IACAPAP Textbook of Child and Adolescent Mental Health

Chapter

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SUBSTANCE USE DISORDERSCANNABIS USE AND MISUSE
Alan J Budney & Catherine Stanger

Alan J Budney PhD
Professor, Department of
Psychiatry, Geisel School of
Medicine at Dartmouth Medical
School, Lebanon, NH, USA
Conflict of interest: researchfunding from the National
Institute on Drug Abuse andthe National Institute on Alcoholand Alcoholism; consultation for
GW Pharmaceuticals

Catherine Stanger PhD
Associate Professor,
Department of Psychiatry,
Geisel School of Medicine at
Dartmouth, Lebanon, NH, USA
Conflict of interest: researchfunding from the National
Institute on Drug Abuse andthe National Institute on Alcoholand Alcoholism
This publication is intended for professionals training or practicing in mental health and not for the general public. The opinions
expressed are those of the authors and do not necessarily represent the views of the Editor or IACAPAP. This publication seeks todescribe the best treatments and practices based on the scientific evidence available at the time of writing as evaluated by the authorsand may change as a result of new research. Readers need to apply this knowledge to patients in accordance with the guidelines andlaws of their country of practice. Some medications may not be available in some countries and readers should consult the specific drug
information since not all dosages and unwanted effects are mentioned. Organizations, publications and websites are cited or linked toillustrate issues or as a source of further information. This does not mean that authors, the Editor or IACAPAP endorse their content or
recommendations, which should be critically assessed by the reader. Websites may also change or cease to exist.
©IACAPAP 2012. This is an open-access publication under the Creative Commons Attribution Non-commercial License. Use,
distribution and reproduction in any medium are allowed without prior permission provided the original work is properly cited andthe use is non-commercial. Send comments about this book or chapter to jmreyATbigpond.net.au
Suggested citation: Budney AJ, Stanger C. Cannabis use and misuse. In Rey JM (ed), IACAPAP e-Textbook of Child and Adolescent
Mental Health. Geneva: International Association for Child and Adolescent Psychiatry and Allied Professions 2012.

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IACAPAP Textbook of Child and Adolescent Mental HealthCannabis is the generic term for the psychoactive substance derived from
Cannabis sativa, a plant grown in many areas of the world and widelyused to alter consciousness. Many know cannabis by other names:
marijuana, hashish, dagga, bhang, ganja, dagga, weed, pot or reefer, to name justa few. Throughout this chapter, we will use “cannabis” to refer to all the various
forms of the substance.
Cannabis, more so than any other substance of potential abuse, has generated
tremendous controversy worldwide. Estimates of global use exceed 166 million
people (UNODC, 2008), and policies related to its legal status and potential for
medical use vary across and within countries. Many have questioned its addictive
potential. That is, they have been skeptical about whether or not someone can really
become dependent or addicted to cannabis. The seriousness of the medical andpsychosocial consequences of cannabis has also been challenged. Some believe thatits status as a “gateway” substance leading to use of even more harmful drugs makes
cannabis dangerous. These questions also lead one to wonder whether there is aneed for potent treatments to help people quit. Recent advances in our knowledge
about cannabis and addiction provide clarity to some of these questions. This
chapter makes available science-based information on cannabis and its potential
Click on the picture above toaccess the National Instituteon Drug Abuse (US) website
and the one below to accessthe National Cannabis
Intervention and Prevention
Center (Australia)

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IACAPAP Textbook of Child and Adolescent Mental HealthAdvertisement in the
Jan 1895 issue of the"Medical Advance
Journal"for harm, with the goal of providing an informed and thoughtful understanding
and appreciation of cannabis and its potential impact on adolescents.
Cannabis throughout history
By some accounts, cannabis first appeared approximately four thousand
years ago in the Chinese culture as a plant grown for use of its fiber to makeclothing, paper, and rope (Abel, 1980). Over time, people from many cultures
have used cannabis as a medicine for various maladies and for spiritual ceremonies
related to its mind-altering effects. Cannabis’ value as useful fiber, its potential for
medicinal use, and its psychoactive effects and abuse potential have combined togenerate debate and controversy across cultures for many centuries.
In the 19th century cannabis became part of the US Pharmacopeia (ca.1870)
based on medical writings describing its potential medicinal applications. Societal
concern related to cannabis misuse and its consequences, however, lead togovernment-sponsored studies, which concluded that cannabis was not “addictive”
and had potential health benefits (e.g., Ohio State Medical Society, 1860 and theIndian Hemp Drug Commission, 1895). Increasing cannabis use was a sourceof public controversy in the US in the early-mid 1900’s as some expressed anirrational fear that marijuana use by African Americans and Mexican Americans
would prompt children of the white middle and upper class to use marijuana.
International concerns also grew, as reports from the International Opium
Conference and the League of Nations indicated that multiple countries felt theneed to place controls on cannabis, while other countries resisted such efforts.
In 1924, the International Opium Conference labeled cannabis a “narcotic” andcalled for strict controls.
In 1941, Britain declared cannabis illegal, and the United States legislateda Marijuana Transfer Tax and removed cannabis from the US Pharmacopeia. In
1944, the New York Academy of Sciences indicated that the public concerns
about cannabis were exaggerated and that cannabis does not lead to addiction,
yet its report described multiple negative aspects of cannabis use. In 1972, the US
National Commission on Marihuana and Drug Abuse recommended that cannabis
possession be decriminalized. In that decade a number of US states replaced prison
terms with civil penalties or misdemeanor fines. Concurrently, the US banned
medical research on cannabis, while the state of New Mexico passed a law allowing
cannabis for medical use.
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In 1999, the Institute of Medicine released a comprehensive reportacknowledging the potential negative effects of cannabis including addiction,
but also provided a clear statement regarding its potential for medical benefits.
Legalization and decriminalization discussions continue to evolve internationallywith still no consensus and a resultant wide range of national and regional policies.

