Donna Hallas, PhD, PPCNP-BC, CPNP, PMHS, FAANP, FAAN 

Even though marijuana, or cannabis, has been identified as the most commonly used illicit drug in the United States,

 in 2012, it was legalized for nonmedical, recreational use among adults aged 21 years old and older in Colorado and Washington State.

 Since then, 15 states and Washington DC, also legalized recreational marijuana use for adults and 36 states legalized medical marijuana.

 After its legalization, several studies were conducted to determine any changes in the use of marijuana among adolescents and college-aged students. A study in Oregon looked at data from adolescents who participated in Student Wellness Surveys in 35 counties (N= 247,403) in 6th, 8th, and 11th graders. The investigators concluded that the legalization and retail availability of recreational marijuana in the state were positively associated with marijuana use among adolescents.

 In another study conducted after the legalization of marijuana in 8 states, investigators examined 2 nationally-representative surveys, the Monitoring the Future and the National Survey on Drug Use and Health, administered to 12th grade students to determine trends in the prevalence of perceived no risk of harm in using marijuana on a regular basis and the prevalence of marijuana use.

 The investigators concluded that there was a resultant increase in the adolescents’ perception of no harm to using marijuana. However, there was not a concurrent increase in use in marijuana among the adolescent population.

In 2019, the Surgeon General’s report detailed changes in concentration of delta-9-tetrahydrocannabinol (THC), the primary psychoactive ingredient in marijuana, from 1995 through 2014 that revealed a 3-fold increase in drug concentration, making the product much stronger.

 A national internet survey on drug use and health conducted by the US Department of Health and Human Services revealed that 18% of persons aged 12 years or older reported using drugs within the month prior to the survey and 1.5% of these adolescents met the criteria for cannabis use disorder.

 In addition, research studies on cannabis use during the adolescent years provide evidence for an altered trajectory in adolescent brain development and that this alteration may persist into adulthood, even following marijuana abstinence for several decades during the adult years.

 A study of 158 men aged 20 years, whose cannabis use was tracked during adolescence, showed a negative pattern of brain function. This was linked to higher levels of depression and mood symptoms and lower levels of attention, decision-making, educational achievement, memory, and motivation.

Another study revealed that marijuana use in a person’s teenaged years may be a result of what happened in utero. Investigators examined the association between prenatal cocaine exposure (PCE) and adolescent substance use and hypothesized that alterations of neurotransmitter systems because of PCE affected fetal brain development and onset of substance use disorders during adolescence.

Study results showed that adolescents with PCE were 2 times more likely to use tobacco and marijuana and have a substance use disorder at age 17 years compared with 17-year-old adolescents who were not prenatally exposed to cocaine.

 The availability and access to tobacco, marijuana, and alcohol during the adolescent years presents unique problems among pregnant and parenting adolescents. Two hundred and fifty-five pregnant adolescents, with a mean age of 16 years, participated in a study that tracked their substance use behaviors, as well as their intentions, attitudes, and beliefs about substance use, from pregnancy to 12 months’ postpartum.

 The investigators documented patterns of low-level use of cigarettes, marijuana, and alcohol during pregnancy and increased substance use in the first 6 months’ postpartum. They concluded that study participants were concerned about their infant’s well-being during pregnancy resulting in less substance use. However, the adolescents returned to their usual pattern of substance use in the postpartum period based on their perception that perceived social norms and attitudes towards substance use in the postpartum period was not opposed by friends, boyfriends, and siblings.

Speaking with adolescents about substance use is a major tenet of pediatric practices whether the adolescent presents to a pediatric primary care office, a school-based health center, an urgent care center, an emergency department, a prenatal office, or a family health care center, including Federally Qualified Health Centers. Creating a safe environment for all adolescents to openly talk with the provider about substance use is the critical first step in creating the foundation for a meaningful conversation with adolescents. Assurance of confidentiality between provider and adolescent is essential and should be clearly explained by the provider at the beginning of the encounter based on individual state law mandates. The American Academy of Pediatrics recommends universal screening in pediatric primary care settings for substance use.

There are 2 reliable and valid evidence-based substance use screening tools that can be integrated into the electronic medical record. The Screening to Brief Intervention and Brief Screener for Tobacco, Alcohol, and other Drugs tools can be completed in 2 minutes.

