Alcohol intoxication is a common comorbidity in traumatic brain injury,with 30%–50% of all TBIs occurring under the influence of alcohol. Preclinical studies have indicated that ethanol pretreatment results in a faster recovery with better outcomes after TBI. However, numerous clinical studies have examined the relationship of alcohol exposure and risk of mortality in patients with TBI with inconsistent results: some studies have found a positive blood alcohol content had no significant relationship with mortality, while others have found that mortality rate due to TBI with alcohol intoxication is lower compared to those without alcohol intoxication. Additionally, marijuana has been implicated as a major risk factor for all types of trauma. The anti-inflammatory properties of endocannabinoids have been demonstrated to provide neuroprotective effects after TBI. A previous study found a positive tetrahydrocannabinol screen to be independently associated with survival after TBI. While the risk of injury from alcohol,marijuana,and other drugs in combination is increased,the neuroprotective effects of combined marijuana and alcohol have not yet been studied. Few studies have determined the effects of combined drug use on mortality after TBI, and the relationship of combined alcohol and THC on TBI outcomes remains unknown.The aim of this study is to use a data-set of regional data from 26 regional hospitals to evaluate the combined effects of a positive THC and alcohol screen on patient outcomes after sustaining mild, moderate, and severe traumatic brain injury.
Our results demonstrate TBI patients with a positive toxicology for THC and alcohol were found to have significantly lower mortality at discharge when compared to patients with no substances.However,mobile vertical rack in a multiple logistic regression, combined BAC and drug class were not found to be independent predictors of mortality at discharge, while age, GCS, ICU days, ISS, and LOS were found to be independent predictors of mortality. Though somewhat contested, the effect of alcohol intoxication on patients with TBI has been shown in many studies to improve mortality. A meta-analysis of observation studies by Raj et al. included 11 studies with 95,941 patients, and found that positive BAC was significantly associated with lower mortality rates in moderate to severe TBI. Conversely, a meta-analysis examining the impact of day-of-injury alcohol consumption on outcomes after TBI by Mathias et al., found that positive blood alcohol levels were associated with significantly poorer cognitive outcomes and higher levels of disability. Overall, they found that day-of-injury alcohol consumption is not consistently associated with better or worse outcomes, other than subtle cognitive deficits. The effect of marijuana on TBI is far less studied than alcohol, though many preclinical studies have shown THC is associated with neuroprotective effects including alleviation of brain edema, attenuated cell apoptosis, improved neurobehavioral function, and enhanced cerebral blood flow. These effects are partially attributed to the upregulation of NFE-2 factor, which regulates the cellular antioxidant response, following TBI and modulation of the mitochondrial apoptotic pathway. A study by Nguyen et al. found that after adjusting for differences between study cohorts, a positive THC screen was found to be associated with increased survival after TBI. With the individual effects of alcohol and marijuana on TBI still contested, their combined effects on mortality have not been explicitly studied.
DiGiorgio et al. investigated the impact of drug and alcohol intoxication on GCS assessment in patients with TBI, and found that intoxicating substances can confound GCS score with impaired patients having a significantly higher mean change in GCS score compared with patients with a negative screening test. A retrospective review by O’Phelan et al. studied the impact of substance abuse on mortality in patients with TBI by comparing amphetamine, benzodiazepine, narcotic, cannabis, cocaine, alcohol, polydrug, and polydrug, excluding alcohol, and found that methamphetamine use was a significant predictor of mortality. They also demonstrated that patients who tested positive for methamphetamine were also more likely to test positive for cannabis and hypothesized the synergistic effects of methamphetamine and THC may have contributed to overall lower mortality in this cohort. In our study we employed a logistic regression model that controlled for age, gender, GCS, ICU days, LOS days, ventilator days, ISS, and complications and found neither THC nor a positive BAC screen to be independent predictors of mortality, which is consistent with the analysis by O’Phelan et al.Over the last decade, marijuana use and the legalization of marijuana, medically and recreationally, has continued to increase in the United States.1 The internet is rife with claims of the beneficial effects of marijuana on several aspects of sexual function including libido, arousal, and orgasm. However, our scientific research on the effects of marijuana on sexual functioning is limited. Recently Palamar et al2 evaluated self-reported sexual effects of marijuana, ecstasy, and alcohol use in a small cohort of men and women aged 18e25. They found that the majority of marijuana users reported an increase in sexual enjoyment and orgasm intensity, as well as either an increase or no change in desire.2 Endocannabinoids, which are structurally similar to marijuana, are known to help regulate sexual function.3 The cannabinoid receptor, discovered in the 1990s, has been mapped to several areas of the brain that play a role in sexual function.3 Cannabinoids and endocannabinoids interact with the hormones and neurotransmitters that affect sexual behavior. Although these interactions have not been clearly illuminated, some studies in rodents have helped to clarify the relationship between cannabinoids and the hormones and neurotransmitters that affect sexual behavior.Although there is less data on human subjects, some studies have measured patient’s perceptions of the effects of marijuana on sexual function. Studies have reported an increase in desire and improvement in the quality of orgasm.