WHAT IS CANNABIS AND HOW DOES IT WORK?
Although cannabis contains many chemical substances, it is delta-9tetrahydrocannabinol (THC) that has been identified as the primary compoundthat produces the “high” that occurs when smoking or ingesting the plant materials.
It is likely that other compounds in cannabis also contribute and interact with
THC to produce its myriad of physical and psychological effects. In particular,
research has focused on better understanding the role of cannabidiol. Some
evidence suggests that cannabidiol may moderate the effects of cannabis, reducing
the potential anxiolytic and psychomimetic effects of THC, yet other studies have
not observed such effects (Bhattacharyya et al, 2010; Karschner et al, 2011).
Awareness and understanding of the compounds other than THC in cannabis has
relevance to evaluating three pressing issues related to cannabis use:
• How the effects of cannabis use compare with the use of the pure THC
that is sometimes administered in medical settings• How the effects of synthetic THC-like compounds being consumed
recreationally (e.g., K2, Spice, Kronic) compare with natural cannabis
use, and• How the other substances contribute to the impact on health when thesmoke from cannabis is inhaled (e.g., carcinogens, tar).
How is cannabis prepared and consumed?
The cannabis plant is cultivated cannabis and then marketed in various
forms. Most often, it is dried and divided either into mixtures that include thewhole plant or only the unfertilized flowers of the female plant. The parts of the

Chemical structure of
THC

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Synthetic cannabinoids sprayed on plant materials: potent CB1 agonists with effects
similar to cannabis, but less reliable and with more adverse effects.

plant have differing THC potency with whole plant mixtures being least potent(2%-5% THC content), and flower-only mixtures having much higher potency(up to 20%). The other common cannabis preparation is hashish, which comprises
the cannabis plant resin, with a typically high potency of THC (10-15%). Hashoil preparations are even more potent; these consist of concentrated resin extract
and may reach potencies up to 60%. Of note, the average cannabis available on
the street for purchase has become increasingly potent over the past 20 years most
likely due to increased expertise in hybridization and growing techniques.
The most common method of administration of cannabis is smoking; theplant material is burned and the smoke is inhaled. Devices for smoking range
from cigarettes (joints), pipes, water pipes (bongs or hookahs), and most recently
hollowed out cigars that are usually called blunts. Smoking cannabis and tobacco
simultaneously either via blunts, spliffs (joints that mix the substances together), orby chasing cannabis with tobacco has become more common recently, particularly
among teens and young adults (Agrawal et al, 2011; 2012; Peters et al 2012)

The average cannabis
available on the street forpurchase has become
increasingly potent over the
past 20 years.

Cannabis can also be “vaporized”, which involves heating it to a temperaturehigh enough to release psychoactive compounds for inhalation, but low enoughthat combustion does not occur. This route of administration is thought to be
somewhat “safer” than traditional smoking methods.
Oral consumption of cannabis is also fairly common and usually involves
dissolving it into food substances, frequently baked goods, although recently
some places that dispense “medical marijuana” have begun to market other edible
products that include doses of cannabis.
Do different administration methods have different effects?
Smoked and vaporized cannabis have similar bioavailability to THC,
which results in a similar time course of intoxication effects. Onset of intoxication
typically occurs within 1-2 minutes, reaches peak usually within 30 minutes, andcan last for up to four hours. When consumed orally, bioavailability is lower, andthus intoxication is delayed with onset usually occurring after at least 30 minutes,
peak effects resulting in approximately two hours, and effects lasting for more thansix hours.

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IACAPAP Textbook of Child and Adolescent Mental Health

Cannabis paraphernalia

What are the general effects of cannabis use?
Cannabis ingestion has numerous, well-documented direct effects, most ofwhich are dose dependent. The effects associated with the feeling of being “high” or“stoned” include euphoria, a sense of relaxation, increased giddiness or propensity
for laughing, the sense that time seems to slow down, an increased appreciation
for music and other art forms, and tendency to prefer nonverbal social activities
or introspection. The less often discussed feelings of anxiety, paranoia, fear, or
panic may also be experienced. These effects occur most often in less experienced
users or following use of higher than usual doses. In rare cases, usually involving
particularly high doses, users may experience hallucinations. These effects are
not life threatening, dissipate with time, and may be reduced with comfort andreassurance.
Use of cannabis also produces several reliable physiological effects. The
mouth becomes dry and appetite is stimulated (i.e., the onset of munchies) which
typically results in an increase in the consumption of food and drink, particularlyhigh calorie products. At low to moderate doses, cannabis typically has antiemetic
effects (reduces nausea), but can induce nausea or vomiting at higher doses
or among less experienced users. Cannabis use has a broad range of effects on
cardiovascular function. Use is associated with increase in resting heart rate, slightincrease in supine blood pressure, and increased orthostatic hypotension (dizzinessor lightheadedness that results from a sudden drop in blood pressure after standing)(Jones, 2002). Also dilation of small blood vessels occurs, which results in rednessof the eyes.
Cannabis can impair focused and divided attention, short term and episodic
memory, some types of complex cognitive processing, and some aspects of motor
ability (Vandrey & Mintzer, 2009). Many of these effects are not large, but are dose-

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IACAPAP Textbook of Child and Adolescent Mental Healthrelated and moderated by cannabis use history (tolerance). Generally, moderate
doses of cannabis appear to have comparable effects to moderate doses of alcohol(BAC approximately 0.05%) on measures of motor ability, attention and episodic
memory.
Sustained use of cannabis can impair attention, memory and complex
cognitive abilities such as problem solving and mental flexibility (Kalant, 2004;
Solowij et al., 2002). Neuroimaging studies indicate that long-term cannabis users
have altered brain function in the prefrontal cortex, cerebellum, and hippocampus.
Again, the functional significance of such impairments is difficult to assess andquantify. Most research suggests that much of the impairment associated withchronic cannabis use is likely reversed following extended periods of abstinence.
How does cannabis interact with the brain?
Cannabis exerts its effects primarily through an endogenous cannabinoid
receptor system. Two receptor subtypes (CB1 and CB2) and five endogenous
ligands have been identified. The psychoactive and reinforcing effects of cannabis
are primarily mediated by activation of the CB1 receptor by the THC compound.
This receptor is abundant throughout the central nervous system, but is expressedin the brain at the highest concentrations in the basal ganglia (reward, learning,motor control), cerebellum (sensorimotor coordination), hippocampus (memory),and cortex (planning, inhibition, higher-order cognition). Changes in brain
activity following administration of THC are localized mostly in these areas, andneuroimaging studies indicate that these brain activity changes are THC dose- andtime-dependent effects. The euphoric effects of cannabis are primarily related to

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THC enhancing dopamine neuronal firing and synaptic dopamine levels in the
reward pathway of the brain (Gardner, 2005), which not surprisingly is a hallmark
neurobiological feature of most abused drugs.
Adolescent neuroimaging studies have indicated that chronic use of
cannabis in adolescence leads to less efficient neural processing on tasks requiring
executive function, and in particular, on tasks requiring higher level control ofattention (Abdullaev et al, 2010). Similarly, frequent or recent cannabis use
among teens, and onset of cannabis use prior to the age of 16 have been foundto be associated with less efficient (overactive) cognitive processing on working
memory tasks (Becker et al, 2010; Jager et al, 2010; Schweinsburg et al, 2010).
Working memory is a cognitive system that holds information, permitting verbal
and nonverbal activities such as reasoning and comprehension processing, which
are important components involved in goal-oriented monitoring or manipulationof information that contributes to decision making (Becker & Morris, 1999).
Adolescent cannabis users also have structural abnormalities including decreased
cortical thickness (Lopez-Larson et al, 2011) and reduced cortical fractional
anisotropy, suggestive of decreased myelination (Ashtari et al, 2009). These findings
suggest that cannabis use alone or in combination with other substance use (e.g.,
alcohol) in adolescence may negatively influence normal neuro-developmental
processes.

