Cannabis is known to be one of the most common psychoactive substances used throughout the world. Previous studies have reported that the users of cannabis equate to approximately 4% of the global population,with most users aged between 15 to 64 years.
The Cannabis plant consists of microscopic projections known as trichomes, from which a variety of concentrates are produced through homemade or commercial extraction methods.
The consistency of the concentrates can range from liquid to solid and most commonly contain cannabidiol (CBD) and δ-9 tetrahydrocannabinol (THC). THC mostly contributes to the psychoactive effects of cannabis. Moreover, there are two types of cannabis concentrates, non-solvent-based and solvent-based. Solvent-based concentrates are reported to contain a higher THC potency compared to non-solvent-based concentrates. Flammable solvents like butane are also reported to produce concentrates that are high in THC levels. CBD, on the other hand, is a less psychoactive component of cannabis and can block the psychotogenic effects of THC.
Clinicians must be aware of the potency and method of consumption of the wide diversity of cannabis products. Dry cannabis is mainly consumed as a joint, spliff, or blunt, while topical cannabis such as creams are not used for intoxication. Cannabis-infused products such as baked foods, frozen foods, beverages, and candies are known as edibles whose THC content is variable along with a slower systemic absorption. Vaporizers (such as vape pens or e-cigarettes) or dabs (sticky, resin-like concentrates) can be used to consume cannabis concentrates and oils.
However, irrespective of the product, there has been a steep rise in THC potency globally. The average THC concentration of illegal cannabis seized in the US by the Drug Enforcement Administration (DEA) was found to increase from 10% in 2009 to 14% in 2019. Furthermore, the increase in THC concentrations is reported to be even higher for cannabis concentrates.
A new review published in The Journal of Pediatrics aimed to summarize the use of cannabis among adolescents, its negative health impacts, and interventions to stop or reduce its use.
Use of cannabis among adults
Although a high level of substance use has been reported among young adults aged between 18 to 24 years, approximately 14 million students who were aged 15 to 16 years were reported to use cannabis in the past year. Cannabis use is highest among young people in the US compared to other continents. High and frequent use of cannabis during adolescence is reported to increase the risk of cannabis use disorder and cause several related complications.
Apart from smoking, adolescents are also reported to use other forms of cannabis, such as vaping oils, edibles, and others. Moreover, the rates of cannabis smoking were found to decrease, and the use of edibles and vaping increased from 2015 to 2018. Cannabis vaping most often involves cannabis concentrates whose THC content can be as high as 95%, which is much higher than those in smoking forms. Studies have highlighted that increased cannabis vaping parallels the growth in vape pen and e-cigarette use. However, many adolescents perceive that the use of cannabis and vaping is of lower risk compared to other substances and their consumption procedures.
Clinical impact of cannabis use
Higher-potency cannabis products have been found to cause earlier and adverse health impacts compared to lower-potency products. Chronic use of cannabis has been reported to cause anxiety, depression, and psychotic symptoms. A multinational study indicated that using high-potency cannabis by 15 years of age leads to twice the risk of psychosis. Moreover, daily users of cannabis are more likely to develop psychotic disorders, with daily users of high-potency cannabis having the highest risk.
Furthermore, deleterious effects of cannabis have been observed on ongoing brain development as well as the fertility of adolescents. Cannabis has also been found to impair cognition in the short term, driving, as well as lead to sleep problems, acute paranoia, delusions, and hallucinations. Many studies also report acute physical harm from the use of high-potency cannabis. High-potency cannabis use can further cause an increase in the frequency of cannabis use compared to low-potency cannabis use leading to the early onset of cannabis use disorder symptoms. However, several additional harms specific to the method of cannabis use have also been identified.
All adolescents are recommended to receive Screening, Brief Intervention, and Referral to Treatment (SBIRT) by the American Academy of Pediatrics and the Substance Abuse and Mental Health Services Administration as a part of their routine healthcare. Many screening tools can help to screen adolescents for the use of cannabis, such as CRAFT (Car, Relax, Alone, Forget, Friends, Trouble; updated cannabis use question in version 2.1), S2BI (Screening to Brief Intervention), and BSTAD (Brief Screener for Tobacco, Alcohol, and Other Drugs).
In the case of identification of cannabis use, clinicians must as questions on the form of cannabis used, its potency, frequency, context, motives, and intensity of use. They must also ask questions about the presence of any cannabis-related harms. Moreover, symptoms of other mental and medical health disorders associated with substance use must also be assessed.
Interventions and harm reduction for cannabis use
Clinicians must respond according to the results of the screening. Counseling techniques can strengthen their commitment and motivation toward stopping or reducing use. In the case of low-potency cannabis use by adolescents, clinicians can implement an Elicit-Provide-Elicit approach where the adolescent is provided knowledge on the risks of cannabis use in a non-judgemental manner as well as an understanding of the adolescent’s views on the provided information.
In the case of high-potency cannabis use during the last 12 months, clinicians must use interventions whose main aim must be abstinence. However, for some adolescents focusing on abstinence can lead to the stigma surrounding treatment and further disengagement. Clinicians must therefore use harm-reduction measures to decrease the use of high-potency cannabis in adolescents who choose not to abstain. Clinicians must also use motivational interviewing to understand the context of the adolescent’s use of cannabis, areas for implementing behavior modification and to build a connection with them. In case the adolescent does not want to or is not ready to abstain from cannabis, clinicians must try to explore their openness to switching to a low-potency cannabis product.
Furthermore, clinicians can also discuss the CBD: THC ratio of the cannabis product as a means of harm reduction. Several studies have shown that CBD can reduce the harmful effects of THC on cognition, psychotic symptoms, and anxiety. Clinicians can review the labeling of cannabis products along with adolescents for the evaluation of their exposure as well as adjust their behavior to reduce harm. Clinicians must also advise adolescents not to drive for at least 6 hours after cannabis smoking.
Clinicians can also refer adolescents who use cannabis more often to specialized programs that include partial, residential, and outpatient programs. Moreover, parents can also play an important role in the reduction of harm as well as the stopping of cannabis use. In acute safety concerns, clinicians can disclose safety planning to the parents or guardians. Still, before that, they must discuss with the adolescent the details and benefits of disclosure. Additionally, consent of parents or guardians can be required for participation in treatments for substance use.
Restrictions, as well as requirements for the purchase of medical cannabis, are reported to vary by location. The usefulness of medical cannabis in a pediatric setting is an important area of research. They can be used in the treatment of seizures as well as vomiting and nausea that is induced by chemotherapy.
However, the acquisition of medical cannabis cards was found to be associated with more frequent cannabis use in the US. Individuals with a medical cannabis card reported higher rates of negative consequences of cannabis use. They were also reported to drive under the influence of cannabis. Therefore, the negative health impact of high-potency cannabis use remains irrespective of whether the cannabis was obtained illegally or from a medical cannabis dispensary.
The use of cannabis can negatively impact adolescents and cause early onset of cannabis use disorder symptoms. Although abstinence is ideal, clinicians must work with adolescents to reduce the risk of cannabis use. Clinicians must also come up with tailored assessments, interventions, and assistance to reduce the risk of harm in adolescents who use high-potency cannabis products.