There is a complexity when it comes to cannabis – it can be safe and benign, it can have medicinal components, and it can be harmful and dangerous. These are all true. As regulations around cannabis continue to loosen, it is imperative that providers understand that cannabis use will probably increase. It is therefore important for providers to work with adolescent patients who use it to help minimize the potential risks. In thinking about cannabis use realistically, it is hard to deter patients from using it at all in their lifetimes, therefore it is the responsibility of providers to help those patients do minimal harm with their cannabis use. Studies have shown that 55% of high school seniors have tried marijuana, 23% use it currently and 6% use it daily. This last group is the most concerning group.
An important starting point is to address this issue in a non-confrontational, non-judgmental way. One way to start the conversation in a way that does not make the patient feel judged or shamed is by asking something like “Tell me about your relationship with cannabis”. It can help to show patients that you can acknowledge that there is some good and bad with cannabis but that the overwhelming evidence shows that there is more harm than good when it comes to cannabis use in adolescents.
Psycho-education on cannabis is very important. There can be a misperception about “medical” marijuana and assuming that it is regulated. Others assume it is “natural” and therefore can’t have any negative effects. Many teens are willing to hear this information once they feel like they can have a more open conversation with their doctors.
When the patient senses that you are willing to have a discussion about the issue rather than just saying “this is bad for you period”, then you can talk more openly about harm reduction use of cannabis. There are important harm reduction strategies to minimize the possible side effects of cannabis use. These can be addressed with patients:
- Using it less frequently and avoiding daily use
- Delaying starting it until adulthood
- Using safer sources and routes
Several studies have looked into the negative effects of cannabis use in adolescence. These negative effects include: increased risk of psychosis, increased risk of substance dependence, and reduction of cognitive skills. Regular cannabis use can increase the risk of subclinical psychotic symptoms, and these symptoms can persist even after a long period of abstinence. Additionally, for patients with schizophrenia, using cannabis can move up the onset of schizophrenia up to 3 years earlier than for patients who do not use cannabis. Regular cannabis use in adolescence can led to a permanent loss of IQ points, something that is not seen as much with cannabis use that starts in adulthood. Regular cannabis use in teens has been shown to impair learning, problem-solving skills and short-term and long-term memory. Studies have shown downward socioeconomic mobility in people who use cannabis at a young age. The take home message is that if a patient is going to start using cannabis, to try to wait until adulthood, because, relatively speaking, it is not as unsafe as it is in adolescence.
It is important for patients to be aware of the sources of cannabis they are using and the route they are ingesting it by. It is particularly important for them to avoid products that are high in THC ((–)-trans-Δ9-tetrahydrocannabino) and to avoid concentrates, which can be made in unsafe environments, and synthetic cannabinoids, which are very potent. Edibles and vaporized cannabis can be safer routes, because they do not irritate the respiratory system.
This is an area that is shifting over time, from a cut-and-dry hardline of abstinence from all non-prescription drugs to working with patients in a way to reduce harm from their use of some of these substances. For that reason, it is important for primary care providers to stay current with the information and be willing to work openly with patients. It is our hope that this edition of the e-Weekly helps us to move in that direction.