BEHAVIORAL, MEDICAL AND PSYCHIATRICADVERSE EFFECTS
Adolescents who report regular use compared to those who do not use
cannabis are much more likely to (Tims et al, 2002):• Use other substances and to develop substance use disorders• Have poor academic performance and drop out of school• Engage in delinquent behavior and get arrested• Have other psychiatric problems and have more emergency room visits• Engage in more risky behavior such as drugged driving, which increases
risk of accidents, and sexual behavior that increases risk of unplanned
pregnancy and of STDs.
In adults, regular cannabis use has also been linked to poor work history
and less satisfactory relationships. Some research has raised concern that cannabis
exposure to the fetus during pregnancy may impact learning and cognitive
function during the school years (Fried et al, 2003). Cannabis has also been
linked to increased respiratory problems (e.g., bronchitis), but has not clearly been
associated with cancer risk, although smoking cannabis produces a high level ofcarcinogens (Tetrault et al, 2007).
Cannabis and schizophrenia
Although it is difficult to demonstrate that cannabis use is a causal factor inthese adverse consequences, certainly it plays some contributing role. Of particularconcern is whether cannabis use contributes to the development of severe mental
illnesses such as schizophrenia (Sewell et al, 2009). A clear association between
cannabis use and the development of psychotic disorders has been repeatedly
demonstrated. Particular risk is associated with frequent use and early onset ofuse. Thus, this concern is of great importance during adolescence and young

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IACAPAP Textbook of Child and Adolescent Mental Healthadulthood. Evidence is not conclusive on whether or not these relationships arecausal (e.g., whether cannabis use actually causes new cases of schizophrenia) orwhether psychosis would have developed eventually without cannabis use (e.g.,cannabis only bringing forward the onset of the illness). Cannabis is likely totrigger early onset of psychosis and perhaps the expression of psychosis among
those with predisposing risk factors for psychosis. Moreover, among those withpsychotic disorders, cannabis use clearly has a negative impact on its course andresponse to treatment, despite some evidence that it may enhance acute cognitive
functioning in some persons with schizophrenia.
Is cannabis “addictive”?
Although agreement on how to best define “addiction” is sorely lacking, by
most indicators, cannabis use can develop into cannabis addiction or diagnosticallyspeaking, a cannabis use disorder. Laboratory, epidemiological, genetic, andclinical studies have demonstrated the biological plausibility, existence, prevalence
and clinical importance of cannabis use disorders.
Neurobiology and genetics
As reviewed above, the neurobiology of how cannabis produces its effects andthe concomitant endogenous cannabinoid system provide biological plausibility

Table G.2.1 Cannabis addiction is similar to other substance addictions
Biological plausibility•••

Endogenous cannabinoid system
Cannabis activates dopamine reward pathways
Genetic determinants of cannabis use disorder

Clinically significant withdrawal syndrome•••

Similar to tobacco withdrawal
Makes quitting difficult
Contributes to failed quit attempts

Phenomenology of cannabis use disorder•••

Full range of abuse and dependence criteria
Multiple social, behavioral, and emotional associations
Moderately less severe syndrome than other substance use disorders

Prevalence••Greater numbers of cannabis use disorders than of other illicit substance use
disorders
Lower percentage of users develop a cannabis use disorder, but many more usersof cannabis than of other illicit substances

Treatment••

Cannabis

Number of cannabis use disorder treatment admissions is comparable to that ofcocaine and opioid use disorders
Treatment response similar to other substance use disorders

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9IACAPAP Textbook of Child and Adolescent Mental Healthfor cannabis addiction. That is, these neural systems and actions closely parallel
those of most other drugs for which people can develop addictive problems. In
addition, multiple studies have established that genetic influences contribute to thedevelopment of cannabis use disorders. Heritable factors – contributing between
30-80% of the total variance in risk of cannabis use disorder – have been reported
and genetic linkage studies of cannabis use disorder and earlier stages of cannabisuse (including frequency of use) further establish a genetic link to cannabis use
problems (Agrawal & Lynskey, 2009). Three sources of genotypic risk (substancespecific, substance non-specific and environmentally modifiable) have been
identified. First, substance specific genes may impact vulnerability to the generaladdictive potential of cannabis. Second, specific genes may increase or decrease
genetic vulnerability to externalizing behavior problems in general, including
adolescent experimentation and misuse of psychoactive substances. Third, certain
genes may impact an individual’s reactivity to environmental variables such as
stress, which may influence risk for substance misuse.
Cannabis withdrawal?
Drug withdrawal is a considered by many as a hallmark of addiction. Thus,
one important part of the larger question of whether you can become addicted tocannabis is: does regular cannabis use result in the experience of withdrawal when
one stops using? The past 10-15 years of research provide a clear answer to thisquestion; a true, clinically significant cannabis withdrawal syndrome is experienced
by many heavy users of cannabis (Budney & Hughes, 2006; Budney et al, 2004).
The neurobiological basis for cannabis withdrawal was established withthe discovery of the aforementioned endogenous cannabinoid system. Studies
with nonhuman animals have shown that administration of a cannabinoid
antagonist can precipitate withdrawal. Studies with humans have demonstrated
that deprivation of THC in some users causes withdrawal symptoms, andthat symptoms abate with re-administration of THC, clearly establishing thepharmacological specificity of cannabis withdrawal (e.g., Budney et al, 2007;
Haney et al., 2004). Moreover, laboratory and clinical studies with adults andadolescents have provided support for the reliability, validity, and time course of acannabis withdrawal syndrome (Budney et al, 2004; Chung et al, 2008; Levin etal, 2010; Milin et al, 2008; Vandrey et al, 2005). Most withdrawal effects appear
within 24-48 hours of cessation, peak in 2-4 days, and return to baseline within
1-3 weeks. A substantial proportion (25%-95% across studies) of heavy marijuanausers reports multiple withdrawal symptoms, with individuals seeking treatment
for cannabis use disorders showing the highest rates of withdrawal.

