Advertisement

Teen Reports of Cannabis for Medical Reasons—What Does That Mean?

      See Related Article on p.103
      The perception of potential harm from regular use of cannabis is at an all-time low among youth [
      • Johnston L.D.
      • Miech R.A.
      • O’Malley P.M.
      • et al.
      Monitoring the future national survey results on drug use, 1975-2019: Overview, key findings on adolescent drug use.
      ], which parallels escalating youth rates of frequent and risky patterns of cannabis use [
      National Institute of Health
      Drug facts: Monitoring the future survey: High school and youth trends.
      ]. These data raise troubling public health concerns because of the well-documented potential for substantial adverse consequences associated with misuse of cannabis among youth, e.g., poor educational outcomes, increased mental health issues, higher rates of substance use disorders, effect on neurodevelopment, impaired driving, and potential respiratory disorders associated with vaping [
      • Volkow N.D.
      • Swanson J.M.
      • Evins A.E.
      • et al.
      Effects of cannabis use on human behavior, including cognition, motivation, and psychosis: A review.
      ,
      • Silins E.
      • Horwood L.J.
      • Patton G.C.
      • et al.
      Young adult sequelae of adolescent cannabis use: An integrative analysis.
      ,
      • Gobbi G.
      • Atkin T.
      • Zytynski T.
      • et al.
      Association of cannabis use in adolescence and risk of depression, anxiety, and suicidality in young adulthood: A systematic review and meta-analysis.
      ,
      • Lisdahl K.M.
      • Wright N.E.
      • Kirchner-Medina C.
      • et al.
      Considering cannabis: The effects of regular cannabis use on neurocognition in adolescents and young adults.
      ].
      Temporally parallel to these disturbing trends is the escalation of cannabis legalization and, in particular, medical cannabis laws—32 of the 50 State congresses in the U.S. have passed “medical marijuana” or “therapeutic cannabis” laws condoning the possession, purchase, and use of cannabis to use as “medicine.” Canada has had national medical marijuana laws in place since 2001 with a steady progression of medical authorizations, particularly in the past few years. The list of health conditions approved for use and purchase of cannabis has steadily increased, de facto informing the public, including minors, that cannabis is a proven effective treatment for a myriad of physical and psychological conditions—with virtually no compelling clinical data to support its efficacy for the great majority of these conditions [
      • Wilkinson S.T.
      • Radhakrishnan R.
      • D’Souza D.C.
      A systematic review of the evidence for medical marijuana in psychiatric indications.
      ,
      • D’Souza D.C.
      • Ranganathan M.
      Medical marijuana: Is the cart before the horse?.
      ,
      • Hadland S.E.
      • Knight J.R.
      • Harris S.K.
      Medical marijuana: Review of the science and implications for developmental-behavioral pediatric practice.
      ,
      • Hill K.P.
      Medical marijuana for treatment of chronic pain and other medical and psychiatric problems: A clinical review.
      ]. In contrast to “recreational” or “commercial” cannabis laws that restrict purchase and possession to those 21 years and older, the minimum age for medical marijuana access is 18 years in 30 of the 32 U.S. States with cannabis medical laws, and most States allow adults to purchase and distribute cannabis products to even younger children with “approved conditions.” Similarly, most stipulations across Canada allow persons of any age to access cannabis if approved by a medical provider. Such earlier age access to youth disregards and weakens the well-accepted 21 years and older restriction/safeguard implemented to reduce the potential developmental consequences of cannabis use and misuse.
      As addressed by Wardell et al. [
      • Wardell J.D.
      • Rueda S.
      • Elton-Marshall P.
      • et al.
      Prevalence and correlates of medicinal cannabis use among adolescents.
      ] in their article in this issue, Prevalence and Correlates of Medicinal Cannabis Use among Adolescents, there has become an urgent need for understanding the phenomenology of youth “medical” use of cannabis and its true impact on teens and young adults in the context of the changing cannabis landscape. Wardell et al. inform us that there is not much of a scientific literature on the topic of youth and medical cannabis. Their primary findings showed a strong positive association between the reporting of “medical use” of cannabis and multiple indicators of cannabis and other substance misuse, and poor health and psychosocial functioning. The few other cross-sectional and prospective published studies, cited in this article’s Discussion, generally affirm this troubling association [
      • Pedersen E.R.
      • Tucker J.S.
      • Seelam R.
      • et al.
      Factors associated with acquiring a medical marijuana card: A longitudinal examination of young adults in California.
      ,
      • Tucker J.S.
      • Rodriguez A.
      • Pedersen E.R.
      • et al.
      Greater risk for frequent marijuana use and problems among young adult marijuana users with a medical marijuana card.
      ,
      • Kim J.
      • Coors M.E.
      • Young S.E.
      • et al.
      Cannabis use disorder and male sex predict medical cannabis card status in a sample of high risk adolescents.
      ,
      • Boyd C.J.
      • Veliz P.T.
      • McCabe S.E.
      Adolescents’ use of medical marijuana: A secondary analysis of monitoring the future data.
      ]. That said, multiple methodological caveats obfuscate the discussion and interpretation of reported findings from these types of studies. Perhaps the most basic of these limitations relates to the simple question, what is meant by “medical” use, i.e., how is it operationally defined?
