Notes from the Field: Death Following Ingestion of an Edible Marijuana Product — Colorado, March 2014 
 
 Jessica B. Hancock-Allen, MSN1,2; Lisa Barker2; Michael VanDyke, PhD2; Dawn B. Holmes, MD3 (Author affiliations at end of text) 
 
 In March 2014, the Colorado Department of Public Health and Environment (CDPHE) learned of the death of a man aged 19 years after consuming an edible marijuana product. CDPHE reviewed autopsy and police reports to assess factors associated with his death and to guide prevention efforts. The decedent's friend, aged 23 years, had purchased marijuana cookies and provided one to the decedent. A police report indicated that initially the decedent ate only a single piece of his cookie, as directed by the sales clerk. Approximately 30–60 minutes later, not feeling any effects, he consumed the remainder of the cookie. During the next 2 hours, he reportedly exhibited erratic speech and hostile behaviors. Approximately 3.5 hours after initial ingestion, and 2.5 hours after consuming the remainder of the cookie, he jumped off a fourth floor balcony and died from trauma. The autopsy, performed 29 hours after time of death, found marijuana intoxication as a chief contributing factor. Quantitative toxicologic analyses for drugs of abuse, synthetic cannabinoid, and cathinones ("bath salts") were performed on chest cavity blood by gas chromatography and mass spectrometry. The only confirmed findings were cannabinoids (7.2 ng/mL delta-9 tetrahydrocannabinol [THC] and 49 ng/mL delta-9 carboxy-THC, an inactive marijuana metabolite). The legal whole blood limit of delta-9 THC for driving a vehicle in Colorado is 5.0 ng/mL. This was the first reported death in Colorado linked to marijuana consumption without evidence of polysubstance use since the state approved recreational use of marijuana in 2012. 
 
 According to the police report, the decedent had been marijuana-naïve, with no known history of alcohol abuse, illicit drug use, or mental illness. In addition to listing inactive ingredients, the cookie label described the psychoactive ingredients as "65 mg THC/6.5 servings (THC, tetrahydrocannabinol, the principal psychoactive agent in cannabis)." The label also noted, "This marijuana product has not been tested for contaminants or potency." According to the police report, the sales clerk had instructed the buyer and decedent to divide each cookie into sixths, each piece containing approximately 10 mg of THC, the serving size, and to ingest one serving at a time. The police report did not indicate whether the sales clerk provided specific instructions for how long to wait between ingesting each serving. 
 
 This case illustrates a potential danger associated with recreational edible marijuana use. Some studies have suggested an association between cannabis and psychological disturbances (1). Second to alcohol, marijuana is the most commonly used recreational drug in the United States, with an estimated 19.8 million past-month users during 2013 (2). In 2012, Colorado and Washington became the first states to permit recreational use of marijuana under their state laws (3). The first state-licensed recreational marijuana stores in Colorado opened in January 2014. An estimated 45% of Colorado's marijuana sales involve edible marijuana, including THC-infused food, drink, and pills (4,5). Colorado's marijuana surveillance system collects adverse outcomes data from hospitalizations, emergency department visits, and poison center calls. 
 
 Systemic THC levels and psychoactive effects after ingestion are highly variable because of differences in bioavailability, rate of gastrointestinal absorption, and metabolic first-pass effect whereby an orally administered drug is partially metabolized (principally in the liver) before reaching systemic distribution (6,7). Because absorption is slower, the onset of effects is delayed (with mean peak plasma concentration at 1–2 hours after ingestion, in contrast with 5–10 minutes to peak plasma concentrations if smoked), and duration of intoxication is longer when THC is ingested compared with when it is smoked (7). Whereas a single-serving recreational edible marijuana dose in Colorado was set at 10 mg of THC, multiple-dose recreational edible products, often containing 100 mg of THC, were available during March 2014 (4). The marijuana store where the implicated cookies had been purchased voluntarily gave all 67 remaining cookies of the same brand to the Denver Police Department. Testing confirmed that the THC levels in the items were within required limits. Because of the delayed effects of THC-infused edibles, multiple servings might be consumed in close succession before experiencing the "high" from the initial serving, as reportedly occurred in this case. Consuming a large dose of THC can result in a higher THC concentration, greater intoxication, and an increased risk for adverse psychological effects. 
 