 Both tools screen for substance use within the past year and can be completed privately on a tablet by the adolescent while waiting to see the provider or by the provider in a face-to-face encounter with the adolescent.

 The CRAFFT Screening Interview tool, which is specifically designed for adolescents, can also be used to determine substance use by adolescents.

 The adolescent’s responses to whichever tool the provider selects must be evaluated by the provider and, if the adolescent has a positive screen, then it is imperative that a specific plan for action must be established by the adolescent and the provider on that day with appropriate follow-up plans in place.

The provider should then address the substance use with the adolescent’s parents. But how does that conversation begin? First, the provider needs to ask the parents about their personal use of marijuana. If the parent or parents are marijuana users, then a provider should ask whether the adolescent is aware? Parental use of marijuana, in the more concrete thought patterns of preteens and younger adolescents, may provide silent permission for them to also use marijuana. Have the parents considered how their child feels about their use of marijuana? Does the adolescent have access to marijuana in their household? These may be difficult and uncomfortable conversations, but providers must ask them if they are to help the parents and their adolescent patients navigate this new world of legalization of recreational marijuana.

A good starting point is to provide evidence-based educational resources for parents on marijuana use in adolescents. Parents may not know that, according to literature, parental marijuana use is associated with an elevated risk of substance use among adolescent and young adult children living in the same household.

 Furthermore, the evidence shows that parental marijuana use in households with adolescents and young adults, that marijuana is a gateway drug for broader substance use including tobacco, alcohol, and opioids.

 Parental knowledge is key. They must know that their behaviors are placing their pre-adolescents and adolescents at risk for decreased brain growth and possible problems with the law. No states have legalized recreational marijuana use for anyone aged younger than 21 years. Parents are role models and encouraging parents to consider all the evidence about substance use in adolescents is step 1 for parents who use recreational marijuana on a regular basis in their homes.

For parents who do not use marijuana, the recommendations below addressing the health care providers role in speaking with adolescents can also be used by parents. It is important for parents to speak with their adolescent(s) in generalities that doesn’t accuse them of using marijuana, other drugs, or alcohol. Providers can suggest that parents use the approach of the CRAFFT tool to begin the conversation. The first question: Have you ever been with a friend or ridden in a car driven by someone who was high or had been using alcohol or drugs? This opens conversation in a non-threatening manner and allows opportunities to listen and provide parental guidance that can help their adolescent avoid dangerous substance use situations.

Whether an adolescent tests positive or negative for substance abuse, it is highly recommended that the adolescent-provider conversation about the topic become a routine part of health care. Providers have a unique opportunity to influence adolescent behaviors via a meaningful conversation that elicits the adolescent’s knowledge base about substance use, personal feelings, and ways to avoid the allure of engaging in substance use. Providers can engage adolescents in insightful conversations about substance abuse, the detrimental effects on brain growth, and the health and well-being of adolescents and young adults. If a provider’s busy schedule does not permit the allocation of time to converse about this topic, then providers may consider having a substance abuse office-based champion who will engage each adolescent in these most important conversations.

Adams J. U.S. Surgeon General’s Advisory: Marijuana Use and the Developing Brain. HHS.gov. August 29, 2019. Accessed February 20, 2021.

 hhs.gov/surgeongeneral/reports-and-publications/addiction-and-substance-misuse/advisory-on-marijuana-use-and-developing-brain/index.html

Mason WA. Recreational marijuana legislation: What parents and adolescents know and discuss. 

 American Psychological Association. Accessed February 20, 2021. 

apa.org/science/about/psa/2015/03/recreational-marijuana

Berke J, Gal S, Yeji, JL. All the states where marijuana is legal — and 5 more that voted to legalize it in November. 

 businessinsider.com/legal-marijuana-states-2018-1

Paschall MJ, Grube JW. Recreational marijuana availability in Oregon and use among adolescents. 

. 2020;58(2):e63-e69. doi:10.1016/j.amepre.2019.09.020

Sarvet AL, Wall MM, Keyes KM, et al. Recent rapid decrease in adolescents’ perception that marijuana is harmful, but no concurrent increase in use. 

