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Home , Cannabis (drug), Decriminalization

Legalization and Youth Kristie Ladegard, MD,a,b Christian Thurstone, MD,a,b Melanie Rylander, MDa,b,c

Various states have legalized marijuana for medical purposes and/or decriminalized abstract recreational marijuana use. These changes coincide with a decrease in perceived harmfulness of the and an increase in its use among youth. This change is of critical concern because of the potential harmful impact of marijuana exposure on adolescents. Marijuana use has been associated with several adverse mental health outcomes, including increased incidence of and comorbid substance use, suicidality, and new-onset . Negative impacts on cognition and academic performance have also been observed. As the trend toward legalization continues, the pediatric community will be called on to navigate the subsequent challenges that arise with changing policies. Pediatricians are uniquely positioned to provide innovative care and educate youth and families on the ever-evolving issues pertaining to the impact of marijuana legalization on communities. In this article, we present and analyze the most up-to-date data on the effects of legalization on adolescent marijuana use, the effects of adolescent use on mental health and cognitive outcomes, and the current interventions being recommended for use in pediatric office settings.

bDepartment of Behavioral Health Services, Health Medical Center, Denver, ; and aDepartments of Psychiatry and cInternal , School of Medicine, University of Colorado, Aurora, Colorado

Dr Ladegard served as the solo first author and contributed to manuscript preparation; Drs Thurstone and Rylander contributed to manuscript preparation and also warrant authorship; and all authors reviewed and approved the final manuscript as submitted and agree to be accountable for all aspects of the work. DOI: https://doi.org/10.1542/peds.2019-2056D Accepted for publication Jan 29, 2020 Address correspondence to Melanie Rylander, MD, Department of Behavioral Health, Denver Health Medical Center, 777 Bannock St, Denver, CO 80230. E-mail: [email protected] PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). Copyright © 2020 by the American Academy of Pediatrics FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose. FUNDING: No external funding. POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

Downloaded from www.aappublications.org/news by guest on September 25, 2021 PEDIATRICS Volume 145, number s2, May 2020:e20192056D SUPPLEMENT ARTICLE Marijuana is the most popular illicit how marijuana use impacts physical higher average marijuana use and substance in the , and and psychological health in youth, lower perception of risk by adolescents and young adults are and describe key strategies and adolescents (8.68%) compared with among the highest users of interventions that pediatricians can states without MMLs (6.94%) during marijuana.1 Policies regarding use when evaluating youth in their the period between 2002 and 2008.20 marijuana have been changing and offices. However, the states with MMLs evolving for the past 30 years. The already had higher use and lower introduced an early wave of IMPACT OF MARIJUANA POLICY perceptions of risk. Therefore, it is statewide CHANGES ON YOUTH not clear that passing the MMLs in legislation. Decriminalization refers certain states actually increased The impact of policy changes on to criminal penalties that are use.20 Longitudinal studies conducted marijuana use among youth are removed and replaced with civil on pre and postlegalized marijuana fi mixed and present a complicated penalties, such as nes or mandatory markets have shown few changes in 2 clinical picture. Understanding trends treatment. Although use among youth, which suggests that in marijuana use among American decriminalization policies apply to differences between states with and youth is an essential step toward the use of marijuana by adults, they without legalized nonmedical developing healthy policy, adequate may affect adolescents by increasing marijuana may be due to preexisting education, and targeted interventions availability and access while trends rather than policy changes.21 It to mitigate potential adverse health decreasing perceptions of harm. is possible that states with higher effects from marijuana use. These changes may then lead to marijuana use and lower perceptions increased adolescent use of The nationwide prevalence of of risk are more likely to enact MMLs. marijuana.2 Beginning in 1996, adolescent marijuana use