 Recreational marijuana is now permitted for persons aged ≥21 years under state law in four states (Alaska, Colorado, Oregon, and Washington) and the District of Columbia; marijuana-attributed morbidity and mortality surveillance can help guide efforts to prevent overconsumption in these jurisdictions. Regulation of recreational marijuana edibles in Colorado continues to evolve. On the basis of initial surveillance data in Colorado and numerous cases of accidental overconsumption, on February 1, 2015, Colorado instituted new packaging and labeling rules, requiring that recreational edible marijuana products contain no more than 10 mg of THC, or have clear demarcation of each 10-mg serving (8). In addition, before distribution, cannabinoid potency testing is now performed on batches of recreational edible marijuana products by state-certified laboratories. Other states permitting recreational marijuana use could potentially reduce adverse health effects by considering similar THC limits in marijuana edible products, and by enforcing clear labeling standards that require information on multidose products. Although the decedent in this case was advised against eating multiple servings at one time, he reportedly consumed all five of the remaining servings of the THC-infused cookie within 30–60 minutes after the first serving, suggesting a need for improved public health messaging to reduce the risk for overconsumption of THC. 
 
 1Epidemic Intelligence Service, CDC; 2Colorado Department of Public Health and Environment; 3Denver Office of the Medical Examiner. 
 
 Corresponding author: Jessica Hancock-Allen, ydi3@cdc.gov, 303-692-2745. 
 
 References ||||| A college student visiting Denver jumped to his death from a hotel balcony after eating marijuana-infused cookies, according to a coroner's report that marks the first time authorities have publicly linked a death to marijuana since legal sales of recreational cannabis began in Colorado. 
 
 Levy Thamba, a 19-year-old student at Northwest College in Powell, Wyo., died last month at a Holiday Inn in northeast Denver. On Wednesday, the Denver coroner released a report concluding that Thamba's death was caused by "multiple injuries due to a fall from height." 
 
 The coroner also listed "marijuana intoxication" from cannabis-infused cookies as a significant condition contributing to the death. The report classifies the death as an accident. 
 
 A brief summary of the investigation that was included in the autopsy report says Thamba, also known as Levi Thamba Pongi, traveled to Denver with three friends on spring break. On March 11, the report says, Thamba consumed "marijuana cookies" and "soon thereafter exhibited hostile behavior (pulling items off the walls) and spoke erratically." 
 
 "The decedent's friends attempted to calm him down and were temporarily successful," the report states. 
 
 "However, the decedent eventually reportedly jumped out of bed, went outside the hotel room, and jumped over the balcony railing." 
 
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 Thamba and his friends were staying on the hotel's fourth floor, according to the report. 
 
 Michelle Weiss-Samaras, a spokeswoman for the coroner's office, said the office often lists alcohol intoxication as a significant contributing factor in a death — for instance, in an alcohol-related car accident. She said the office also has seen cases involving apparent marijuana-impaired driving, but she said she believes this is the first time it has listed marijuana intoxication from an edible product in such a way. 
 
 Weiss-Samaras said Thamba had no known physical or mental-health issues, and toxicology tests for other drugs or alcohol came back negative. 
 
 "We have no history of any other issues until he eats a marijuana cookie and becomes erratic and this happens," she said. "It's the one thing we have that's significant." 
 
 According to the autopsy report, Thamba's marijuana concentration in his blood was 7.2 nanograms of active THC per milliliter of blood. In impaired driving cases, state law sets a standard of 5 nanograms per milliliter at which juries can presume impairment. 
 
 In January, Colorado became the first state in the country to allow people 21 and over to legally buy marijuana for any purpose from regulated stores. Weiss-Samaras said investigators believe a friend of Thamba's purchased the cookies in a recreational marijuana store. 
 
 "We were told they came here to try it," she said. 
 
 Julie Postlethwait, a spokeswoman with the Colorado Marijuana Enforcement Division, which regulates marijuana stores, confirmed that the agency was cooperating with police in the investigation. But she said she couldn't provide more information because the investigation was ongoing. 
 
 Denver police have not yet finished the investigation, so they have not released more details and reports about the case. 
 
 It remains unclear how much of the marijuana-infused product Thamba consumed or how long after consuming it that he died. 
 
 Marijuana edibles — which account for 20 to 40 percent of overall sales, industry experts estimate — have been controversial in Colorado, and the legislature will likely take up the issue again this session. Rep. Frank McNulty, R-Highlands Ranch, said he and Rep. Jonathan Singer, D-Longmont, plan to introduce a bill as early as this week that would further cap the potency of edibles and prohibit them from being made in forms that might appeal to children. 
 
 Current Colorado law prohibits edible products sold at recreational marijuana stores from containing more than 10 milligrams of THC, the main psychoactive chemical in marijuana, per serving. The law allows one individually packaged product — for instance, a single marijuana-infused brownie — to contain up to 10 servings, or 100 milligrams of THC. 
 
 "We can try to make sure there's some level of equivalency and there's some limit on how potent these things are," McNulty said. 
 
 Thamba, who was from the Democratic Republic of the Congo in Africa, started taking classes at Northwest College in January. Thamba was studying engineering at the college, which has about 2,000 students and is 75 miles east of Yellowstone National Park. 
 