.2018;1(186):68-74. doi:10.1016/j.drugalcdep.2017.12.041

National survey on drug use and health. Substance Abuse and Mental Health Services Administration. 2018. Accessed February 26, 2021. 

Crews F, He J, Hodge C. Adolescent cortical development: a critical period of vulnerability for addiction. 

 2007;86(2):189-199. doi:10.1016/j.pbb.2006.12.001

Jager G, Ramsey NF. Long-term consequences of adolescent cannabis exposure on the development of cognition, brain structure and function: an overview of animal and human research. 

. 2008;1(2):114-123. doi:10.2174/1874473710801020114.

Lichenstein SD, Musselman S, Shaw DS, Sitnick S, Forbes EE. Nucleus accumbens functional connectivity at age 20 is associated with trajectory of adolescent cannabis use and predicts psychosocial functioning in young adulthood. 

. 2017;112(11):1961–1970. doi:10.1111/add.13882

Meruelo AD, Castro N, Cota CI, Tapert SF. Cannabis and alcohol use, and the developing brain. 

. 2017;325(Pt A):44–50. doi:10.1016/j.bbr.2017.02.025.

Minnes S, Min MO, Kim J-Y, et al. The association of prenatal cocaine exposure, externalizing behavior and adolescent substance use. 

 2017;176: 33-43. doi:10.1016/j.drugalcdep.2017.01.027

Morrison DM, Spencer, MS, Gillmore, MR. Beliefs about substance use among pregnant and parenting adolescents. 

Journal of Research on Adolescents: The Official Journal of the Society for Research on Adolescence. 

1998;8(1):69-95. doi:10.1207/s15327795jra0801_4.

Knight J, Roberts T, Gabrielli J, Van Hook S. Adolescent Alcohol and Substance Use and Abuse. 

Performing Preventive Services: A Bright Future Handbook. 

 brightfutures.aap.org/Bright%20Futures%20Documents/Screening.pdf

Parental marijuana use was associated with elevated risk of substance use among adolescent and young adult offspring living in the same household. Substance Abuse and Mental Health Services Administration. November 27, 2019. Accessed February 28, 2021.

 samhsa.gov/newsroom/press-announcements/201911271230

Articles

Over the past 9 years, a number of states have legalized the recreational use of marijuana in adults aged 21 years and older. Although teenagers aren't legally allowed to consume the substance, the legalization for adults can make it more available to teenagers and young adults. This article covers the latest evidence and offers recommendations for talking to teenagers.

Adolescent marijuana use and anticipatory guidance: What does the evidence support?

As we reflect on the past year of living within the coronavirus disease 2019 (COVID-19) pandemic, adjusting to the day-to-day demands on the entire spectrum of our lives has been overwhelming for many individuals, families, communities, as well as how to best provide individual health care and manage health care delivery systems. However, several positive changes have occurred including, most notably, the rapid development and delivery of efficacious vaccines to fight this pandemic, and the reduction in normal pathogens that notoriously adversely affect the pediatric (and adult) populations (eg, prevalence of respiratory pathogens, influenza, asthma, pneumonia, respiratory syncytial virus, etc) that provide insight to the need for public health measures to better control these illnesses. Additionally, the remarkable delivery of education and continuing education materials through significant improvements from our pre-COVID-19 digital world to the fast forward one-year later digital world has been amazing. 

is an exemplar of significant positive change in the availability of high-quality continuing educational materials readily available to the busy pediatrician and pediatric nurse practitioner (PNP).

 are easily available via hyperlinks throughout the journal. For example, in the March 2021 edition of 

, there’s a link on page 8 to the Physician Educational Resources (PER) session entitled 

 as well as a link on page 14 to an entire collection of 

 are also available for selected articles that, once scanned via a smartphone, offer additional information on a related topic.

 there is a noticeable increase in the number of organized tables and diagrams that provide cognitive organization of the most important principles in the article.

Article citations are also available via a clickable link for each article in the journal.

 from readers with easy access to emails for the Senior Editor and the Editor-in-Chief of 

In summary, I highly recommend using all of the digital tools available in each edition of the 

journal to meet continuing educational needs.