increased This explanation is supported in the marijuana use was legalized for rapidly and surpassed use current analysis by the observation medical purposes in .30 states and prevalence between 2008 and 2011, that among states that eventually the District of Columbia, suggesting with the prevalence of lifetime enacted MMLs, use was higher and a trend toward a more normative marijuana use rising by 21% and perceptions of risk were lower even view of marijuana.3 In 2014, Colorado past-year marijuana use rising by before passage of MMLs.2 These became the first state to legalize 31%.17 Nine percent of youth in findings provide evidence for the recreational marijuana, and since grades 9 to 12 use marijuana daily or importance of public education then, 10 additional states have nearly every day, an increase of 80% campaigns that typically accompany followed suit.3 Evaluating and since 2008.17 In the national marijuana legislation to help inform researching the effects of marijuana conversation regarding legalization, communities of the risks and adverse policies on adolescents is a public many legalization proponents portray outcomes of marijuana use. marijuana use as harmless. Research health priority because of the Whether the passage of MMLs caused has shown that perception of harm is potential adverse outcomes a direct increase in adolescent a potential indicator of marijuana use marijuana can have on youth, marijuana use, other studies have and that a reduction of perceived including an increase in the use of illustrated concerning outcomes for harm is commonly associated with an marijuana and other substances, new- youth in general and African increase in marijuana use.18 A study onset psychosis, suicidality, American youth specifically. Studies that used Monitoring the Future data marijuana-related motor vehicle have found the frequency of showed that eighth-grade students crashes, and neurocognitive decline marijuana use was significantly from schools located close to medical over time, including educational associated with the use of other illicit 4–16 marijuana (short underperformance. As the , such as or crack and traveling distance, ,5 miles) were movement of legalization continues to , and this association was more likely to have recently used expand, pediatricians will be called found to be particularly strong in marijuana compared with those from on to provide care to youth who are adolescents.22 Adolescents residing in schools located farther from at risk for potential adverse states that have legalized medical dispensaries (.25 miles).19 individual and public health marijuana were more likely to use outcomes. Our purpose in this article The national trend of increased rates cocaine or crack and heroin in the is to provide pediatricians with an of adolescent marijuana use is clear; past 12 months; however, MML overview of the epidemiology of however, it is not clear whether this implementation was not associated marijuana use among youth before increase is due to changing marijuana with increased use of other illicit marijuana policies change and as they policies. States with medical drugs or misusing prescription change, advance their knowledge on marijuana laws (MMLs) reported medications.23 Another study that

Downloaded from www.aappublications.org/news by guest on September 25, 2021 S166 LADEGARD et al used data from repeated cross- Changes in the legal status of Diagnostic and Statistical Manual of sectional US general population marijuana have led to increased Mental Disorders, Fifth Edition surveys during 2001 and 2002 availability in many regions for recognizes .32 compared with 2012 and 2013 adolescents.29 There has been an Approximately two-thirds of youth showed that in adolescents, increase in marijuana-related who present for substance use marijuana use increased in African emergency and urgent care visits, for treatment report physical Americans.24 This is concerning example, in the pediatric population dependence, including tolerance and because African American youth have in state and Colorado withdrawal from the drug.33 decreased access to substance use since the commercialization of Symptoms of withdrawal treatment compared with white medical and recreational marijuana.29 include , feeling hot and cold, youth, and if they are able to access Despite several studies showing that , irritability, mild tremors, treatment, it is more likely to be adolescent use has not increased in restlessness, strange dreams, and through juvenile justice states after medical and recreational weight loss. Symptoms start