Preventing cannabis use among minors

As access to cannabis products increases in the United States, there are potential health implications for children and adolescents. Maria H. Rahmandar, MD, physician at Northwestern’s Feinberg School of Medicine, explores the risk factors, screening strategies and impacts that cannabis use may have on this population.

Speakers

• Maria Rahmandar, MD, physician, Lurie Children's Hospital; medical director, Substance Use & Prevention Program, and associate professor of pediatrics, Northwestern University Feinberg School of Medicine 
• Michael Suk, MD, JD, MPH, MBA, professor and chair, Musculoskeletal Institute and the Department of Orthopedic Surgery, Geisinger Health System; chair, AMA Board of Trustees
• Jesse Ehrenfeld, MD, immediate past president, American Medical Association

Listen to the episode on the go on on on Apple Podcasts, Spotify or anywhere podcasts are available.

Dr. Ehrenfeld: Welcome to Moving Medicine, a podcast by the American Medical Association. Today’s episode is part of the Cannabis Education series, brought to you by the AMA Cannabis Task Force. 

I'm Dr. Jesse Ehrenfeld, senior associate dean, tenured professor of anesthesiology, and director of the Advancing a Healthier Wisconsin Endowment at the Medical College of Wisconsin. I'm also the immediate past president of the AMA and co-chair of the AMA Cannabis Task Force. Michael, take it away!

Dr. Suk: Thanks, Jesse. I'm Dr. Michael Suk, professor and chair of the Musculoskeletal Institute and the Department of Orthopedic Surgery at Geisinger Health System. I'm chair of the AMA Board of Trustees and your co-chair of the AMA Cannabis Task Force.

Through expert discussions and insights, this podcast series features information that can help physicians of all specialties understand cannabis and the health effects of cannabis use.

Dr. Ehrenfeld: The AMA forms mission-specific task forces like this one to tackle current medical issues in our nation. Make your voice heard by becoming a member today. Visit ama-assn.org/more. And now, on to the show.

Dr. Suk:  Joining me today to talk about cannabis use and prevention among children and adolescents is Maria Ramandar. She's a pediatrician, a medical director of substance use prevention program at Lurie Children's Hospital in Chicago, and a member of the executive committee for the American Academy of Pediatrics section on adolescent health. Welcome to our show.

Dr. Rahmandar: Thank you so much for having me.

Dr. Suk: Maria, I'd like to start by discussing the statistics and the trends. Often as parents, we might worry about children and cannabis, but is that a valid concern? What rates of cannabis usage are we seeing in the pediatric population?

Dr. Rahmandar: So first off, I'd like to just say that most youth are making healthy decisions on a regular basis not to use cannabis. So, it is really important to just reset social norms and understand that this is certainly a problem, but not everybody is doing it. And that is a really important prevention message too, so that youth don't think that it's okay, everybody's doing it.

And parents don't assume that all kids are gonna do it. We see that in the past year, based on most recent data, about a quarter of youth have used e-cigarettes in the past year. Half have used alcohol in the past year and around a third have used cannabis in the past year. And so, it's one of the top substances tried and used by adolescents.

And you know, over the past couple decades, we've seen that cannabis use among young adults has gone up to kind of all-time highs. But in youth, so adolescents, you know—high school age people, this is actually gone down from peak in the 70s. But that doesn't mean I'm like, this is fine, I'm not worried about it, because you know, it's time to celebrate. I think cannabis has really changed over time.

And we see the way youth use cannabis changes. It's not just smoking joints anymore. It is really concentrated. So, we're seeing the percentage of THC in plants going up over time. This is potent cannabis plants that are becoming more potent cannabis concentrates used for vaping, used for edibles, used for dabbing. And so, you know, fortunately, most youth aren't using it, but those that are using it, I'm particularly concerned about.

Dr. Suk: Dr. Rahmandar, the SAMHSA National Survey shows that there is a rise in the use of cannabis among the pediatric and adolescent populations. What are the reasons that pediatric patients may start using cannabis? And what are the risk factors that a physician can be aware of and potentially provide support for?