Cannabis
withdrawal
symptoms
•
•
•
•
•
•
•

•

Irritability, anger, oraggression
Nervousness oranxiety
Sleep difficulty (e.g.,
insomnia, disturbing
dreams)Decreased appetite or
weight loss
Restlessness
Depressed moodPhysical symptoms:
stomach pain,
shakiness/tremors,
sweating, fever, chills,
or headacheLess common
symptoms: fatigue,
yawning, difficulty
concentrating

Concern about the clinical significance or importance of this withdrawal
syndrome was a primary reason for the omission of this condition from theDSM-IV. However, data now show that cannabis withdrawal is comparable inmagnitude and severity to the well-established tobacco withdrawal syndrome(Budney et al, 2008; Vandrey et al, 2008); many adolescent and adult users reportthat withdrawal symptoms adversely impact their attempts to quit, and lead to theuse of cannabis or other drugs to relieve withdrawal symptoms (Copersino et al,2006); a substantial proportion of adults and adolescents in treatment for cannabis
use disorder complain that these symptoms make cessation more difficult; and theseverity of withdrawal appears to have predictive validity – adolescents with more

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IACAPAP Textbook of Child and Adolescent Mental HealthPhoto: Tony Fischer

severe withdrawal have a higher probability of poor treatment outcome (Chung etal, 2008; Cornelius et al, 2008).
In summary, the cannabis withdrawal syndrome does not typically include
major medical or psychiatric consequences and might be considered “mild”
compared with heroin and alcohol withdrawal. However, the emotional andbehavioral symptoms that are a hallmark of cannabis withdrawal impede cessation
attempts, and as such should be assessed and addressed in clinical settings or whenself-quitting.

EPIDEMIOLOGY OF CANNABIS USE DISORDER
As with other drugs, the majority of people who have tried cannabis do
not develop a problem with addiction. However, the number of persons who
at some time in their lives meet criteria for a cannabis use disorder as defined in
the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) (American
Psychiatric Association, 2000) is more than double the number that meet such
criteria for any other illicit drug (Anthony & Helzer, 1991; Anthony et al, 1994).
This reflects the fact that many more people have ever used cannabis comparedwith having ever used other illicit drugs of abuse. In contrast, the percentage of
persons who have ever used cannabis and who then develop dependence is lower(approximately 9% in the US) than with other illicit substances; for example, 15%of those who try cocaine and 24% of those who try heroin develop dependence.
The 9% dependence rate among cannabis users may seem low but, given the large
number of people who have used cannabis, this results in a substantial number of
persons with cannabis use disorders. It is of some concern that the prevalence of
cannabis use disorders has been increasing despite stable rates of use (Compton etal, 2004). Increased potency of cannabis available in the streets and earlier age ofinitiation of cannabis use may contribute to this trend. Early onset of cannabis use(or any substance of abuse) is particularly worrying as it is a strong predictor of

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Figure G.2.1 Percent of US 12th grade students reporting marijuana and cigarette use in thepast month, 1975 to 2011.

Source: Monitoring the Future study, University of Michigan

both substance use and mental health problems in young adulthood (Degenhardt
et al, 2003; Fergusson et al, 2002; Gfroerer et al, 2002)
Severity
In most respects, the phenomenology of cannabis use disorders appears quite
similar to that of other substance use disorders (Budney, 2006). Adults in treatment
for a cannabis use disorder, on average, have been using cannabis daily for 10 years
and made multiple unsuccessful attempts to quit (Budney, 2006; Copeland etal, 2001; Stephens et al, 2002). They experience the full range of symptoms ofabuse or dependence. For example, they report continuing to use cannabis despite
experiencing social, psychological and physical problems related to their use; they
perceive themselves as unable to stop and most experience withdrawal symptoms
when they stop abruptly. Moreover, they acknowledge relationship and family
problems and guilt associated with using, financial difficulties, low energy and selfesteem, dissatisfaction with their productivity levels, sleep and memory problems,and low life satisfaction (Gruber et al, 2003; Stephens et al, 2002).
Though the phenomenology of cannabis use disorder is similar, there
appear to be differences in severity (Budney, 2006; Budney et al, 1998). On average,
individuals with cannabis dependence do not meet as many DSM dependence
criteria as with alcohol, cocaine or opioid dependence. The withdrawal experiencecauses discomfort but is not associated with major health risks, and the associatedhealth and psychosocial consequences, although substantial, are on average notas severe. Despite this milder dependence syndrome, quitting cannabis once
problematic use has developed does not appear to be any easier than trying to quit
other substances (see section on treatment below).
Treatment admissions
Paralleling the rise in cannabis use disorders, admissions to treatment
services for primary cannabis use disorder have been dramatically increasing in

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IACAPAP Textbook of Child and Adolescent Mental Healthsome countries (e.g., US, Australia) such that the percentages of those in treatment
for cannabis use disorder is comparable to those in treatment for cocaine andheroin use disorders. This may be due to increased number of people developing
cannabis use disorders, the growing recognition and acceptability of a need fortreatment, and the availability of specific treatments. Moreover, the existence ofsuch treatment programs may raise awareness of cannabis’ addictive potential,
which may result in more cannabis users contemplating the possibility that it
might be a significant problem for them.
Among adolescents, cannabis is by far the most commonly acknowledged
substance used among those entering treatment (Substance Abuse and Mental
Health Services Administration, 2008). In the US, over 40% of treatment
admissions for cannabis use disorder are persons under 20 years of age. Adolescents
appear to be more vulnerable to the development of cannabis use disorders thanadults, as indicated by more rapid development of cannabis use disorder fromtime of onset of use. There is a clear need for effective, easily accessible treatments
specifically for cannabis use disorders and especially for adolescents.
Summary
Findings from a growing body of multidisciplinary research indicate thatdebate over whether or not cannabis use can lead to dependence or addiction
should be considered obsolete. Cannabis misuse and addiction are relatively
common and are associated with significant negative consequences. Moreover,cannabis-related problems reflect a significant public health issue that requires
continued attention and action towards developing more effective treatment andprevention interventions.

GATEWAY EFFECT
Cannabis has been described as a “gateway” drug because its use usually
precedes use of “harder” drugs such as cocaine and heroin, and frequent cannabis
users have a much greater probability than nonusers of using heroin or cocaine intheir lifetime. Such data, in addition to the high co-morbidity rates of cannabis use
disorder and other substance use disorders, raise the question of whether cannabis
use is causally related to use and misuse of other substances. Although cannabis
use typically precedes other drug use, so do tobacco and alcohol. Recently, it has
become more apparent that the timing of initiation of use of different substances
varies geographically and by culture, indicating that drug availability and societal
factors likely contribute to specific drug-onset trajectories. Hypotheses for cannabis
as a gateway substance include:••••

Cannabis

Neurobiological effects of cannabis use may increase sensitivity to thedesirable effects of other substances
Cannabis use increases opportunity for other substance use by placing
the user in contact with those who use or sell other drugs
Use of cannabis may impact cognitive functioning and decision making
affecting choice of whether or not to use other drugs
Common intrapersonal and environmental characteristics determine
risk of substance use in general (e.g., conduct problems, neighborhood,neurobiology, parental factors).

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IACAPAP Textbook of Child and Adolescent Mental HealthResearch demonstrates that genes, environmental factors and common preexisting risk factors account for much – but not all – of the association between
early initiation of cannabis use and future other substance use, suggesting that allthese hypotheses have merit (Agrawal et al, 2007; Lynskey et al, 2006). However,each of these factors would also explain alternative sequences of the onset of drug
use.