      The Wardell et al. study fails to provide a highly meaningful definition, which unfortunately reflects the current norm in the field. The survey item used to designate medical use reads, “In the last 12 months, have you used cannabis (in any form) to manage pain, nausea, or any other medical problem?” Those who respond yes are designated as the medical use group, and are compared with those who respond no, i.e., the recreational use group. To their credit, Wardell et al. discuss the substantial limitations of this item and the resulting characterizations of the groups: (1) nearly all those in the medical use group also would likely respond yes to an item that asks, have you used for recreation or for the pleasurable effects; (2) it is not clear if the medical use question includes use for mental symptoms or disorders, which are the most prevalent medical reasons provided by users of cannabis other than for pain; the authors suggest that their respondents likely did not consider psychiatric issues as medical disorders, but I would posit that we do not know how youth (or adults) interpret the phrase “any other medical problem” particularly in the context of a cannabis use survey; (3) no information is available on what medical problem(s) these youth perceive they have, or on whether they have “authorization” to use cannabis from a health care provider; and (4) we do not know if those that respond “no” have health conditions that impact their cannabis use without being aware of this connection.
      An equally important methods’ issue that will be obvious to some but perhaps not to others is the failure to define “cannabis.” Clinical research on cannabis, whether as an addictive or therapeutic substance, must differentiate between use of cannabis products with substantial amounts of delta-9 tetrahydrocannabinol (THC) or cannabidiol (CBD). THC is the compound that produces the typical euphoric and pleasurable effects and the adverse effects commonly associated with marijuana, including misuse and addiction. CBD is the compound that has generated a tremendous amount of recent interest related to its potential for therapeutic effects. Note that CBD does not produce the euphoria or the adverse effects commonly associated with THC-laden cannabis [
      • Babalonis S.
      • Haney M.
      • Malcolm R.J.
      • et al.
      Oral cannabidiol does not produce a signal for abuse liability in frequent marijuana smokers.
      ,
      • Larsen C.
      • Shahinas J.
      Dosage, efficacy and safety of cannabidiol administration in adults: A systematic review of human trials.
      ]. In Wardell et al., it appears that the definition used in asking about medical use is “cannabis (in any form)”. Therefore, we do not know what type of cannabis products these youth are referring to when they report medical use, or if what they use differs at all from what the comparison group uses.
      Given these methodological weaknesses, what can we glean with confidence about “medicinal” use of cannabis from this data set? The observed associations or the lack thereof between medical use and patterns of cannabis use and consequences, other substance use patterns and consequences, and specific psychosocial problems can lead to intriguing speculation about what reporting medical use may tell us about these youth, how it impacts the frequency and quantity of their use patterns or their general functioning, and how regulatory policy contributes to these findings. Such suppositions, however, should not be considered completely harmless observations offered to stimulate better designed and controlled research studies. In many instances, discussion points from these types of observational studies are intentionally or unintentionally cited as evidence by those seeking to either promote or demonize cannabis use. The consequences of which can have important public health impact by influencing perceptions of risks and benefits and regulatory policy. Notably, Wardell et al. generally do well in refraining from speculation and alerting the reader to the limitations of their study. One could assert that the only valid conclusions from the study are that youth responding “yes” to a relatively vague question about using cannabis for medical reasons is a marker for greater probability of also reporting (1) risky patterns of cannabis use; (2) problems typically associated with cannabis misuse; and (3) other health psychosocial problems, than youth who respond “no.” Hence, this exact question could potentially serve as a screening item for predicting problems among youth who report cannabis use, but it tells us very little about medical use of cannabis.
      It is time to elevate our research efforts on this topic. We have a pressing need for higher quality, more sophisticated epidemiologic survey research on what is now commonly referred to as medical marijuana. The public, health care providers, and regulatory bodies require better science and more accurate reporting of research findings to facilitate an informed and nuanced discussion of this phenomenon. The increasing acceptance of cannabis as medicine with concurrent decreasing perceptions of its risks has high potential to have substantial adverse impact on the physical and mental health of our youth. We can do much better. We should try to avoid conducting surveys that include just one or two ill-defined items on medical use, and instead include the multitude of questions needed to accurately describe cannabis use patterns and antecedent motivations for use, e.g., THC/CBD product content, use/dosing frequency and quantity, existing medical or psychiatric symptoms or condition(s), health care provider authorized or not, “nonmedical” use frequency and quantity, duration of use, and alternative motivations for cannabis use, perceptions of benefits and risks, and so forth. Such studies must also ensure that participants understand what is being asked, particularly in regard to what is meant by cannabis or marijuana (THC-laden, CBD only, and so forth.). Similarly, reports and publications must strive to use more exact language to describe the cannabis that is under study or the definition used to operationalize medical use. Moreover, inclusion of background education on cannabis compounds and regulations can ensure more accurate and informative communications to the reader.
      The current culture of cannabis legalization and medicalization has strong implications and societal consequences for youth and adults, although their nature and magnitude remain unclear [
      • Budney A.J.
      • Sofis M.J.
      • Borodovsky J.T.
      An update on cannabis use disorder with comment on the impact of policy related to therapeutic and recreational cannabis use.
      ]. Quality research and accurate information is desperately needed to provide guidance on how best to reduce risks to those most vulnerable to the adverse consequences of cannabis, and to evaluate potential therapeutic benefits of the different cannabis compounds [
      • Borodovsky J.T.
      • Budney A.J.
      Cannabis regulatory science: Risk-benefit considerations for mental disorders.
      ]. Studies like Wardell et al. are a start, but much more sophisticated inquiries and methods are required to avoid confusion, speculation, and misrepresentation of research findings related to the poorly defined phenomenon of medical marijuana.

