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The Prevention of Nonmedical Marijuana Use Must Extend Past Adolescence

      See Related Articles on p.47
      Concerns about the normalization of marijuana use among youth are growing as liberalization of state drug laws becomes more prevalent. Although the available research on the effects of the legalization of nonmedical (“recreational” or “adult”) marijuana use on young people is still in its early stages, most published studies focus on changes in marijuana risk perceptions [
      • Johnston L.D.
      • Miech R.A.
      • O’Malley P.M.
      • et al.
      Monitoring the Future national survey results on drug use 1975-2021: Overview, key findings on adolescent drug use.
      ], initiation [
      Center for Behavioral Health Statistics and Quality
      Results from the 2020 National Survey on Drug Use and Health: Detailed tables.
      ], use [
      • Lachance A.
      • Bélanger R.E.
      • Riva M.
      • Ross N.A.
      A systematic review and narrative synthesis of the evolution of adolescent and young adult cannabis consumption before and after legalization.
      ], and consequences [
      • Scheier L.M.
      • Griffin K.W.
      Youth marijuana use: A review of causes and consequences.
      ,
      • Lorenzetti V.
      • Hoch E.
      • Hall W.
      Adolescent cannabis use, cognition, brain health and educational outcomes: A review of the evidence.
      ] among adolescents. This focus is reasonable since adolescence is a stage of development when the human brain undergoes dramatic change and is highly vulnerable to the lures and consequences of any type of addictive substance, including marijuana [
      • Levine A.
      • Clemenza K.
      • Rynn M.
      • Lieberman J.
      Evidence for the risks and consequences of adolescent cannabis exposure.
      ,
      • Hurd Y.L.
      • Manzoni O.J.
      • Pletnikov M.V.
      • et al.
      Cannabis and the developing brain: Insights into its long-lasting effects.
      ,
      • Peters K.Z.
      • Zlebnik N.E.
      • Cheer J.F.
      Cannabis exposure during adolescence: A uniquely sensitive period for neurobiological effects.
      ].
      Yet, these concerns do not disappear when a child turns 21, the age at which certain forms of substance use becomes legal, despite no scientific evidence that 21-year-olds are markedly less susceptible to the same substance use–related concerns as their adolescent counterparts. In fact, the scientific consensus points to the mid- to late twenties as the age when intense brain development and maturation is closer to complete, making early adults as vulnerable as adolescents to the adverse effects of marijuana [
      • Sowell E.R.
      • Thompson P.M.
      • Holmes C.J.
      • et al.
      In vivo evidence for post-adolescent brain maturation in frontal and striatal regions.
      ,
      • De Faria L.
      • Mezey L.
      • Winkler A.
      Cannabis legalization and college mental health.
      ]. That is why research on emerging or young adults is so important, especially as there are indications that while a growing number of them are reducing their alcohol use, they are increasing their use of nonmedical marijuana [
      • Alley Z.M.
      • Kerr D.C.R.
      • Bae H.
      Trends in college students' alcohol, nicotine, prescription opioid and other drug use after recreational marijuana legalization: 2008-2018.
      ,
      • Schulenberg J.E.
      • Patrick M.E.
      • Johnston L.D.
      • et al.
      Monitoring the Future national survey results on drug use, 1975–2020: Volume II, College students and adults ages 19–60.
      ].
      It has become clear in recent years that, with few exceptions, rates of all forms of substance use, including marijuana use, are trending downward among adolescents [
      • Johnston L.D.
      • Miech R.A.
      • O’Malley P.M.
      • et al.
      Monitoring the Future national survey results on drug use 1975-2021: Overview, key findings on adolescent drug use.
      ]. However, the same is not true among early adults. The Monitoring the Future study found that daily marijuana use reached a 40-year all-time high among 19- to 22-year-old full-time college students in 2020 [
      • Schulenberg J.E.
      • Patrick M.E.
      • Johnston L.D.
      • et al.
      Monitoring the Future national survey results on drug use, 1975–2020: Volume II, College students and adults ages 19–60.
      ]. Similarly, the National Survey on Drug Use and Health found no recent decline in marijuana use among young adults, despite significant declines among adolescents [
      Substance Abuse and Mental Health Services Administration
      Key substance use and mental health indicators in the United States: Results from the 2020 National Survey on Drug Use and Health (HHS Publication No. PEP21-07-01-003, NSDUH Series H-56).
      ]. The research also suggests that state legalization of nonmedical marijuana use is associated with higher usage rates among young people [
      • Lachance A.
      • Bélanger R.E.
      • Riva M.
      • Ross N.A.
      A systematic review and narrative synthesis of the evolution of adolescent and young adult cannabis consumption before and after legalization.