Keeping up to date with changes in clinical practices guidelines and guidance from many sources including the Centers for Disease Control and Prevention, American Academy of Pediatrics, and other national pediatric organizations has been especially challenging throughout this pandemic. We all know that what is considered best practices today, may not be best practices tomorrow based on emerging scientific evidence, in particular related to COVID-19. 

 offers access not only to summaries of clinical practice guidelines but also to evolving and significant changes in the guidelines and national guidance not only in the journal but also in a 

Best practices for managing care in the world of COVID-19

 many of the articles written by content experts discuss content relevant to managing the child through a COVID-19 lens. For example, Drs. Jones and Wright offer a

 that will enable providers to consider diagnoses of seasonal allergies and/or COVID-19 presentations.

Drs. Chowdhury, Briskin, and Synder discuss

 sports for adolescents and children who have recovered from COVID-19

. This article is so relevant for PNPs in school-based health centers who perform pre-participation sport physicals or make decisions about children and adolescents’ participation in gym classes.

Managing mental health has taken center stage in child and adolescent health care during this pandemic. The need for an additional focus on integration of mental health best practices in pediatric primary care is a critical step in the recovery processes post COVID-19 pandemic.

As the world has changed because of coronavirus disease 2019, the digital world has kept pace with ever-changing best practices and guideline updates.

Digital world advances during COVID-19

In the summer of 2020, many health care professionals (HCPs) were concerned about the potential devastating effects of individuals contracting coronavirus disease 2019 (COVID-19) and influenza. For young pediatric patients, adding respiratory syncytial virus (RSV) to the ‘mixture’ of offending respiratory organisms was a major concern. Dr. Carnazzo discusses these issues in her article entitled, 

The perfect storm: Influenza and RSV during the season of COVID-19

The author provides a comprehensive presentation for COVID-19, influenza, and RSV with comparisons to one another that will enable HCPs to accurately diagnose the ill child presenting to an office-based practice or hospital settings. 

I believe that the concerns expressed prior to influenza season by all HCPs laid the foundation for parents and adults to make informed decisions about vaccinating themselves, their family members, and most importantly for the pediatric populations for parents to have their infants, children, and adolescents vaccinated against influenza each year. Media coverage also supported influenza vaccinations to prevent the ‘perfect storm’ of COVID-19 colliding with influenza resulting in higher rates of respiratory illnesses and deaths.

It always concerns me that pediatric and adult patients die during the influenza season, when we have a primary prevention strategy: administering the influenza vaccine, to prevent influenza, community spread of influenza, and deaths. The Centers for Disease Control and Prevention has recommended an annual influenza vaccine. And yet, in the 2019-2020 influenza season, there were 38 million illnesses, 18 million medical visits, 405,000 hospitalizations, and 22,000 deaths related to influenza.

 Additionally, during the 2019-2020 influenza season, there were 254 children aged between 0-4-years and 180 children/adolescents aged between 5-17 years who died from influenza.

In New York State, there are no reported pediatric deaths from influenza during the 2020-2021 influenza season as compared to the 2019-2020 influenza season in which 14 deaths were reported.

 Vaccinations, a primary prevention strategy, are an effective measure for the prevention of so many vaccine preventable diseases. Pediatricians and nurse practitioners should employ scientifically based strategies to support parents in their decision making prior to the influenza season and for all vaccines on the immunization schedule.

At this time, Pfizer and Moderna are enrolling or planning to enroll children aged older than 5 years in studies to determine the efficacy of COVID-19 vaccines in the pediatric populations. Once the studies are completed and emergency use authorization from the Food and Drug Administration is issued, pediatricians and nurse practitioners will play a critical role in helping parents make the decision to vaccinate their children against COVID-19. Time will tell if the COVID-19 vaccine, once approved for children, will prevent multisystem inflammatory syndrome in children, the severe presentation of COVID-19 disease, that has presented in some children, especially in Black and Hispanic populations.

1. Center for Disease Control and Prevention. Estimated influenza illnesses, medical visits, hospitalizations and deaths in the United States – 2019-2020 influenza season

Updated October 6, 2020. Accessed February 19, 2021.

 https://www.cdc.gov/flu/about/burden/2019-2020.html

2. New York State Department of Health. Weekly influenza surveillance report

 Updated February 6, 2021. Accessed February 19, 2021.

 https://www.health.ny.gov/diseases/communicable/influenza/surveillance/2020-2021/flu_report_current_week.pdf

3. Hester, M. Certain groups may be at greater risk of MIS-C. Published December 4, 2020. Accessed February 10, 2021. 

https://www.contemporarypediatrics.com/view/certain-groups-may-be-at-greater-risk-of-mis-c

As the 2020-2021 influenza season loomed, many in health care worried that the seasonal disease would add to the extraordinary burden of coronavirus disease 2019 and create a perfect storm. Have various prevention strategies helped prevent this potential issue?