SCREENING, ASSESSMENT AND DIAGNOSISAssessment of cannabis use and cannabis use disorders is similar to that forother substance use disorders, with formal criteria for clinical diagnoses found in
the DSM or the International Classification of Diseases (ICD). Structured or semistructured diagnostic interviews (e.g., Structured Clinical Interview for DSM-IV[SCID]) are most appropriate for determining cannabis use disorder diagnoses.
In addition, the Substance Dependence Severity Scale, a five-item scale designed
to measure dependence severity, has been validated for assessing dependence incannabis users (Miele et al, 2000).
A few cannabis specific instruments for screening for problematic cannabis
use have been developed (Piontek et al, 2008). For example, The Cannabis Use
Disorder Identification Test is a short screen for DSM-IV diagnosis of abuse ordependence (Annaheim et al, 2008). The Cannabis Problems Questionnaire
has adult and adolescent versions that yield a severity score for cannabis-related
problems (Copeland et al, 2005; Martin et al, 2006). The Marijuana Screening
Inventory (Alexander & Leung, 2006) assesses patterns of use and identifies
clinical cases.
Standard instruments that assess all types of substance use problems
have a longer history and more data supporting their psychometric properties
than cannabis-specific instruments. For adolescents, the CRAFFT is a 6-item
questionnaire designed to screen for high-risk alcohol and other drug use (seeTable G.2.2). It has excellent psychometric properties with adolescents, is selfadministered, and can be used in a variety of health and educational settings(Knight et al, 2002). A positive CRAFFT screen suggests that further assessmentof substance use disorders is warranted.
Two instruments that have been used primarily to measure change during
treatment rather than as diagnostic or screening tools are the Marijuana Problem
Table G.2.2 Screening for adolescent substance use problems: the
CRAFFT questionnaire
C

Have you ever ridden in a CAR driven by someone (including yourself) who was“high” or had been using alcohol or drugs?

R

Do you ever use alcohol or drugs to RELAX, feel better about yourself, or fit in?

A

Do you ever use alcohol or drugs while you are by yourself, or ALONE?

F

Do you ever FORGET things you did while using alcohol or drugs?

F

Do your family or FRIENDS ever tell you that you should cut down on yourdrinking or drug use?

T

Have you ever gotten into TROUBLE while you were using alcohol or drugs?

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IACAPAP Textbook of Child and Adolescent Mental Health“Millon Porros” demonstration in Madrid in 2008 seeking legalization of cannabis use

Inventory and the Marijuana Withdrawal Checklist. The Marijuana Problem
Inventory yields a severity score of specific cannabis-related consequences(Marijuana Treatment Project Research Group, 2004), and is a useful index of
response to treatment. The Marijuana Withdrawal Checklist can be used to assess
withdrawal symptom history but has more commonly been used in research studies
to examine changes in withdrawal during the early stages of abstinence (Budney etal, 2003). Such information can be used to assess and manage treatment strategies
related to concerns about withdrawal. Another withdrawal assessment tool,
Cannabis Withdrawal Scale is under development and holds promise for use inclinical settings (Allsop et al, 2011).
Testing for cannabis use
Testing for evidence of recent cannabis use is a vitally important screening
and treatment outcome tool for adolescents and adults, as many persons in suchcontexts may have good reason for not being truthful about their substance use.
Multiple methods for reliable and valid urine testing for THC metabolites areavailable. Easy to use and inexpensive dipstick methods provide qualitative results(yes vs. no) in approximately 2-5 minutes. Other more sophisticated techniques(e.g., gas chromatography-mass spectrometry) are also available but require
relatively expensive equipment or transport to a laboratory. Most importantly, for
any of these tests, reliability and validity will be high only if specimen collection
procedures ensure the integrity of the sample by:•••

Observation of specimen provisionTemperature check and testing for urine concentration level andcontaminants
Personnel with adequate training to accurately interpret the results(Cary, 2006).

Misconception and cynicism are common related to urine testing forcannabis. Clinical staff must develop expertise for collection and testing protocols,and interpretation of results.

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Saliva and hair specimens can also be used. However, these technologies
have limitations related to their window for detection of cannabis use. For example,
current methods for saliva testing can detect only very recent use, while hair testing
may detect fairly distant cannabis use and also has the potential for false positives
caused by passive cannabis smoke. In summary, use of any biological screening
methods requires comprehensive knowledge to facilitate reliable and valid testingand interpretation of results.

TREATMENT AND OUTCOME
People dependent on cannabis typically use the drug multiple times perday, may be ambivalent about its negative effects, acknowledge multiple perceived
positive effects, and cost is relatively low; all these factors make quitting difficult.
Treatment studies with adults and adolescents indicate that abstinence and relapse
rates observed following treatment are highly similar to those observed with othersubstance use disorders (Budney, 2007; Waldron & Turner, 2008). Below we
discuss treatment approaches for adolescents.
Most information on the efficacy of treatment for teens with cannabis use
disorders comes from studies that have included youth who use various substanceswith the understanding that the majority have a primary cannabis use disorder.
Multiple types of behavioral interventions have shown promise in randomized
clinical trials including (Stanger & Budney, 2010; Waldron & Turner, 2008):•

Group and individual cognitive-behavioral therapy (CBT)•CBT combined with motivational enhancement therapy•

Motivational enhancement therapy or CBT combined with contingency
management, community reinforcement approach counseling,
functional family therapy, multidimensional family therapy•

Multisystemic therapy•

Brief strategic family therapy•

Family support network, and•Family behavior therapy.

The motivational enhancement therapy and CBT interventions that havebeen tested are similar in scope and duration to those used with adults. The familyfocused interventions take advantage of social networks (parents, schools and othersocial agencies) that are somewhat unique to adolescents. These generally include
efforts to address maladaptive family patterns that contribute to substance use (e.g.,parent drug use, parent-child relationship problems, parent supervision), make useof resources in the school and criminal justice system, and address problems thatmight be associated with the teen’s peer network. Although not clearly supportedby the empirical literature (Dennis et al, 2004; Hendriks et al, 2011) some assertthat these behaviorally-based, family approaches produce a more potent effect thanthose that do not include a family component.
That said, even with the most effective interventions tested to date, observed
reductions in substance use have been modest and robust effects on abstinence
rates have been difficult to demonstrate. In the largest clinical trial reported todate, 600 adolescents with cannabis use disorders received one of five treatments

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IACAPAP Textbook of Child and Adolescent Mental Health(Dennis et al, 2004):•

Motivational enhancement therapy and CBT5 (2 individual and 3group sessions)•

Motivational enhancement therapy and CBT12 (2 individual and 10
group sessions)•

Motivational enhancement therapy and CBT12 plus family support
network•

Adolescent community reinforcement approach counseling, and•Multidimensional family therapy.