      ,
      • Barker A.K.
      • Moreno M.A.
      Effects of recreational marijuana legalization on college students: A longitudinal study of attitudes, intentions, and use behaviors.
      ,
      • Bae H.
      • Kerr D.C.R.
      Marijuana use trends among college students in states with and without legalization of recreational use: Initial and longer-term changes from 2008 to 2018.
      ,
      • Han D.H.
      • Seo D.C.
      Identifying risk profiles for marijuana vaping among U.S. young adults by recreational marijuana legalization status: A machine learning approach.
      ] and may be associated with more adverse marijuana-related consequences [
      • Chandler L.
      • Abdujawad A.W.
      • Mitra S.
      • McEligot A.J.
      Marijuana use and high-risk health behaviors among diverse college students post- legalization of recreational marijuana use.
      ,
      • Matthay E.C.
      • Kiang M.V.
      • Elser H.
      • et al.
      Evaluation of state cannabis laws and rates of self-harm and assault.
      ].
      With all the uncertainty surrounding the effects of nonmedical marijuana legalization on youth well-being, studies that approach this question in a rigorous way without bias or an obvious agenda are in short supply. This type of research is sorely needed to inform the debate around broader legalization efforts on the state and federal levels; to determine the most effective provisions to include in state regulations that can protect minors and young adults from exposure, access, and use of the drug; and to identify where to focus prevention and early intervention efforts and resources.
      Through a set of clear analyses of young adult marijuana use in the context of nonmedical legalization in Washington State—one of the first two states to do so—Fleming et al.’s [
      • Fleming C.B.
      • Ramirez J.J.
      • Rhew I.C.
      • et al.
      Trends in alcohol, nicotine, and nonprescribed pain reliever use among young adults in Washington State after legalization of nonmedical cannabis.
      ] study, published in this issue, provides an objective assessment of some of the possible effects of legalization on young adult substance use. The findings are consistent with other research showing the general longstanding trend toward polysubstance use among youth, especially those who use marijuana [
      • Chandler L.
      • Abdujawad A.W.
      • Mitra S.
      • McEligot A.J.
      Marijuana use and high-risk health behaviors among diverse college students post- legalization of recreational marijuana use.
      ]. What is unique is their finding that this polysubstance use pattern appeared to trend downward in recent years among young adults, especially with regard to the co-occurring misuse of alcohol and opioids. This is supported by research showing declining preference for alcohol among young adults, especially in states with legalized recreational marijuana use [
      • Alley Z.M.
      • Kerr D.C.R.
      • Bae H.
      Trends in college students' alcohol, nicotine, prescription opioid and other drug use after recreational marijuana legalization: 2008-2018.
      ] (even the alcohol industry is voicing concern about keeping and growing a customer base in light of diminished interest in alcohol products among young people [
      • Asimov E.
      The wine business sees a problem: Millennials aren’t drinking enough. The New York Times.
      ]) and the significant decline in national rates of prescription opioid misuse among those ages 18–25 [
      Substance Abuse and Mental Health Services Administration
      Key substance use and mental health indicators in the United States: Results from the 2020 National Survey on Drug Use and Health (HHS Publication No. PEP21-07-01-003, NSDUH Series H-56).
      ]. Whether this trend away from polysubstance use among those who use marijuana is related to legalization of nonmedical marijuana cannot be determined by this study, leaving open the question of whether the “decoupling” of marijuana use and other substance use among young adults is unique to the circumstances in a state where the drug has been legalized and likely normalized, or whether it merely demonstrates a trend of young adults’ preference for marijuana over other forms of substance use.
      Although the alcohol and opioid misuse trends found by Fleming et al. are encouraging, the findings speak to the need to broaden marijuana-related prevention efforts to focus on young adults as well as adolescents. It is within this age group that such use is not only normalized and perceived as relatively harmless, but is also legal to use, further reinforcing the false belief that once young people exit adolescence, they are no longer in need of protection from the drug. Unless we change the narrative around marijuana use to more clearly acknowledge the accumulating research evidence regarding its risks to adolescents and to early adults as well, the young adult age group is likely to face yet another addiction-related crisis as they continue to be hardest hit by the vaping and opioid epidemics in the United States.

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        (Available at:)

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