Dr. Rahmandar: Yeah, the rise in rates from that SAMHSA survey, the National Survey on Drug Use and Health, was among young adults. And youth were still concerned about steady rates of youth and that, you know, we can't always see what's going to happen over time. But the fact that this is increasing among any young population with a developing brain is concerning. And so, we do get concerned about any use in adolescents or young adults because the developing brain is particularly susceptible to negative impacts of substance use. So, we may not see the same problems for an adult who starts using cannabis as we do for youth who start using cannabis. And to get back to your question, which was about why would somebody use that there's many reasons that youth use. 

It may start as simple as I want to try something. Youth are trying to develop who they are, developing independence, trying new things, and that might involve substance use. And so, they may want to see how it makes them feel. Some youth use because they've tried it a couple of times and they can't stop, and we're worried about a developing addiction or cannabis use disorder. And there are some youth that used to deal with mental health conditions that they already have to deal with past trauma, to try to manage stress, sleeping problems and things like that. Those are some of the more common reasons I hear people using.

Dr. Suk: Dr. Rahmandar, it appears that there are a number of screening tools that might be available to help clinicians understand their children and adolescent patients when it comes to cannabis use. Perhaps you can talk a little bit about that.

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Dr. Rahmandar: Sure, the American Academy of Pediatrics does recommend screening youth for substance use, and then providing brief intervention and referral to treatment when appropriate. A couple tools exist that have been validated in adolescents and that are freely available. And these tools are better than the questions we think up in our heads. And so, they do a good job of capturing substance use and concerns that could develop into substance use disorders. So, some tools I'll mention are the CRAFFT that continues to be developed and evolve over time.

The most recent CRAFFT tool is the 2.1 plus N that also screens for e-cigarette use and other nicotine products and includes, of course, cannabis and other synthetic cannabis products too in that tool. And another one I'll mention is the S2BI or screening to brief intervention. And that screens for a variety of substance use, and then you know, can kind of estimate the likelihood of a substance use disorder based on those responses.

And so, you know, positive screens on either of those should trigger a conversation around substance use, you know, using some motivational interviewing, and then you know, connecting to local resources and following over time because we know a lot of youth are not, you know, ready on that first divulging of substance use to, you know, to find a treatment and also treatment takes time. This is a chronic disease, and it can be done within the primary care setting for those comfortable in doing it.

And these tools should be used in a confidential way. Of course, there's limits to confidentiality around safety and knowing what your state laws are, but creating a welcoming environment, knowing the limits of confidentiality, but providing a private space to complete them and review them is really important.

Dr. Suk: Thanks for that. And when a teenager starts or at least tries cannabis, maybe we can talk a little bit about the health impact of cannabis use on children and adolescents.

Dr. Rahmandar: So usually most teens who use don't end up having a problem with it. They may try it, they may use it a couple times, they might use it more than that, and fortunately, most people who try a substance, including cannabis, don't end up developing a substance use disorder. But that doesn't mean it's not without risks, and it's hard to predict who's going to have a problem with it. And you know, certainly we're worried about a cannabis use disorder, or addiction developing. But there's also other effects that we can get worried about. I see that cannabis can impact youth motivation to get things done. 

And studies can be mixed on the impacts of cannabis. And also, I wonder if studies are mixed because they're happening over time where cannabis was much less potent. So, we may see different things in the literature as more studies happen. But there certainly is a relationship between mental health and cannabis use. It's not always clear if there's a direct, cannabis causing mental health, but there does seem to be a strong relationship between people who did not have depression or suicidality when they started using cannabis as a teen, then developing depression or suicidality over time. There does seem to be a link between psychosis and cannabis, and fortunately again, most people who use it do not have psychosis, but people who have family history of psychosis—genetic loading for that—use especially potent products more likely to develop psychosis. And certainly, that can happen acutely. So, meaning like in the intoxication phase, we could see psychosis happening, but we are concerned about it triggering more long-term psychosis. 

