Characteristics of Marijuana Usage in Sickle Cell Patients: A Nationwide Analysis
Authors: Roy Arya Mariam , Konda Manojna , Goel Akshay , Sasapu Appalanaidu 
Published: November 2019

Introduction
Sickle cell disease (SCD) associated pain is a significant health care issue in the United States which prompts physicians to prescribe opioids to help treat and prevent the recurrent acute painful episodes. Despite nationwide efforts to reduce narcotic pain medication usage, opioids still remain as the mainstay of pain management in SCD. Many SCD patients are using marijuana to help with their pain, anxiety, appetite, mood and sleep as per recent studies. Cannabinoids in marijuana interact with the body's endocannabinoid system which has receptors in almost every major bodily system. The effect of cannabinoids on these receptors reduces the signaling of inflammatory responses and also reduce cytokine production. Very few states have approved SCD as a qualifying condition for medical marijuana. But we are still unsure about the medical benefits of marijuana in SCD patients as there are very limited studies done so far. In our study, we sought to examine the characteristics and complications of marijuana usage in sickle cell patients.
Methods
The National Inpatient Sample database for the year 2016 was used to identify admissions with a primary diagnosis of SCD and we grouped patients into those who have a diagnosis of cannabis related disorders (CRD) and those who do not have the diagnosis. ICD- 10 codes are used for identifying the SCD patients and also for CRD. Statistical analysis was performed using STATA and univariate and multivariate analysis were performed. The outcomes that are studied included mortality, length and cost of stay, hospital regions and the association of marijuana use with anxiety, mood disorders. We also studied the association of marijuana with the complications of SCD such as sickle cell pain crisis, vaso occlusive crisis, acute chest syndrome, splenic sequestration, avascular necrosis.
Results
A total of 37,307 admissions with a principal diagnosis of SCD were identified, out of which 4.09% (N= 1526) had cannabis use disorders. The median age of patients with CRD was found to be 31.21 ± 0.3 when compared to 30.67 ± 0.09 in patients without CRD. Even though SCD admissions were more commonly seen in females when compared to males (61.78% vs 38.22%), cannabis use was seen more associated with males (57.97% vs 42.03%). The in-hospital mortality of SCD was less (0.56%) as compared to the mortality rates of other hematological malignancies. The association of cannabis use with in-hospital mortality was found to be not statistically significant. Also, the median length of stay was less in patients with CRD when compared to patients without CRD (4.88 ± 0.2 vs 5.11 ± 0.03) and also likewise cost of stay. Based on the hospital regions in the US, Cannabis use in SCD was seen more prevalent in South region (44%), then Midwest or north-central (26%), northeast (19%), west (10%) and the result was statistically significant (p= 0.003). The association of cannabis use was not found to be statistically significant with acute chest syndrome and splenic sequestration. Cannabis use was, however, found to be associated with the vaso occlusive crisis and avascular necrosis (OR=1.02, p=0.003 and OR= 1.14, 0.022 respectively) even though we cannot say that cannabis use could be a risk factor as there are other confounding factors like coagulopathy, chronic debilitating conditions. Interestingly, SCD patients with CRD have more risk of developing anxiety (OR= 2.32, p=0.000) and also mood disorders (OR= 2.5, p= 0.001) when compared to SCD patients without CRD. The difference persisted after adjusting for age, gender, race, co-morbidities.
Conclusion
Marijuana use is more seen in the southern and north-central regions in patients with SCD. Marijuana use was not found to be associated with in-hospital mortality in sickle cell patients. SCD patients are using marijuana mainly for alleviating their pain and sometimes for its euphoria effect. Our study showed that it can cause anxiety and mood disorders. The main limitation of our study was the moderate sample size for SCD patients with CRD. The impact and interaction between CRD and SCD complications need to be evaluated separately in a larger study to get accurate values. Large randomized control trials have to be done to assess if SCD qualifies for prescription of medical marijuana as it possesses benefits as well as risks.

Disclosures
No relevant conflicts of interest to declare.