within involvement.25 marijuana legalization, marijuana is 1 day of abstinence, peak on days 2 to still the most commonly used illicit 4, and last ∼2 weeks. Early onset of Unlike medical marijuana, drug among adolescents.1 marijuana use by 16 years of age recreational marijuana is only Approximately 1.6 million predicts a 2.7-fold increased risk of recently legal in 11 states, so adolescents used marijuana in the developing a .34 evidence on its impact is limited. Both past month in 2016, which translates Adolescent use also predicts a two- to Colorado and Washington state have to 6.5% of the entire adolescent threefold increased risk of using seen a decrease in the perceptions of population.1 According to the other substances.35 harm from marijuana use; however, Monitoring the Future survey, high this has been an overall trend across school students are using marijuana Marijuana Use and Development of 26 Psychosis the United States. One study at higher rates than other drugs, showed a significant decrease in the whereas and illicit drug use, Marijuana intoxication may cause perceived harm associated with in general, have declined.30 In acute psychosis.36 This effect may marijuana use and an increase in addition, the perceived risk of depend on the potency and amount past-month marijuana use after the marijuana use is at an all-time low, that is ingested. Maximum blood enactment of recreational marijuana with only 20% of high school seniors concentration after consuming legalization among students in eighth perceiving marijuana use as marijuana edibles occurs in ∼2 and 10th grades in Washington state harmful.30 Evidence on the impact of hours.37 Therefore, people may but not in Colorado.21 A longitudinal marijuana legalization remains consume marijuana and not feel any study of families that lived in preliminary given that the regulation effects initially. As a result, they may Washington state for .1 generation changes have only recently been continue consuming and ultimately found that after marijuana implemented. Therefore, it is critical extreme and legalization, parents were 3 times to continue researching this issue and psychosis.38 In addition, adolescent more likely to say they would tolerate monitor youth clinically for the exposure to marijuana predicts up to marijuana use compared with the negative consequences of marijuana a twofold increased risk of developing previous generation, suggesting that on overall health and functioning. psychosis and in changes in legal status can indeed adulthood.35 This finding has been impact risk perception.27 Recent data replicated multiple times in large IMPACT OF MARIJUANA USE ON published in the Journal of the cohort studies controlling for MENTAL HEALTH OUTCOMES American Medical Association multiple variables, including family Pediatrics showed no increase in Addiction, development of psychosis, history, psychosis preceding teenaged marijuana use after and are among the serious marijuana use, and intoxication at the marijuana medicalization and mental health concerns associated time of final assessment. This finding a possible decrease in use after with adolescent marijuana use. is also dose dependent, meaning that recreational marijuana legalization.28 the more marijuana to which youth However, interpretation of these Marijuana Use and Addiction are exposed, the greater the odds are results is limited by pooling states An estimated 17% of youth who use of developing psychosis as an adult.35 with different medicalization and marijuana develop a cannabis use legalization structures and by the disorder.31 Symptoms of cannabis use Marijuana Use and Suicide findings discussed above that states disorder are similar to those of other A recent study of 7805 dizygotic and with a high prevalence of use are substance use disorders, and the 6181 monozygotic twins showed that more likely to legalize marijuana. American Psychiatric Association among twins discordant for using 100

