally reach for, that I don’t want to reach for, if I’m doing lipid therapy?
Dr. Tina Wismer:
So it can inhibit things like serenia, things that are going to act within the CNS, but things that you are given orally, like your proton pump inhibitors or things like that, it has minimal effects.
Dr. Andy Roark:
Is there benefits of inducing vomiting, or things like activated charcoal? Are there places for either of those?
Dr. Tina Wismer:
That’s a great question. So marijuana is actually a antiedemic. You think about people who are undergoing chemotherapy, they use THC to help decrease the nausea. So getting these guys to vomit, can be difficult. If you are going to induce vomiting, we have best effects using something that acts locally like peroxide, apomorphine, and those new ropinirole eye drops to induce vomiting, don’t seem to work. Charcoal, we rarely give it with marijuana, unless it’s a huge dose and we’re worried about signs and we couldn’t induce vomiting.
Dr. Andy Roark:
Gotcha, okay. Well that makes sense. Are there common mistakes that you see practitioners making, that you would warn against?
Dr. Tina Wismer:
I think the thing is that with our supportive care, we need to make sure that these guys stay warm, because they can get quite cold. And if they’re cold, we’re going to see decreased metabolism. So they’ll be with you longer, so keep them warm.
Dr. Andy Roark:
Yeah. That totally makes sense, that’s super helpful. Awesome. Well, Tina, where can people find you and learn more about ASPCA poison control?
Dr. Tina Wismer:
ASPCA.org, and we’ve got articles about treating many different toxins on there, including marijuana.
Dr. Andy Roark:
Thanks again for being here. I really appreciate your time.
Dr. Tina Wismer:
You’re welcome.
Dr. Andy Roark:
And that is our show. That’s what we got for you. I hope it was useful. I hope it was helpful. Guys, it was good to get little refreshers, quick to the point, super useful, knowledge lumps that we can just pop in our mouth on the way to work. It’s a little knowledge lump for you. If I ever have a candy, I’m going to call it a knowledge lump, and how can I fail? I think that’s amazing. Anyway, guys, I’d love to see you, if you’re a practice owner. I’d love to see you in December at our practice owner summit, for uncharted. Remember registration closes on the 15th of November, link in the show notes. Everybody else, I’d love to see you when I get to see you.
Dr. Andy Roark:
I hope life treating you well. And I hope you are-. God, I hope you’re not already hearing Christmas music because I am, the day after Halloween, my radio station I listen to in the morning. When the alarm comes on, it switched to the Christmas station and I just can’t handle it. I hope that you’re not dealing with the stress, but if you are, let’s stick together. We’ll get through this, ultimately one way or another. We’ll survive the holiday music in November trend. So anyway, that’s enough of that. That’s a whole nother podcast. Guys, take care of yourselves. I’ll see you later. Bye.