      References

        • Johnston L.D.
        • Miech R.A.
        • O’Malley P.M.
        • et al.
        Monitoring the future national survey results on drug use, 1975-2019: Overview, key findings on adolescent drug use.
        Institute for Social Research, The University of Michigan, Ann Arbor2020
        • National Institute of Health
        Drug facts: Monitoring the future survey: High school and youth trends.
        National Institute of Health, 2019 (Drug Facts. Available at:)
        • Volkow N.D.
        • Swanson J.M.
        • Evins A.E.
        • et al.
        Effects of cannabis use on human behavior, including cognition, motivation, and psychosis: A review.
        JAMA Psychiatry. 2016; 73: 292-297
        • Silins E.
        • Horwood L.J.
        • Patton G.C.
        • et al.
        Young adult sequelae of adolescent cannabis use: An integrative analysis.
        Lancet Psychiatry. 2014; 1: 286-293
        • Gobbi G.
        • Atkin T.
        • Zytynski T.
        • et al.
        Association of cannabis use in adolescence and risk of depression, anxiety, and suicidality in young adulthood: A systematic review and meta-analysis.
        JAMA Psychiatry. 2019; 76: 426-434
        • Lisdahl K.M.
        • Wright N.E.
        • Kirchner-Medina C.
        • et al.
        Considering cannabis: The effects of regular cannabis use on neurocognition in adolescents and young adults.
        Curr Addict Rep. 2014; 1: 144-156
        • Wilkinson S.T.
        • Radhakrishnan R.
        • D’Souza D.C.
        A systematic review of the evidence for medical marijuana in psychiatric indications.
        J Clin Psychiatry. 2016; 77: 1050-1064
        • D’Souza D.C.
        • Ranganathan M.
        Medical marijuana: Is the cart before the horse?.
        JAMA. 2015; 313: 2431-2432
        • Hadland S.E.
        • Knight J.R.
        • Harris S.K.
        Medical marijuana: Review of the science and implications for developmental-behavioral pediatric practice.
        J Dev Behav Pediatr. 2015; 36: 115-123
        • Hill K.P.
        Medical marijuana for treatment of chronic pain and other medical and psychiatric problems: A clinical review.
        JAMA. 2015; 313: 2474-2483
        • Wardell J.D.
        • Rueda S.
        • Elton-Marshall P.
        • et al.
        Prevalence and correlates of medicinal cannabis use among adolescents.
        J Adolesc Health. 2021; 68: 103-109
        • Pedersen E.R.
        • Tucker J.S.
        • Seelam R.
        • et al.
        Factors associated with acquiring a medical marijuana card: A longitudinal examination of young adults in California.
        J Stud Alcohol Drugs. 2019; 80: 687-692
        • Tucker J.S.
        • Rodriguez A.
        • Pedersen E.R.
        • et al.
        Greater risk for frequent marijuana use and problems among young adult marijuana users with a medical marijuana card.
        Drug Alcohol Depend. 2019; 194: 178-183
        • Kim J.
        • Coors M.E.
        • Young S.E.
        • et al.
        Cannabis use disorder and male sex predict medical cannabis card status in a sample of high risk adolescents.
        Drug Alcohol Depend. 2018; 183: 25-33
        • Boyd C.J.
        • Veliz P.T.
        • McCabe S.E.
        Adolescents’ use of medical marijuana: A secondary analysis of monitoring the future data.
        J Adolesc Health. 2015; 57: 241-244
        • Babalonis S.
        • Haney M.
        • Malcolm R.J.
        • et al.
        Oral cannabidiol does not produce a signal for abuse liability in frequent marijuana smokers.
        Drug Alcohol Depend. 2017; 172: 9-13
        • Larsen C.
        • Shahinas J.
        Dosage, efficacy and safety of cannabidiol administration in adults: A systematic review of human trials.
        J Clin Med Res. 2020; 12: 129-141
        • Budney A.J.
        • Sofis M.J.
        • Borodovsky J.T.
        An update on cannabis use disorder with comment on the impact of policy related to therapeutic and recreational cannabis use.
        Eur Arch Psychiatry Clin Neurosci. 2019; 269: 73-86
        • Borodovsky J.T.
        • Budney A.J.
        Cannabis regulatory science: Risk-benefit considerations for mental disorders.
        Int Rev Psychiatry. 2018; 30: 183-202

      Linked Article