 During his few months at the college, Thamba made many friends, and his death was felt across the campus, school officials said. 
 
 "The Northwest College campus community continues to grieve after Levy's death," said a school statement released Wednesday. "All of us were deeply saddened by this tragic incident and feel for his family." 
 
 John Ingold: 303-954-1068, jingold@denverpost.com or twitter.com/john_ingold 
 
 Staff writer Ricardo Baca contributed to this report. ||||| A college student who jumped to his death from a Denver hotel balcony last month ate six times the recommended amount of a marijuana cookie before his death. 
 
 Levy Thamba, a 19-year-old student at Northwest College in Powell, Wyo., died last month at a Holiday Inn in northeast Denver while visiting with three friends. 
 
 An investigative report by Denver police into Thamba's death released this week details events leading up to the young man's death. 
 
 This story was first reported by CBS4. 
 
 Denver police presented the case to the Denver District Attorney's Office. Prosecutors decided not to pursue criminal charges against Bessie Gondwe, the only person of legal age among the foursome who would be able to purchase recreational marijuana in Colorado. 
 
 Thamba, who was from the Democratic Republic of the Congo in Africa, ate an entire "Sweet Grass Kitchen" lemon poppy seed cookie. It contained 65 milligrams of THC and was labeled 6.5 servings, the report said. 
 
 Gondwe, 23, one of the students and a friend of Thamba, told investigators that the cookie was purchased at a downtown marijuana store, Native Root Apothecary, on the 16th Street Mall. 
 
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 An employee at the store told them to "cut the cookie into six pieces and to only eat one piece at a time," the police report said. 
 
 The group purchased four cookies, one for each one of them, at a price of $10 apiece. 
 
 Back at the hotel they all consumed a single slice of the cookie. Thamba said "he didn't feel anything and he ate the remainder of his cookie all at once." 
 
 Thamba awoke early that morning, shivering and speaking in French, the report said. The others — the group was sharing a room — calmed him down. 
 
 But he awoke several times, again in incoherent states, at one point apparently talking to a room lamp. 
 
 During one of the intervals, Thamba left the fourth- floor hotel room, returned and said: "This is a sign from God that this has happened, that I can't control myself," Anna Jakaovljeveic, 20, Thamba's friend, told investigators. "It's not because of the weed." 
 
 He went back to sleep, but awoke "crazy" and began smashing room furniture, lamps and the television. 
 
 He ran from the room, out the front door, and tumbled over a railing on an elevated hallway overlooking the lobby. 
 
 Two hotel employees witnessed the fall and told police no one was near him at the time. 
 
 Andres Bigum, 20, was bolting after Thamba from the room, but wasn't able to catch up with the victim. 
 
 As part of the investigation police confiscated all Sweet Grass cookies Native Root had in stock. All of the 67 cookies had THC levels that tested within "required limits," the report said. 
 
 The Denver coroner listed "marijuana intoxication" as a significant condition contributing to his death. According to an autopsy report, Thamba's marijuana concentration in his blood was 7.2 nanograms of active THC per milliliter of blood. In impaired driving cases, state law sets a standard of 5 nanograms per milliliter at which juries can presume impairment. 
 
 Kieran Nicholson: 303-954-1822, knicholson@denverpost.com or twitter.com/kierannicholson
– There's a saying in the health care world: dose matters. It certainly did in the case of 19-year-old Levy Thamba, a native of the Democratic Republic of the Congo who was studying at Wyoming's Northwest College. While in Denver with friends on spring break in March of 2014, the teen jumped to his death from a Holiday Inn balcony after ingesting a whole lot of weed. In this week's Morbidity and Mortality report, the Centers for Disease Control and Prevention review his death, the first "linked to marijuana consumption without evidence of polysubstance use" since pot became legal in the state in 2012. (The lemon poppyseed cookie was purchased legally by a 23-year-old friend; Thamba, however, wasn't of age and therefore didn't consume the pot legally.) The police report stated he initially ate just the recommended single portion of the cookie; some 30-60 minutes later, still feeling no effects, Thamba—called "marijuana naive, with no known history of alcohol abuse, illicit drug use, or mental illness"—ate the whole cookie, constituting 6.5 servings. Roughly 2.5 hours later, Thamba exhibited "hostile behavior," according to his friends. He had no other drugs in his system at the time he jumped, and his death was ruled an accident. The legal blood limit for THC for drivers in the state is 5.0 ng/mL; his blood level was 49 ng/mL. LiveScience reports that regulations were put in place in February regarding the labeling of edible marijuana items; if they contain more than 10 mg of THC, each 10 mg serving must be clearly indicated. The cookie Thamba ate contained 65 mg. (Thamba's friends reportedly tried to calm him.)