Dr. Steven Ross informs readers of the risks and the benefits of medical cannabis for people who are still developing.
Cannabis is bad for kids. We have all heard this. Nobody really debates the issue for recreational use. But as a cannabis physician, I need to dig deeper than that. Do we know exactly how is it bad for young people? How much is needed to be bad? How young? Finally, despite the common knowledge that it is not good for young people, are there times that young people have issues that make the use of cannabis worth the risks?
Obviously, the voters of Oklahoma felt that, yes, there are situations where the use of cannabis is worth the risk, giving the physicians of this state the ability to recommend cannabis for any age, with the appropriate safeguard of requiring two doctors to recommend under the age of 18.
Not all cannabis clinics will recommend under the age of 21 or 18. We sometimes do, but we evaluate each case carefully and specifically. We will go through some of the evidence about this subject that helps formulate my decision-making regarding these complex issues.
Some of you might feel this is a Debbie-downer column. Some of what I will be speaking about puts cannabis in a bad light at a time when we are all excited that this helpful medication has finally been allowed to be used in a legal manner. I hope it is not taken that way. For example, we are all thrilled to have the freedom to travel with automobiles and would never want to give them up. However, it is helpful to have knowledge that they can crash, seatbelts can be helpful, not every age should drive and other safety concerns that make the use safer. Think of this similarly. To start, I need to explain a critical point in medical studies that is often misunderstood in articles. This is the difference between an association and causality (the cause). For example, when days are longer, people eat more ice cream. That is an association, but not a cause. More people eat ice cream in the summer because it is warm, not because the days are longer. Most studies of cannabis in teens show an association with issues but are not able to show that it is a cause. It does not mean that associations are not important, just that the study design is not strong enough evidence to show cause. This confusion of associations and causes are how you get crazy headlines like “Eating nuts improves your sex life,” which really should say, “People that eat nuts appear to have a better sex life for some reason.”
In addition, all of the available studies are regarding recreational cannabis use, which can be far different than medical use.
There are many studies that associate cannabis use in teens and young adults with many medical conditions and social issues. Some of these studies are poorly done, yet others contain robust evidence. Cannabis use has strong associations in teens with mental health disorders, risk-taking behavior and short-term memory impairment. There are less consistent associations with longer-term memory impairment, decreased academic success, poorer job attainment and changes in brain architecture. In addition, there are likely young people with a disposition toward cannabis dependence, and this risk is increased in those who begin use before the age of 16.
But why are these issues so prominent in younger people yet are not a significant issue for older adults? Research has shown that adolescence and young adulthood is a time of significant changes in the architecture of the brain. Poorer functioning dendrites (nerve cells) are being cleaved during this age and shrink, while other areas of the brain, such as the hippocampus and amygdala, grow in volume. These areas are involved in memory and emotion. There is a predominance of CB1 cannabinoid receptors in these areas. What is so far unclear is the exact effect that early cannabis use has on these structures. Some studies have shown a decrease in size with cannabis use, while others have not.
For specific mental health issues, there is differing data. There does not appear to be an association between early cannabis use and depression later (measured at age 29). However, early cannabis use is associated with anxiety disorders at that same age. Schizophre-nia is more interesting with pretty robust evidence of an association between early cannabis use and the onset of schizophrenia. However, in an attempt to show cause, only a weak causal pattern was found for cannabis causing schizophrenia, but a strong pattern was found that genetic inclination toward schizophrenia would cause increased cannabis use.
Looking at the incomplete data that we have, there is clearly an association between early cannabis use and certain detrimental effects. While it is fortunate that the majority of these detrimental effects are subtle and longer-term, it also makes it more difficult to fully attribute a cause. These effects appear to be more prominent in the heavy early teen user and are moderated in the less frequent user who starts at a later time. There is not enough evidence to proclaim cannabis a cause of most of these issues, but it appears that is likely for some. Ideally, research in the future will help to detail more about causal relationships.
Risk vs. reward
As a physician who is recommending medical cannabis, these findings are a concern; however, in my opinion, they do not exclude cannabis as a therapy. Physicians always have to balance the risk to the benefit of any therapy, and the major risk appears to be in the early heavy recreational user.
Based on these findings, how should a young patient requesting medical cannabis be assessed? I look at four primary factors and one secondary factor:
1) The severity of the condition that is being treated
2) The patient’s use of other methods to treat the condition
3) The age at onset of use and frequency of use (if any) prior to evaluation
4) The patient’s understanding of the risk of the use of cannabis
Finally, as a secondary factor, will the patient be better served by the availability of medical cannabis instead of obtaining from illicit sources?
First is the severity of the condition being treated. Some conditions such as chronic pain or seizure disorders can be quite severe, and this step can be fairly easy to assess. For others, there is more nuance. Adolescence is a difficult time of transition in our lives. Issues such as severe anxiety, depression or Tourette’s syndrome can be truly debilitating at a time when humans are supposed to be honing their social skills. On the other hand, a certain amount of anxiety and social apprehension is a normal part of the growth process and should not be treated with medicine. For these conditions, making this determination is a critical part.
Second is the patient’s use of other methods to treat the condition. Given that there is a heightened risk to cannabis therapy in this age group, it is unwise to recommend cannabis as a first-line therapy if other potentially safer methods have not been attempted. For example, cognitive behavioral therapy can be very helpful for insomnia and has no side effect risk. I do not feel it would be wise to recommend cannabis in this age group for insomnia to someone who has not tried other effective therapies. Of course, many sleep pharmaceuticals have a worse side effect profile than cannabis in this age group, so that isn’t a requirement.
Third is the pattern of use of cannabis before coming to the clinic. Many of my teen patients have never even tried cannabis before wanting therapy or only tried it once or twice. More difficult to assess is the teen who has already been using cannabis, particularly if that use appears to be frequent and recreational.
Fourth is the patient’s understanding of the risks. I typically ask, “What have you heard about the risk of cannabis in your age group?” I have been pleasantly surprised by how many young people have already looked this up and have a good appreciation of the issue. Others take some counseling while a few just do not seem ready to comprehend the risk. Parental involvement is important at that point, particularly for the younger patients. At times, a lack of appreciation of the risks involved prevents me from recommending.
Finally, the very difficult issue of the patient who is already self-medicating with illegally obtained cannabis. I cannot be swayed to a recommendation for an inappropriate reason based on the fact that the young person is going to use it anyway. However, there are patients who I feel have not exhausted all other alternatives first and are using cannabis with good results and have no intention to stop. As the safety profile of cannabis in the dispensary is better and there is more availability of high CBD cannabis, which is preferable for many of these issues, I have recommended in these situations on a case-by-case basis.
This is a brief overview of the concepts used when considering cannabis therapy for the younger patient. I hope it gives people an appreciation that it is not as simple as “This doctor will do it; this doctor will not.” We do enjoy helping young people if the rationale for treatment is there. I have had patients with symptoms so severe they could not leave their bedroom, but with cannabis therapy, they were able to finish school and get a job. These successes make the difficulty of evaluation worth it.
Dr. Steven Ross, MD
Dr. Steven Ross is a physician who has practiced and taught medicine in several countries worldwide and is now a practicing cannabis clinician and founder of MMDOKC in Oklahoma City. He has a passion for assisting patients with cannabis recommendations and guidance for medical use.