Downloaded from www.aappublications.org/news by guest on September 25, 2021 PEDIATRICS Volume 145, number s2, May 2020 S167 or more times in their life, the twin cerebellum.42 These changes in gray- despite efforts to reduce exclusionary using marijuana was 2.1 times more matter volume are associated with discipline. One limitation of these likely to have a lifetime history of reduced performance on a perceptual data is that they include all major depressive disorder, 2.6 times reasoning index and generalized substances. Future studies will more likely to have a lifetime history anxiety symptoms.42 hopefully track school suspension of suicidal ideation, and 4.4 times and expulsion rates by substance. more likely to have a lifetime history Marijuana Use and Cognition of a suicide attempt.39 Of note, youth Marijuana intoxication causes Other studies found significant with onset of depression, suicidal impairments in attention, positive associations between ideation, or suicide attempt before concentration, decision-making, marijuana use during marijuana use were not included in impulsivity, and working memory.35 and later anxiety and depression, these analyses. A recent meta-analysis In daily users, this impairment may paralleled by academic did not find a relationship between last for up to 4 weeks after last use.35 unpreparedness, delinquency, and 49 acute marijuana use and suicidal It appears that marijuana use of at poorer academic performance. The ideation or behavior but did find least 4 days per week starting in negative consequences of failing to associations between chronic or adolescence and continuing into complete schooling on outcomes later heavy marijuana use and death by adulthood predicts a decline in IQ of in life have also been demonstrated. suicide (odds ratio [OR] = 2.56), up to 8 points.43 This finding only Marijuana use before 21 years of age suicidal ideation (OR = 2.53), and applied to adolescent-onset, not was associated with higher suicide attempt (OR = 3.2).40 adult-onset, users and did not change unemployment, welfare dependence, with a year of abstinence.43 lower levels of income, lower Frequency of use predicts decreased satisfaction with relationships, and IMPACT OF MARIJUANA USE ON executive functioning and learning, lower life satisfaction at 25 years of COGNITIVE OUTCOMES 50 especially for adolescents with age. Three principle concerns have been initiation of use by 14 years of age.44 associated with marijuana use and Furthermore, weekly use compared cognitive outcomes in youth: negative with no marijuana use predicts MARIJUANA USE AND DRIVING impact on brain development, deficits in executive functioning and negative impact on cognition, and verbal IQ for up to 30 days.45 Driving while impaired can result in negative impact on academic automobile crashes, injuries, and performance. Marijuana Use and Academic death. The National Highway Traffic Performance Safety Administration recommends Marijuana Use and Brain There is strong evidence that youth not driving for at least 3 hours after Development who use marijuana, on average, have marijuana. Drivers who During adolescence, the brain less academic success.46,47 For consume edibles may need to wait undergoes major brain maturation example, in a 10-year longitudinal longer. One study examined the processes, including gray-matter study of 1265 youth in , proportion of traffic fatalities reduction, myelination, rewiring, teenagers who used marijuana by nationally in which the driver tested decrease in synapses and dendrites, 15 years of age were 3.6 times less positive for marijuana.51 The study and changes in the ratio of various likely to graduate from high school, found significant increases in neurotransmitters. Because the 2.3 times less likely to enroll in Colorado compared with nonmedical adolescent brain is still developing, college, and 3.7 times less likely to marijuana states starting in 2009. adolescent marijuana use may be earn a college degree.46 Furthermore, One limitation of the study is a lack of associated with enhanced negative youth who use marijuana at least information on the amount of effects on brain structure and weekly, compared with those who do intoxication at the time of the crash. function.41 A more recent study not use, are 60% more likely to drop Therefore, conclusive data on the revealed greater gray-matter volume out of high school.47 School impact of legalization on traffic in adolescents with only 1 or 2 suspensions and expulsions for fatalities are still needed. However, instances of marijuana use in regions substance use further hinder recent evidence suggests that traffic rich in type 1 graduation and academic fatalities related to marijuana use are and gene performance. In 2009, the Colorado increasing.51 Therefore, teenagers expression.42 These regions include Department of Education reported and parents should be counseled to the bilateral medial temporal lobes as a 40% increase in school suspensions avoid driving within at least 3 hours well as the bilateral posterior and expulsions for substance use.48 of smoking marijuana and longer if cingulate, lingual gyri, and This increase has been sustained edibles are consumed.

