Cannabis and the pediatric patient

As of August 2023, 38 US states, 3 territories, and Washington, DC, have approved the use of medical marijuana, and 23 states plus Washington, DC, have approved recreational marijuana.¹ Each state differs in how they define and regulate its use, prescription, and sale. With these trends toward legalization, children and adolescents face increasing exposure to the drug, both intentionally and accidentally. As a result, pediatric health care providers (HCPs) are being asked by caregivers and patients themselves about the use of the drug for recreational and medical purposes. Different types of marijuana and how they are used can make these conversations confusing. HCPs need to know the evidence about potential risks and benefits and be ready for open and honest conversations with patients and their family members.

Cannabidiol (CBD) and Δ-9-tetrahydrocannabinol (THC) are 2 of the many cannabinoids present in the cannabis plant. CBD and THC interact with different cannabinoid receptors in the brain and produce different effects. CBD does not create the sensation of being high that is associated with THC. CBD products are available in oils, gummies, capsules, and tinctures. In addition to edible forms, oils, and tinctures, THC-containing products also are available in smokable forms.²

Medical marijuana use

Qualifying conditions for medical marijuana vary by state and include epilepsy, nausea, muscle spasms, cancer, and other terminal conditions.^3,4 Regulations also vary by state, but medical marijuana is typically purchased at qualified dispensaries.¹ Legalizing treatments for specific medical conditions may not always require high-grade evidence regarding their effectiveness.

Pharmaceutical-grade cannabidiol has been approved by the FDA for a small number of pediatric conditions, including seizures in the setting of Dravet syndrome, tuberous sclerosis complex, and Lennox-Gastaut syndrome, notes Rebecca A. Baum, MD. Baum is a clinical professor in the Division of General Pediatrics and Adolescent Medicine and chief of the Section of Development, Behavior, and Learning at University of North Carolina Health in Chapel Hill. Rigorous studies have evaluated the potential of pharmaceutical-grade cannabidiol for clinical benefit and evaluated the possibility of adverse effects for patients with these conditions. This is a much higher level of regulation than is necessary for medical marijuana purchased through dispensaries.

Recreational use

According to 2021 data from the National Institutes of Health, 18.7% of individuals 12 years or older reported using marijuana in the previous 12 months. Young students also appear to be using marijuana, with 2022 data showing that an estimated 8.3% of eighth-graders, 19.5% of 10th-graders, and 30.7% of 12th-graders reported using marijuana in the previous 12 months.⁵

“It’s our responsibility to make sure that patients know the potential risks of marijuana use and advise them not to start,” Baum says. “If they are using, pediatricians should support their efforts to reduce it or stop, as well as congratulate those patients who have not used marijuana and support their efforts to avoid starting.”

In a recent study that looked at the effects of cannabis on the developing mind of different age groups over time,⁶ researchers followed teenagers who had started using and compared them with nonusing control groups. Data showed that those adolescents who continued using for 3 years at least 2 times per week had thicker cerebral cortexes, particularly in the frontal and parietal regions compared with controls. Marijuana users performed more poorly on cognitive tests, especially in attention and memory tasks, and teenagers who started using earlier in life performed more poorly than those who started using later or who were nonusers. Additionally, short- and long-term risks associated with THC include mental health problems such as depression and anxiety, as well as possible triggers for the development of psychosis and risk factors for suicidality.²

The pediatrician’s role

The relationship that pediatricians have with their patients puts them in a unique place to have confidential and candid conversations about marijuana use.

Guidelines put forward by the American Academy of Pediatrics (AAP) are designed to help clinicians screen, discuss, and provide recommendations regarding the use of marijuana and other substances.⁷ The AAP suggests that adolescents and preteens can be screened for substance use and brief intervention, as recommended in the Screening, Brief Intervention, and Referral to Treatment (SBIRT) policy statement, and that this technique be used in pediatric practices as part of routine care.⁸

Besides the AAP, national organizations such as the Substance Abuse and Mental Health Services Administration have developed resources to help clinicians communicate a clear message to patients and their families. “If you’re not already talking with your patients and their families about marijuana use, or doing universal screening in your practice, now is a great time to start. The AAP’s statement on SBIRT provides guidance and additional resources to support pediatricians in this important work,” Baum says.