Comparably significant decreases in drug use and symptoms of cannabis
use disorder were observed with each treatment. Yet approximately two-thirds ofthe youth continued to experience significant substance-related symptoms. Thatis, many never achieved abstinence or substantial reductions in cannabis use, andmany of those who were initially successful relapsed. Such modest outcomes are
similar to those observed with earlier studies evaluating the aforementioned familyfocused and individual/group therapies, indicating a strong need for continued
development of more potent adolescent treatment models and interventions(Compton & Pringle, 2004).
Contingency management interventions
A recent evaluation of a novel contingency-management based intervention
has shown some promise for enhancing treatment outcomes for teens withcannabis use disorders (also described in Chapter G.1). Contingency management
interventions are based on extensive basic science and clinical research evidence
showing that drug use and abuse are sensitive to systematically applied
environmental consequences, i.e., reinforcement and punishment contingencies(Higgins et al, 2004). Contingency management approaches have become oneof the most thoroughly researched and effective behavioral procedures to increase
drug abstinence and other treatment targets across adult substance-dependence
disorders (Higgins et al, 2008; Petry & Simic, 2002; Stitzer, 2006); however, suchinterventions have received only minimal attention in the adolescent substance use
disorder treatment literature.
Contingency management may help address a number of importantsituational factors that affect treatment effectiveness. First, teens rarely seek
treatment on their own accord, but rather are brought to treatment by their parents
after being caught either using or getting in trouble because of use at home, school,or by the police. Accordingly, teens frequently do not perceive their cannabis use
as a problem and motivation to quit using and remain abstinent is typically low.
In contrast, parents usually consider their teens’ cannabis use a problem and are
motivated to take action. Contingency management for teen cannabis use, as
described by Stanger and colleagues (Kamon, 2005; Stanger, 2009) addresses theseissues via:•

Cannabis

An incentive program to motivate and reward teens to not use
substances, which involves providing tangible incentives for
documented abstinence from all substances

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Table G.2.3

Adolescent Substance Abuse: Contingency Management Intervention*

Intervention components

Description

Motivational enhancement
therapy/ cognitive behavior
therapy (CBT)

Teens receive individual counseling including two sessions of motivational
enhancement therapy followed by 10 sessions of CBT. Sessions address:•
The positive and negative consequences of substance use•
The teen’s goals for the future and for treatment•
Coping skills related to substance use (refusal skills, relapse prevention,
coping with cravings) and•
General life skills (problem solving, mood management, anger management).
•••

Clinic based contingency
management

Teens earn incentives at each visit
Incentives for documented abstinence escalate with continuous abstinence
Substance use or failure to submit a specimen resets voucher values to thestarting value, but are reset back to the maximum after three consecutive
negative tests.
Teens who remain abstinent throughout weeks 1–14 can earn vouchers worth$590.

Twice weekly urine drug
testing

Objective testing for substance use is necessary to conduct the abstinence-based
contingency management program, and is also necessary for valid evaluation oftreatment progress. During treatment, teens submit twice weekly urine samples
that are tested immediately in the clinic, with results shared with the teen, parents
and clinical staff.

Substance monitoring
contract

Parents create a contract specifying rewards the teen earns after each ½ week
period of abstinence (documented by teen and parent report, urine drug testing,and parent administered breathalyzers—see Appendix G.2.1 for a model). Parents
also specify consequences for substance use that last until the next period of
documented abstinence.

Family management
curriculumThis curriculum from the “adolescent transitions program” teaches parents basic
principles and skills to decrease problem behaviors and increase prosocial
behaviors (Dishion & Kavanagh, 2003).

Parent incentives

Parents receive incentives for:•Attending sessions•
Attending urine drug testing appointments with the teen•
Completing assignments to track teen behavior at home•
Document parenting changes, and•Enforcing the substance monitoring contract
Parents typically earn about $100 over the 14-week program.

* Stanger et al (2009).

••

A behavioral parenting intervention that focuses on the development
and implementation of an abstinence-based contract directing parents
to provide tangible incentives for drug abstinence and to deliver
negative consequences for evidence of continued use, andIncentives that motivate and reward parents for adhering to a parent
training program and the abstinence contract.

These contingency management components are integrated with weekly
individual motivational enhancement therapy/CBT counseling and twice weekly
urine drug testing and alcohol breath testing (see Table G.2.3 and Appendix
G.2.1).

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Clinic-delivered incentive program
Teens receive incentives each time they provide urine specimens that test
negative for cannabis and other drugs. In addition, to receive the incentive, parents
must report that the teen has not used alcohol since the last scheduled urine test.
Parents are provided with disposable breathalyzers and instructed on how to use
them. Incentives have a monetary value that increases with each consecutive
negative urine test and parent report. Cash is not provided, instead, gift cards/
certificates from various retailers are used.
Parent-delivered contingency management program.
Parents are expected to:••••Model appropriate behavior related to substance use
Increase monitoring of their youth's behavior
Learn to develop clear, consistent, and effective consequences for
substance use, andDevelop effective methods to motivate drug abstinence.

Therapists assist parents to develop a contract (see Appendix G.2.1), which
includes specific positive and negative consequences that the parent will
implement in response to urine and breath test results.
Objective testing
Objective testing for substance use is necessary to conduct the abstinencebased contingency management program and for valid evaluation of progress.
Teens rarely show high motivation for abstinence and also typically face aversive
consequences from parents, schools, or juvenile justice if they continue to use
substances. Thus, they are motivated to give inaccurate self-reports and avoid ormanipulate the objective testing procedures. Teens provide urine specimens prior totheir counseling session under direct staff observation according to a twice weekly
schedule throughout treatment. Specimens are immediately screened for cannabis,
cocaine, opioids, benzodiazepines, amphetamines, and methamphetamine, andresults are provided to teens, parents, and therapists within 10-15 minutes ofproviding the specimen if possible. Adulterant testing is conducted to assess fordilution and attempts to directly alter test results.
With cannabis, up to two weeks of abstinence (and sometimes longer)
are needed to allow sufficient time for a valid negative test result (e.g., for
THCCOOH: 50ng/ml cutoff). This time is highly variable and influenced byindividual difference in physiology, amount and duration of cannabis use, andrecent activity level. The contingency management program used in Stanger et al(2009) and in adult contingency management studies targeting cannabis use wasdelayed two weeks before implementing the incentives program. Teens are clearly
informed and repeatedly reminded about the need to be abstinent for 1-2 weeks
before urinalysis testing will result in a cannabis-negative finding. The other drugs
tests performed typically take 3-7 days post use to test negative at their respective
standard cutoff levels.
Results
This contingency management program combined with motivational
enhancement therapy and CBT was compared with an intervention that included