Are primary prevention strategies altering the course of the perfect storm?  

Drs Saporta-Keating and Nyquist’s article, 

 provides a detailed review of how scientists and health care providers have unraveled some of the complexities of the coronavirus disease 2019 (COVID-19) over the past 11 months. Much of what has been learned worldwide has been garnered from adult populations who were diagnosed with COVID-19. Seniors and vulnerable populations have suffered tremendously and have died in large numbers in the United States and worldwide. As we know, COVID-19 has adversely affected children who experienced multisystem inflammatory syndrome in children (MIS-C). International efforts to diagnose and treat MIS-C were presented as soon as the newly identified symptoms emerged, first in England, and then in New York City. I vividly recall listening to the first group of physicians from England and the United States discuss the presenting symptoms and the newly identified syndrome. As of this writing, some states that are surging with new adult cases are also reporting MIS-C cases in children. Some children diagnosed in April 2020 with MIS-C are currently experiencing the after effects of the MIS-C diagnosis and only time will tell how the overall health of these children may be affected.

There is hope as vaccines are administered

The US Food and Drug Administration’s (FDA) emergency authorization for 2 vaccines from Pfizer and Moderna represents hope and shines a light for all at the end of this dark tunnel. The remarkable safety and efficacy data for both of these vaccines and the potential for additional vaccine approvals, provides further support for hope. In addition, Pfizer and Moderna are planning clinical studies to investigate the safety and effectiveness of their vaccines in the pediatric population. All pediatric providers look forward to reading and reviewing the results of these studies. As we wait for these results, all pediatric providers can encourage parents and grandparents who are eligible to receive the vaccine to get vaccinated. Pediatric providers have a unique body of knowledge about vaccines, as we administer 23 vaccines to infants in the first 24 months of life, and then continue to administer vaccines into the adolescent and young adult years. We know and understand vaccine hesitancy and vaccine refusers. We are skilled communicators and can use this skill set to encourage all those eligible to take the vaccine.

The mental health and well-being of our pediatric and adolescent patients is and has been front and center throughout this pandemic. We cannot talk about COVID-19 without acknowledging the real and potential mental health trauma that children/adolescents and their parents are experiencing on a daily basis. Dr Man’s article, 

Pandemic pediatric tips for mental health

 provides 10 tips that pediatric health care providers may prioritize as part of routine primary care office visits. Are there other ways that pediatric providers can help with the mental health of the populations that they serve? Is it feasible to offer a bi-monthly Friday night Zoom ‘talkathon” for parents and/or their children? Parents and children trust their pediatricians and pediatric/family nurse practitioners and pediatric nurses. Sharing the responsibilities among office-based pediatric health care providers is one way to make such an option feasible. A 10-minute digital access presentation on a topic of interest to parents, eg, “My child feels anxious: What can I do?”; “My child feels lonely having classes only on Zoom: What can I do?”; “Coping skills 101: How do I help myself and my children apply effective coping skills in this pandemic?”; and/or other topics relating to children or parenting during this pandemic would most likely be very popular. The 10-minute presentation can be followed by a 5-minute pre-screened question and answer period. It may be that a virtual 15-minute meeting twice a month or weekly, for larger practices, may inspire communities to continue on a lighted path that leads us out of this pandemic with newly acquired coping skills that reduce the burden of COVID-19 induced behavioral and mental health issues.

With the good news of the 2 successful vaccines and a much greater understanding of COVID-19, it is time to consider what lies ahead for 2021.

Donna Hallas, PhD, PPCNP-BC, CPNP, PMHS, FAANP, FAAN

Articles

Adolescent marijuana use and anticipatory guidance: What does the evidence support?

Digital world advances during COVID-19

Are primary prevention strategies altering the course of the perfect storm?

COVID-19: Moving forward cautiously