Downloaded from www.aappublications.org/news by guest on September 25, 2021 S168 LADEGARD et al EFFECTIVE INTERVENTIONS FOR procedure used to screen teenagers for deterring substance use in MARIJUANA USE IN THE PEDIATRIC may be important as well because multiple contexts, including schools VISIT evidence suggests that adolescents and pediatric care.60 A handful of The Screening, Brief Intervention, and perceive computer-administered studies on family-focused BI in high Referral to Treatment approach is substance use screens to be more school settings and pediatric clinics widely recommended as part of the confidential than paper-and-pencil demonstrated that BI incorporating routine visit in pediatric primary and/or interview screening formats caregivers has added value over 61 care.52 Pediatricians should ask all and therefore may provide more valid adolescent-only BI. This patients about marijuana use during and accurate responses on intervention may be ideal when 57 routine and preventive appointments technology-based screens. families are involved; however, as well as during nonpreventive pediatricians should inform For patients who report marijuana appointments. The American adolescent patients that they will use, pediatricians should inquire fi Academy of Pediatrics policy maintain con dentiality. Adolescents about frequency and amount, statement on Screening, Brief are more likely to disclose substance tolerance and withdrawal symptoms, Intervention, and Referral to use behavior with pediatricians when and attempts to reduce use and fi 62 Treatment suggests that adolescents con dentiality is assured. provide counsel about marijuana- be asked about their use of alcohol, related harms.58 Pediatricians should An important issue in adolescent tobacco, and other drugs every time offer all patients with problematic use substance use is cooccurring they seek medical services.52 brief advice and counseling while psychiatric disorders, which present Adolescents report a desire to discuss incorporating simple motivational an opportunity for pediatricians to alcohol and drug use with their interviewing (MI) techniques because effectively intervene by treating these pediatricians but have apprehension preliminary research of brief conditions. For example, the Cannabis about bringing up the topic.53 interventions (BIs) for cannabis users Youth Treatment Study found that Pediatricians have a unique has shown promising results.59 At ∼80% of youth had a cooccurring opportunity to encourage teenagers a 3-month follow-up, for example, psychiatric disorder and 60% had to talk about substance use and guide teenagers who received a BI of MI a history of emotional, physical, or them into treatment if warranted. reported less marijuana use, lower sexual abuse.63 The prevalence of When screening adolescents, using perceived prevalence of marijuana these conditions were found even a validated tool is imperative because use, fewer friends who used with exclusion criteria that excluded a large study found that pediatricians marijuana, and lower intention to use youth with severe psychiatric and conducting informal screening marijuana in the next 6 months substance use disorders. fi identi ed only 63% of adolescents compared with teenagers assigned to Pediatricians can identify and treat with substance use, with the lowest usual care.59 At first, this may seem comorbid depression, with data detection rates being observed for impractical because of time suggesting that fluoxetine may be youth with the most serious constraints of clinical practice, but the a good first agent.64 Although 54 substance use problems. The Car, use of computers to facilitate the attention-deficit/hyperactivity Relax, Alone, Forget, Friends, Trouble process can increase the frequency disorder symptoms are not “ ” (also known as CRAFFT ) Screening and quality of brief advice from the uncommon in adolescents with Test is a validated screening tool to physician with minimal time burden , and identify problematic use and has been during the visit. One study, for comorbidity is frequent, studies have recently updated to include vaping example, used a brief advice system not conclusively demonstrated the and edibles as methods of consisting of computerized screening efficacy of atomoxetine.65 There is 55 administration of marijuana. and an educational component before empirical support that osmotic- However, if pediatricians are limited the visit, which took 5 minutes of can lead to by time, a single screening question patient time, and provider advice improvement in attention-deficit/ (ie, “How often have you used during the visit, which took 2 to hyperactivity disorder symptoms and marijuana over the past year?”)isas 3 minutes during the encounter.60 a reduction in positive drug screen effective as the full screening test This intervention resulted in reduced results.66 However, addressing when triaging adolescents into 4 risk adolescent alcohol and marijuana use comorbidities will not cure the categories, including no risk (no in Prague, with effects persisting substance use disorder (including history of use), mild risk (history of through the 12-month study period.60 marijuana), so continual evaluation past-year use), moderate risk (history Adolescent substance use education for relapses is a must.67–69 of monthly use), and severe risk and personalized feedback are pillars Addressing cooccurring psychiatric (history of weekly use).56 The of BI that have shown positive effects problems may be a way for teenagers