And then we've also seen, this was before COVID, so people may have forgotten about evali, but this is something we saw with vitamin E acetate likely contributing to lung disease. But even without evali, we are worried about impacts of smoking or inhaling or vaping these products into lungs, you know, triggering cough, asthma attacks. And then what I see a lot in the hospital is cannabis hyperemesis syndrome or cannabinoid hyperemesis syndrome—meaning that use who have youth cannabis and it's really kind of, there's not a clear pattern, you know, regular use of potent products, coming in and not being able to stop throwing up and becoming dehydrated. And it's really hard to treat without just abstinence. And so stopping, which can be really hard when you have a cannabis use disorder.

Dr. Suk: Yeah. Dr. Rahmandar, thanks for that information. Recognizing that many cannabis products are now available in some edible forms and other things, we worry a little bit about the unintentional digestion and or exposure to cannabis. Perhaps you can talk about that and maybe some signs and worry or concerns around toxicity.

Dr. Rahmandar: Yeah, in my state in Illinois, we saw a very dramatic rise in accidental ingestions among children following the legalization of adult use cannabis. And so, edibles—in the form of gummies, brownies, cookies, all sorts of things that, you know, kids like to eat. This is luring them to use them when they are out and it's really concerning. Fortunately, most kids do not die from an accidental ingestion, but they can be agitated, become unconscious.

It can be a really confusing picture and an unclear picture when maybe the ingestion wasn't witnessed. It can look like so many things—agitation, anxiety. Really, it's important for emergency room doctors to just have a wide differential when they're evaluating somebody coming in with an unknown, possible ingestion. Important to do ABCs, of course, first and foremost, you know, consider drug testing. And I think that people do that, you know, in the ER when you don't know what you're seeing, and somebody is coming in with some unknown complaint. 

But fortunately, I think most probably in-house tests do look for THC. And so that may come back positive, but there are all sorts of different products out there these days that outside of dispensaries and even within them, but with Delta-8 THC's and all sorts of synthetic cannabinoids that may not turn up positive on a typical drug screen. So, considering sending out, which can take time. So, it's tricky and there's new products always being developed to circumvent legal landscape and regulations. So, we just have to kind of keep our minds open. 

But I would encourage people who do keep edibles within their house to keep them locked away from kids, away from their pets and away from teenagers, as well, who may be looking to try some things.

Dr. Suk: Great, thank you. You know, as we wrap up this session, I wonder, Dr. Rahmandar, if you would like to highlight three main points that you'd like the audience to take away from our conversation around cannabis use among children and adolescents.

Dr. Rahmandar: Sure. So, I would say that remembering that not everybody's doing it. Most youth are making healthy decisions to avoid cannabis use. But we are particularly concerned about use among youth with developing brains and bodies because use of cannabis when you're an adolescent means that you're more likely to develop a cannabis use disorder or other problems. There are some validated screening tools that can be helpful in screening for cannabis use in the pediatric setting. And that can be a way to open up the door for conversation. And I would encourage people to consider using them on a routine basis, and certainly when there's concerns around mental health or substance use disorders but making sure that these conversations happen in a confidential way and in a space, just knowing your state laws around what youth can consent to, and creating a welcoming environment so you can have open conversations with youths about these issues.

Dr. Suk: Excellent. Dr. Rahmandar, thank you so much for joining us on this educational series on cannabis and really, really welcome your thoughts and advice as it comes to this topic.

Dr. Rahmandar: Thanks, it was a pleasure to be here. I appreciate time to talk about this important topic.

Dr. Ehrenfeld: Don’t miss the next episode in this series—be sure to subscribe to Moving Medicine on your favorite podcast platform. This content is for educational and informational purposes only and does not constitute medical or legal advice. The viewpoints expressed in this podcast are those of the participants and do not reflect the views and policies of the AMA, unless otherwise indicated.

Dr. Suk: This has been Moving Medicine. Thanks for listening.

Disclaimer: The viewpoints expressed in this podcast are those of the participants and/or do not necessarily reflect the views and policies of the AMA.