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IACAPAP Textbook of Child and Adolescent Mental Healthmotivational enhancement therapy, CBT, weekly
educational parent sessions, and an attendance-based
incentive program. Both treatments included twice
weekly urine testing with results provided immediately tothe parents and the teen. The contingency management
group demonstrated greater rates of continuous
abstinence during treatment than the comparison
intervention, but this effect did not clearly extend topost-treatment assessments. Overall, rates of cannabis
abstinence in both treatment conditions were relatively
high compared with those reported in previous studies,suggesting that the comparison condition might also
warrant further evaluation to determine its efficacy. The
twice-weekly urine testing program provided in both
treatment conditions, which systematically reported
results to parents, was unique to this study and may bean active component in its own right.
Maintaining treatment effects
An intervention for teens focused on maintaining
treatment gains (reducing relapse), “assertive continuingcare”, warrants mention (Godley et al, 2007). With assertive continuing care,adolescents are assigned a case manager for 90 days after discharge from an inpatient
treatment facility. The case manager makes weekly home visits with the goalsof engaging the youth in other identified services, development of a new social
support system involving pro-social activities, and generally reinforcing strategies
to maintain abstinence. In a randomized trial comparing assertive continuingcare to usual care, the assertive continuing care intervention was more effective inincreasing adolescents’ engagement and retention in care, and resulted in higher
longer-term abstinence from cannabis.

Parent public service
announcement

Pharmacotherapy
Research exploring medications for cannabis use disorder has been stimulatedby the increased recognition of the need for cannabis use disorder treatments,
combined with new findings about cannabis withdrawal and better understandingof the endogenous cannabinoid system (Benyamina et al, 2008; Hart et al, 2005;
Nordstrom & Levin, 2007; Vandrey & Haney, 2009). Unfortunately there iscurrently no strong evidence supporting any specific medication – thus there areno medications for cannabis use disorder approved by regulatory bodies. Amongthe many laboratory studies and a few clinical trials that have been published, only
one study has assessed a medication for cannabis use disorder in adolescents oryoung adults. A small open label trial of N-acetylcysteine – a medication targetingglutamate – showed promise for reducing cannabis use in 18-21 year olds withcannabis use disorder (Gray et al, 2010). Preliminary reports from a controlled
follow-up study appear to provide further support for the potential efficacy of thismedication.
Medications research is targeting a number of different mechanisms. For
example, agonist medications that have a similar mechanism of action as THC and
can either substitute for cannabis or blunt the euphoric effects of cannabis if used

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IACAPAP Textbook of Child and Adolescent Mental Health(in the case of relapse), or be used short-term to suppress withdrawal symptoms;
CB1 receptor antagonists can reduce binding to the receptor and thereby reduce
euphoric effects if cannabis were used or, possibly, prompt withdrawal symptoms
in the case of inverse agonists. Although some promising data have emerged for one
such antagonist, rimonabant, concerns regarding its safety (i.e., putatively causes
depressive symptoms and suicidality) have stopped investigation and halted its use.
Another approach has been to test medications that might provide
symptomatic relief of withdrawal or reduce desire or craving. To date, moststudies have been unsuccessful in finding promising candidate medications using
this approach. Two medications that improve sleep, lofexidine and zolpidem, haveshown some promise for reducing withdrawal symptoms and in particular sleep
difficulties that occur with abrupt cessation of cannabis.
Secondary prevention“Check-up” interventions, originally developed to reach adult cannabis
users who were ambivalent about stopping their use or who did not perceive
their use to be a problem (Stephens et al, 2007), have recently been adapted foradolescents. An initial US study tested a check-up intervention with teens ingrades 9-12 who had used cannabis at least 9 times in the past month (Walker et al,2006). The check-up consisted of a computerized assessment and two 30-minutemotivational enhancement sessions. Teens were recruited with posters and healtheducation lectures and then were randomized to either the check-up intervention
or a 3-month delayed treatment condition. Teens in both conditions significantly
reduced their cannabis use, yet between-group differences were not observed. A
second study with a similar sample of teens compared the same brief motivational
enhancement intervention with an “educational feedback control” intervention
and a delayed feedback control group (Walker et al, 2011). The two active
treatments reduced cannabis use over 3 months with a greater reduction observedin the motivational enhancement condition. Both conditions showed reductions
over 12 months with no between-group differences. Three additional studies
further demonstrated that brief motivational enhancement-based interventions
show promise for reducing cannabis use in adolescents outside a treatment setting(Martin & Copeland, 2008; McCambridge & Strang, 2004; Winters & Leitten,2007). This body of research clearly shows that cannabis-using teens will engage
in brief interventions that address cannabis use, and that these interventions can
reduce use. Note that reduction and not abstinence is the most common outcome
among teens exposed to these interventions.
In summary, a number of behavior- and family-based psychosocial
interventions have been developed that are efficacious for treating cannabis
use disorders in adolescents. Unfortunately, as with treatment in adults and for
substance use disorders in general, the rates of abstinence are modest. Integrating
contingency management-based programs is one way of enhancing response rates,
but still many teens do not respond. Clearly, further development of effective
treatments will be required to better prevent and meet the needs of those who
experience problems related to cannabis use.

RISK FACTORSIn addition to the aforementioned genetic risk for the development of
cannabis use disorder – or substance use disorders in general – environmental
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IACAPAP Textbook of Child and Adolescent Mental Healthfactors contribute to the use and abuse of cannabis. Perhaps availability is of
most importance. Because of high demand and ease of growing, cannabis is themost widely available illicit drug in the world. Legal policies regarding cannabis
possession likely impact access and use rates. Although some argue that “legal use”
– such as that in the Netherlands where use of cannabis by adults and regulated
sale of small quantities is tolerated – does not increase rates of use and cannabis use
disorder, this may be because cannabis is widely available and accessible even incountries where it is not tolerated. In the US, where it is illegal, cannabis is almost
as easy for teens to obtain as alcohol or tobacco (Johnston et al, 2009).
Other factors that strongly predict cannabis use and cannabis use disorders
include (Brook et al, 2001; von Sydow et al, 2002):
•
•
•
•
•
•
•
•

Delinquent behavior
Chaotic home environment
Low socio-economic status
Other psychopathology
Low perceived risk of harm
Use of other substances
Use by peers, andUse by family members.

Moreover, early initiation of use increases the probability of developing acannabis use disorder, any substance use disorder, and other psychiatric disorders.

Click on the picture
above to access NIDA’s
publication “Marijuana:
Facts Parents Need toKnow” and the picture
below for “Marijuana:
Facts for Teens”.
Both provide reliable
information.