Downloaded from www.aappublications.org/news by guest on September 25, 2021 PEDIATRICS Volume 145, number s2, May 2020 S169 without motivation to change to promising outcomes. The first youth ,18 years of age. Of these, 1.1 access care initially. In fact, baseline successful selective intervention is million (92%) go untreated, most motivation for change does not the Nurse-Family Partnership, which often because of a lack of access to predict adolescent substance provides in-home educational and care.77 Access is even worse for treatment outcomes.70 Therefore, emotional support to new mothers.73 African American and Latino youth, engaging precontemplative teenagers This support has been shown to who are more likely to access in treatment can be a helpful significantly reduce arrests, treatment through juvenile justice intervention. Pediatricians should convictions, risky sexual behaviors, involvement compared with white refer patients who are unable to and substance use at 15 years of age. youth.25 Providing treatment in reduce use or who are experiencing Another selective intervention nontraditional community settings, harms from marijuana use to program called Project Towards No such as recreational centers, pediatric substance use treatment while Drug Abuse provides 6 weeks of 40- clinics, and schools, might be a way to ensuring that those patients remain to 50-minute lessons in social skills.72 improve access to care. In terms of connected to primary care.71 This intervention can be delivered in access, the primary care setting school-based and other nonclinical presents a unique venue to intervene EFFECTIVE INTERVENTIONS AND settings. Although studies show it with adolescents who use substances TREATMENTS does not reduce marijuana use, it because 62% of youth 14 to 17 years does seem to reduce use of of age visit a physician at least once Fortunately, adolescent substance use substances other than tobacco and per year, and 83% of youth from this treatment after legalization is just as 72 marijuana. Finally, MI is another age group are seen at least once over effective as it was prelegalization. 78 promising selective intervention. For a 2-year period. During a time when Universal prevention programs are example, 1 to 3 sessions of MI for marijuana policies continue to shift frequently administered in school- high school students using substances and youth continue to explore the use based settings and provide all youth has been shown to reduce substance of substances, pediatricians are with education and substance-refusal use compared with assessment only uniquely positioned to educate and skills.72 The effect size of universal at 6-month follow-up.74 positively intervene with youth using prevention programs is generally low. substances, thereby promoting health Despite the popularity of these For youth with cannabis use disorder, for vulnerable communities. programs due to their ability to reach cognitive behavioral therapy plus a large number of students, there are contingency management increased only 3 universal prevention programs 72 the proportion of youth achieving that have empirical support. The a month of abstinence by the end of CONCLUSION, GAPS, AND FUTURE fi DIRECTIONS rst program is the Good Behavior treatment (from 31% to 53%) Game, which is used to promote compared with youth who just As the trend toward legalization social and emotional learning for received cognitive behavioral therapy evolves, the medical community will fi rst- and second-grade students. The alone.75 Another study showed that continue to see adverse health second program is the Unplugged the inclusion of contingency impacts on youth. Pediatricians will program, which was designed in management with MI into adolescent increasingly find themselves Europe to teach middle school marijuana treatment decreased the confronted with the challenges of students life skills related to end-of-treatment frequency of treating this vulnerable population. substance use prevention. Finally, the marijuana use and related We have attempted to summarize the Life Skills Program provides middle consequences while increasing the key issues known to date as they school students with general life use of coping strategies and the relate to marijuana consumption and skills, such as problem-solving and pursuit of additional treatment. MI health outcomes. However, we must drug refusal. These skills are then plus contingency management emphasize that long-term data on reinforced with booster sessions in resulted in a significantly lower outcomes of early-onset marijuana high school. frequency of marijuana use initially at use are still in their infancy, and there The research on selective and the end of treatment (8 weeks after are still unknown factors. There does indicated prevention interventions baseline to the intervention) but not not seem to be a safe amount of for adolescent substance use is even at follow-up 16 weeks after marijuana for adolescents to more limited than the body of baseline.76 Despite having effective consume, and some adolescents seem research on universal school-based treatments for adolescent substance to be most vulnerable to marijuana’s prevention programs.72 Among the use, access to treatment is a problem. effects. Future studies are needed to selective intervention programs, For 1.2 million youth each year, identify populations that could be there are 3 that have shown occurs in more at risk for psychiatric and

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