Cannabis-Infused Edible Products in Colorado: Food Safety and Public Health Implications

Alice E. White, MS; Christine Van Tubbergen, MPH; Brianna Raymes, MPH; Alexandra Elyse Contreras, MPH; Elaine J. Scallan Walter, PhD


Am J Public Health. 2020;110(6):790-795. 

In This Article

The Future of Food Safety and Cannabis

As the edible industry expands, it is important for epidemiologists and environmental health professionals to understand the prevalence of edible cannabis use, symptoms associated with cannabis intoxication, and foodborne illness risks associated with edible production. The US Drug Enforcement Agency continues to categorize cannabis as a Schedule 1 drug, restricting the use of funds for regulating the industry. For states, this means that the responsibility for the regulation of cannabis, including the safety of edibles, falls to state and local jurisdictions, and many environmental health agencies do not routinely inspect and regulate edibles manufacturers as food facilities. In an edible-associated investigation, public health partners may participate in or lead an investigation. As of 2018, emergency treatment, hospitalization, and death related to exposure of cannabis products are reportable conditions in Colorado. The surveillance of edibles-associated illnesses involves public health and other partners, including the National Poison Data System, highlighting the importance of interagency collaboration and communication.

As our review demonstrates, cannabis-associated investigations have most often occurred in incidences related to unintentional ingestion of a cannabis product. Although only one investigation was associated with a microbiological pathogen, hepatitis A and aspergillosis have previously been associated with users of smoked cannabis.[32,33] Reported incidents appear to be increasing with legalization and present novel challenges to investigators, including nongastrointestinal symptoms, and new partners (e.g., law enforcement). It is increasingly important that we have the capacity to do surveillance to detect these incidents, as they are likely underreported. Recalls, consumer advisories, and other media reports of potentially hazardous cannabis edible products identified in routine inspections have also been reported. This highlights the importance of routine inspections in facilities producing cannabis-infused products and the importance of identifying the public health authority to recall products.

In anticipation of potential public health events, public and environmental health agencies have taken steps to respond to cannabis-related incidents. For example, CDPHE has developed a guidance document for local public health agencies on handling suspected outbreaks or complaints of enteric illness associated with cannabis edibles.[34] CDPHE is conducting surveillance in coordination with emergency departments, the Rocky Mountain Poison and Drug Center, and local health agencies.[35] CDPHE has added questions about edibles to routine enteric disease questionnaires and created a supplemental outbreak questionnaire.[9,35] The Colorado Integrated Food Safety Center of Excellence has developed educational materials for public health professionals, including a tabletop exercise to educate enteric disease investigators on cannabis and how to prepare for a cannabis-related outbreak investigation.[36] DDPHE has developed sanitation guidance for the cannabis industry and an inspection checklist to prepare cannabis operators for regulatory inspections.[37] Finally, the National Environmental Health Association has its "Cannabis 101 Glossary," the document "Food Safety Guidance for Cannabis-Infused Products," and a cannabis webinar series.[16]

In summary, edibles present a number of public health concerns and will continue to challenge public health professionals as their popularity increases. There are currently no comprehensive food safety recommendations and regulations for cannabis-infused products. It is important for public health agencies, particularly environmental health and enteric disease programs, to be familiar with the cannabis industry, including regulatory partners, signs and symptoms of cannabis ingestion, the scope of edible products sold and consumed, and the food safety risks unique to cannabis products. In addition to the preparation and education of public health professionals, research is needed to determine food safety interventions (e.g., hazard analysis critical control point plans) that will prevent cannabis-associated illness. Researchers should also investigate public health risks associated with consuming cannabis and how consumption patterns and risks differ by populations known to be at higher risk for complications associated with enteric illnesses.