Most recently, Klein et al6 evaluated the correlation between serum levels of 2 endogenous endocannabinoids and found a significant negative correlation between endocannabinoids and both physiological and subjective arousal in women. Sumnall et al7 reported that drugs such as cannabis and ecstasy were more frequently taken to improve the sexual experience than was alcohol. The primary aim of this study was to determine how women perceive the sexual experience, specifically overall sexual satisfaction, sex drive, orgasm, dyspareunia, and lubrication, when using marijuana before sex. The magnitude of the change was also evaluated. The secondary aim sought to understand the effect of the frequency of marijuana use, regardless of marijuana use before sex, on satisfaction across the different sexual function domains.Women were enrolled prospectively from a single, academic, obstetrics and gynecology practice from March 2016eFebruary 2017, and their data were retrospectively reviewed. The protocol was approved by the Institutional Review Board. Eligibility criteria consisted of being a female, 18 years of age, and presenting for gynecologic care irrespective of the reason. Each participant completed a confidential survey, including demographic data without unique identifiers after their visit, which was placed in a sealed envelope and dropped in a lock box at the clinic. The Sexual Health Survey was developed for the purpose of this study based on the aims of the study. There are several validated tools for evaluation of sexual function. The Female Sexual Function Index 8 assesses several domains of sexual function, but it does not address specifically marijuana or other substance usage. The Golombok Rust Inventory of Sexual Satisfaction 9 specifically relates to vaginal intercourse, but, for purposes of this study, sexual activity was deliberately left open-ended and not restricted to vaginal penetration. In addition, the goal was not to measure whether women had sexual dysfunction, which the FSFI addresses, but to assess basic questions regarding overall sexual activity. To limit bias, the authors embedded the questions about marijuana deeper into the questionnaire.
If these specific questions had been added to the standard FSFI, there was concern that the questionnaire would have been too long and that the patients would get questionnaire fatigue and not finish or answer thoughtfully. Measurement of marijuana use before sex was dichotomized as yes or no. The exact timing of marijuana use in relation to sex was not defined, and the majority of users were smokers of marijuana. For purposes of the study, groups consisted of non-marijuana users, marijuana users before sex, and marijuana users who didn’t use before sex. Patients reported their usage as several times a day or week or year, once a day, week or year and less than once a year. For purpose of analysis, frequency of marijuana use was measured by dichotomizing into frequent and infrequent .In our study, the majority of women who used marijuana before sex reported positive sexual effects in the domains of overall sexual satisfaction, desire, orgasm, and improvement in sexual pain but not in lubrication. Women who used marijuana before sex and those who used more frequently were more than twice as likely to report satisfactory orgasms as those who did not use marijuana before sex or used infrequently. Our study is consistent with past studies of the effects of marijuana on sexual behavior in women. In the above-mentioned study by Palamar et al,2 38.6% of respondents were women. Participants were asked questions similar to this study’s questions regarding sexual domains, including sexual enjoyment, desire, and orgasm intensity and how these were affected by being under the influence of marijuana. The majority of respondents noted an increase in sexual enjoyment and orgasm intensity,whereas 31.6% noted an increase in desire, and 51.6% noted no difference.2 Our data showed a higher percentage of participants reporting improvements in each domain across the board. However, vertical grow rack their data included both men’s and women’s responses, and their questions were worded differently. Dawley et al10 evaluated a group of marijuana using students and found that marijuana smokers reported increased sexual pleasure, increased sensations, and increased intensity of orgasm. Only more-frequent users felt that marijuana was an “aphrodisiac,” a surrogate measure of desire. This study included only 22% women.10 Finally, Koff11 evaluated sexual desire and sexual enjoyment after marijuana use in women via a questionnaire. The majority of the female respondents reported that sexual desire was increased.
Sexual enjoyment increased 42.9% of the time.11 Interestingly, Sun and Eisenberg12 reported a higher frequency of sexual activity in marijuana users, even when controlling for multiple variables.The authors surmise from their data that marijuana use does not seem to impair sexual function. However, it is important to note that marijuana use may be harmful. Our study provides an interesting insight into women’s perceptions of the effect of marijuana on the sexual experience. It differs from other studies in that it is one of the largest series to date and has a wider range of ages. It also differed in that it was a cross-section of healthy women presenting for routine gynecologic care, where most studies target younger patients and include both sexes. For this reason, it is difficult to directly compare the studies, because the sexual activity, frequency, and expectation of these groups may be very different. However, we believe it is important to understand the potential effect in this patient population. The question of how marijuana leads to these positive changes in sexual function is unknown. It has been postulated that it leads to improvement in sexual function simply by lowering stress and anxiety.It may slow the temporal perception of time and prolong the feelings of pleasurable sensations.It may lower sexual inhibitions and increase confidence and a willingness to experiment.7 Marijuana is also known to heighten sensations such as touch, smell, sight, taste, and hearing.Although this was not specifically addressed in this article, according to Halikas et al,the regular female marijuana user reported a heightened sensation of touch and increased physical closeness when using marijuana before sex. It is postulated that marijuana works through a variety of mechanisms. It is recognized that marijuana and the hypothalamic-pituitary-gonadal axis, which controls the sex hormones, interact with each other. There are cannabinoid receptors in the hypothalamus that regulate gonadotrophinreleasing hormone and oxytocin release, both of which play a role in normal sexual functioning.In addition, marijuana has been shown to affect testosterone levels, which play a role in sex drive, but how and in which direction in women is unclear.Female sexual function is not only regulated by hormones, but also by centrally acting neurotransmitters, such as dopamine and serotonin.