Adds Lucien Gonzalez, MD, MS, FAAP, “This initial screen is ideally a standard screening instrument, validated in the pediatric age group. If kids are routinely screened, it gets them accustomed to the idea that this is a health-related topic that will be discussed like any other during visits. In my opinion, ideally the subject of substance use would be approached with parents/caregivers before kids reach screening age.” Gonzalez is an associate professor of general pediatrics and adolescent medicine at University of North Carolina School of Medicine in Chapel Hill.

“Pediatricians serve as an important source of education, support and intervention for youth and families. They should engage parents and caregivers on the topic of substance use before the age of screening and before the age when youths typically initiate use. This is an opportunity to find out what a parent’s own use and attitudes toward substance use are, and to discuss their hopes and expectations for their kids around substance use. Pediatricians can provide support and additional education around the parents’ plan,” Gonzalez notes.

Baum adds, “Sometimes we have the feeling that if we don’t ask about it, it isn’t happening. Marijuana use is something that is happening, and parents, children, and teens are thinking about it. The pediatric office has always been a place where families can get evidence-informed information about a variety of child health topics, and marijuana should be no exception. Universal screening for substance use is a terrific way to begin the conversation.”

Some teenagers may also believe that “Marijuana is natural so it can’t be harmful” or “It’s legal, so it’s OK for me to do it.” It is important that pediatric patients and their families understand that even though cannabinoids are a naturally occurring substances, there is still the possibility of negative effects, especially on the developing brain. It is important to note that legal age limits are present for recreational use in all states and, in many states, for medical use as well.¹

When it comes to discussion, pediatricians can use brief, motivational interviewing strategies (eg, avoid talking down to, listen carefully to the patient, ask open-ended questions) to convince their patients who are using to cut down or stop. The discussion should also include the amount and frequency of marijuana use and the circumstances and motivations associated with its use. Adolescents and teenagers may turn to marijuana for self-medication for problems such as negative moods or sleep issues. Pediatricians can make recommendations for healthier options. Referral for counseling or to a behavioral health specialist may be needed for those with more frequent use.

For adolescents who do not use marijuana, the AAP suggests providing positive reinforcement and eliciting their reasons for abstaining to help support their decision.⁷

Finally, Gonzalez suggests, “Engage with them respectfully and honestly, and avoid exaggerating the risks or research findings. Instead, be transparent about what is known, unknown, and hypothesized about the impacts of use and your reasons for your recommendations to them. Elicit and validate the young person’s reasons for using. Validating their experience and goals will likely leave them more open to the offering of additional information that may guide their choices.”

Click here for more from the October 2023 issue of Contemporary Pediatrics®.

References:

1. National Conference of State Legislatures. Medical use update. Updated June 22, 2023. Accessed August 23, 2023. https://www.ncsl.org/health/state-medical-cannabis-laws#:~:text=Medical%2DUse%20Update&text=24%2C%202023%2C%2038%20states%2C,medical%20use%20of%20cannabis%20products

2. Campbell CT, Phillips MS, Manasco K. Cannabinoids in pediatrics. J Pediatr Pharmacol Ther. 2017;22(3):176-185. doi:10.5863/1551-6776-22.3.176

3. Dharmapuri S, Miller K, Klein JD. Marijuana and the pediatric population. Pediatrics. 2020;146(2):e20192629. doi:10.1542/peds.2019-2629

4. FDA and cannabis: research and drug approval process. FDA. February 24, 2023. Accessed August 23, 2023. https://www.fda.gov/news-events/public-health-focus/fda-and-cannabis-research-and-drug-approval-process

5. What is the scope of cannabis (marijuana) use in the United States? July 2020. Accessed August 23, 2023. https://nida.nih.gov/publications/research-reports/marijuana/what-scope-marijuana-use-in-united-states

6. Jacobus J, Squeglia LM, Meruelo AD, et al. Cortical thickness in adolescent marijuana and alcohol users: a three-year prospective study from adolescence to young adulthood. Dev Cogn Neurosci. 2015;16:101-109. doi:10.1016/j.dcn.2015.04.006

7. Ryan SA, Ammerman SD; Committee on Substance Use and Prevention. Counseling parents and teens about marijuana use in the era of legalization of marijuana. Pediatrics. 2017;139(3):e20164069. doi:10.1542/peds.2016-4069

8. Committee on Substance Use and Prevention. Substance use screening, brief intervention, and referral to treatment. Pediatrics. 2016;138(1):e20161210. doi:10.1542/peds.2016-1210