PREVENTION
Given the difficulty in successfully treating cannabis use disorders,prevention efforts become paramount for reducing the consequences associatedwith cannabis use and cannabis use disorders. Targets and strategies for prevention
are similar to those for other types of substance use disorders and are focused on
the risk factors mentioned. Educational campaigns, social policies, and media
portrayals of cannabis that increase the perception that cannabis is potentiallyharmful and may lead to problems are likely to reduce the probability of use anddelay initiation. Parenting education and training on effective family approaches
to discuss and handle substance use in general and cannabis use in particular, areimportant targets (Stormshak et al, 2011). A number of websites (mentioned
elsewhere in this chapter) offer excellent science-based information to guide thisprocess. Similarly teen educational approaches that are balanced, science-based
and rational, rather than based on “scare-tactics” are also available and likely to havepositive impact. More broadly, particular school-based prevention programs canbe helpful (Porath-Waller et al, 2010; Rohrbach et al, 2010). And last, enhanced
general education programming and approaches for low socio-economic, high risk
youth can be an effective method for reducing or delaying the onset of cannabisuse (Tobler et al, 2011).

MEDICAL MARIJUANA AND LEGALIZATION
Controversy related to the potential for medicinal use of cannabis and its
legalization has caused confusion and mistrust of the data about cannabis andits potential adverse consequences and benefits. These issues warrant discussion

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IACAPAP Textbook of Child and Adolescent Mental Healthbecause laws and regulations can strongly affect a teen’s perception of the risk ofharm associated with cannabis – and thereby the likelihood that they may try it or
decide to use it regularly.
Medicinal use
In 1999, the Institute of Medicine acknowledged the importance ofstudying the risks and benefits of the use of cannabis and cannabinoids for specificmedical conditions. Available data clearly suggest that the compounds in cannabis
have potential beneficial effects for a number of medical conditions. This is not
surprising as oral preparations of pure THC have been approved by regulatory
bodies in multiple countries for AIDS wasting syndrome and for cancer patients
receiving chemotherapy. The synthetic cannabinoid nabilone has been approved foruse in cancer patients undergoing chemotherapy. An oro-mucosal spray extract,which contains THC and cannabidiol is approved for use in Canada and New
Zealand to manage muscle spasticity in patients with multiple sclerosis and forneuropathic pain in cancer patients.
The important question, however, is whether smoked cannabis should beconsidered a “medicine” and be prescribed for specific ailments. Arguments foradded benefit from smoked cannabis compared with oral or oral-mucosal modesof administration are related to the more rapid onset and absorption of THC that
occurs from inhalation of the smoke, and the possible therapeutic contribution of
constituents of cannabis other than THC (e.g., delta-8-THC and cannabidiol).
Disadvantages include the adverse effects of smoke on the respiratory system andits potential carcinogenic impact, difficulty in determining therapeutic doses andreliably delivering such doses through smoke inhalation, increased probability
for intoxication, and the potential to develop a cannabis use disorder with its
associated social, cognitive, and behavioral consequences. Currently, the evidence
for determining the efficacy and safety of specific doses of smoked cannabis fortargeted medical indications does not approach that required by regulatory bodies
to even consider approval.

Vaporizer used to consume
cannabis.

Our rapidly increasing knowledge about the endocannabinoid system
has increased optimism for the eventual use of cannabinoids (cannabis-likecompounds) as medicines in areas such as treatment of pain, neuromuscular andneurodegenerative disorders, eating or appetite disorders, autoimmune diseases,
and other psychiatric disorders (Budney & Lile, 2009). The target of such work
is to produce alternative synthetic cannabinoid-based medications that reproduce
the putative positive effects of smoked cannabis while reducing the aforementioned
concerns. This path might approximate that of opioid medications, which havebeen developed and marketed for pain despite their abuse potential and substantial
side effects, but have not included a smoked formulation for administration.
Discussion of legalization of cannabis can obviously influence how ateen may perceive the potential harm associated with cannabis use. Controversy
regarding its legal status has grown since the early part of the 20th century. Procannabis groups have been calling for decriminalization or legalization for many
years, with most recent efforts directed at legalization for medical use. Arguments
for legalization include:••
Cannabis

Alcohol use and abuse are more harmful and costly
Regulated and taxed cannabis would provide fiscal benefits to society
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IACAPAP Textbook of Child and Adolescent Mental Health

•
•

•
•

and quality control for cannabis
Addictive potential is relatively low
Reduce crime related to dealing and prevent criminal status labels andfuture consequences for those who get arrested, and reduce the costs
associated with prosecution
Cannabis has medical benefits
Criminalization impinges on personal freedom.

Counter arguments include:
•
•

•
•

The psychosocial, health, and psychiatric consequences associated withcannabis misuse and related disorders are substantial
Reduced cost combined with marketing/advertising would increase use
and cannabis use disorders, particularly in vulnerable groups such asteens and those of low socioeconomic status
Medical potential can be claimed for most substances that are abused
and illegal
Legalization would reduce the perceived harm and increase use,
increased use will result in more driving under the influence of drugs
and accidents.

Many of these points made by both pro- and anti-cannabis supporters havemerit. Policymakers, who must decide how to manage cannabis in their respective
cultures, are faced with a most difficult task of balancing multiple factors; mostcountries to date have sided with arguments related to the government protectionof the public, including teens, from a potentially harmful substance.

CONCLUSION
Cannabis misuse, abuse, dependence and withdrawal are real and relatively
common problems with significant associated consequences that reflect a clear
public health problem, particularly for adolescents and young adults. In mostrespects, cannabis use and the development of cannabis use disorders approximate
what is observed with most other substances of abuse. A reasonable perspective is toacknowledge that some level of cannabis use can and does result in harmful effects.
Like all other substances, including alcohol, that have addictive potential, mostindividuals who initiate cannabis use do not experience significant consequences,
but others misuse, abuse, or become dependent and experience adverse outcomes.
Fortunately, recent research has provided a wealth of knowledge for guiding theassessment, diagnosis, and treatment of cannabis use disorders, as well as prevention
efforts. Hopefully, science will continue to provide more information that will
enhance the development, availability and effectiveness of clinical and prevention
approaches.

Cannabis coffee shop in
Amsterdam

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Appendix G.2.1
SUBSTANCE MONITORING CONTRACT
If <name of adolescent>’s urine drug screen is negative (no drugs detected or reported) andthere were no positive or refused alcohol breath tests since the last drug screen, I will:
1.

Praise the progress!

2.

Ask how I can help them keep up the good work

3.

Celebrate their progress by <list rewards>:____________________________________________________________________________________________________________________________________

If <name of adolescent>’s urine drug screen is positive (drugs detected or reported) and/or
there were positive or refused alcohol breath tests since the last drug screen, and/or urine
screen is refused, I will:
1.

Remain calm!

2.

Not give a lecture3.

Ask how I can help them4.

Express confidence that they can do better next time

5.

Use the following consequence:______________________________________________

Parent Signature								DateTeen Signature								DateTherapist Signature								DateCannabisG.2

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