Preventing cannabis use in adolescents

Regular cannabis use produces a wide range of physical and psychological effects, some even at low doses. These effects vary from person to person, depending on age, dosage, expectations, and whether it is consumed alone or with others. Initially, users experience a feeling of euphoria, followed by a depressive phase.

The main effects of cannabis use are:

• Deterioration of cognitive ability: confusion, difficulty memorizing simple tasks, expressing oneself clearly, solving problems, etc.
• Altered attention: increased reaction time.
• Alteration of the sense of time: everything happens more slowly.
• Distortion of the senses: alteration of colors, sounds, distances, etc.
• Alteration of heart rhythm and blood pressure.
• Risky sexual practices.

In Spain, cannabis is primarily consumed by smoking it mixed with tobacco in the form of a cigarette. Smoking it without a filter, inhaling the smoke deeply, holding it in the lungs, and swallowing it all, increases the risk of developing illnesses such as chronic bronchitis, emphysema, and lung cancer. Furthermore, its bronchodilator effect enhances the absorption of toxic substances.

Some people, generally, after consuming high doses, experience symptoms such as anxiety attacks, panic and paranoid states, or hallucinations .

Since it impairs attention and coordination, it increases the likelihood of traffic or workplace accidents . Furthermore, cannabis use is an illegal substance, therefore, it entails other legal problems such as penalties for drug use or possession in public, access to other drugs, etc.

Similarly, the risk increases with the earlier the age of initiation, being four times greater if it begins early. In Spain, the average age of initiation is 14.8 years for boys and 14.9 for girls, according to the latest ESTUDES 2022 survey. Drugs always carry a significant health risk, and cannabis is no exception.

We cannot say that there is a safe way to consume cannabis.

Cannabis use often begins in adolescence, a crucial stage because the brain is still developing and actively growing until around age 25. Therefore, cannabis use will cause alterations and interference in normal brain function and impact its proper neurophysiological maturation.

When cannabis is consumed, the so-called endocannabinoid system is activated. This is a system within the brain that performs functions such as learning, pain, emotions, perception, motor activity, and more. When cannabis is consumed, this endogenous system is activated externally and artificially, thus altering many of its functions and producing what Dr. Gonzalo Herradón has called a "mental impoverishment."

The medium- and long-term risk of cannabis use depends on factors such as frequency and amount of use, product purity, user age, and pre-existing health conditions.

Daily or near-daily use, starting use in adolescence, and using high-purity cannabis are associated with increased risks of dependence, mental health problems, and adverse effects on brain development.

Individuals with a genetic predisposition to mental health disorders or addiction, or with specific health conditions, may face additional risks.

Several circumstances have contributed to widespread cannabis use among young people:

• The low social perception of risk. In the latest ESTUDES Survey The myth that tobacco use is more dangerous than cannabis use continues to persist.
• Social permissiveness, which is perceived as a close, normalized substance integrated into leisure spaces.
• Easy access to the substance. Of all illegal drugs, cannabis has the highest perceived availability: 6 out of 10 students think it is easy or very easy to obtain.
• The myths and misconceptions surrounding cannabis . For example: that it is a natural, ecological substance with therapeutic effects or less harmful than smoking tobacco, which are compounded by the commercial interests of companies focused on marketing products.

This is also reflected in the study published by the Reina Sofia Center of FAD Youth , "Social Representation of Cannabis 2022. Evolution from the Differential Perspective of the Young Population ," which shows that more and more young people see cannabis as an accessible, close, visible, tolerated substance integrated into leisure spaces and even connoted as a natural substance compared to other substances considered chemical and more harmful (such as alcohol and tobacco).

According to ESTUDES, the drugs of early initiation among students aged 14 to 18 are legal drugs: alcohol, tobacco, and non-prescription hypnotics and sedatives.

Cannabis is considered the third most commonly used psychoactive substance among students aged 14 to 18 (after alcohol and tobacco) and the most commonly used illegal drug. Those with problematic cannabis use also tend to consume a lot of alcohol, but alcohol does not necessarily lead to cannabis use.

Similarly, several studies show that cannabis use is not a trigger for the use of other drugs ; however, when it is daily and begins at an early age, it can lead to the use of other illegal drugs. Cannabis use in adolescence is associated with a higher likelihood of developing dependence in adulthood and with the use of other drugs.

Yes. The family is an essential sphere for preventive action regarding cannabis use. The family can exert a positive influence by promoting protective factors. A protective factor is any attribute, condition, or characteristic that reduces or minimizes the risk and likelihood of initiating or continuing drug use. helping them to have the resources to face decisions with autonomy and a sense of responsibility.

• Boost their self-esteem. Accept them as they are. Set expectations aligned with their abilities. Value what they do well. Praise effort more than success. Encourage them toward goals and help them achieve them. This is what we call the Pygmalion Effect. Knowing that we believe in them will increase their self-esteem and self-concept. A person with healthy self-esteem is an empowered person.
• Lead by example . Be a positive role model and a reliable source of information, demonstrating healthy behaviors and making your opinion and stance on this issue known. In psychology, we call it vicarious learning when children learn by observing; therefore, it is important to maintain attitudes and behaviors consistent with the values and norms taught at home.
• Establish rules and boundaries. These should be clear, reasonable, and age-appropriate. They can be agreed upon with the children and reviewed based on their age and level of responsibility. Furthermore, they should know that there will be consequences if these rules are not followed. When children demonstrate responsibility and comply with family rules, this behavior should be reinforced with praise and recognition. One strategy is to sign a behavioral contract outlining the agreements and commitments of both parties.
• Promoting positive parent-child communication is essential. Establishing good two-way, reciprocal communication with children is crucial. Pay attention to them, creating spaces for dialogue where they can share things with each other through active listening, taking their opinions into account and respecting them.
  

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• Encourage critical thinking and reflection. Teach them to analyze situations and experiences objectively in order to make decisions and solve problems appropriately. Teach them to verify information and identify its sources. Today, the difficulty is not finding information, but knowing whether it is truthful and objective.
• Share healthy leisure and free time alternatives. Create a list of shared activities and interests (sports, cultural, etc.) and create opportunities for families to meet and enjoy them. Also, encourage their participation in activities and teamwork such as youth, cultural, and community associations, volunteering, etc.
• Collaboration and follow-up with the school. The school and the family are two fundamental pillars for preventative intervention. Family and school must work together not only for academic monitoring, but also for supervising classroom behavior, peer relationships, and, of course, promoting healthy habits.
• Managing emotions. Emotions are very important.   We must empower adolescents and young adults to manage, express, and navigate the world of emotions: frustration, anger, rage, sadness, and so on. They need to be able to identify, recognize, and effectively manage and regulate their own feelings. It's important to be able to talk about emotions, how they feel, and to have alternative activities to cope with them—to have a "resource cabinet," as psychologist Patricia Ramírez points out, of tools for managing them appropriately: meditation, physical exercise, helping others—activities that contribute to improved emotional well-being.
• Monitor your children's behavior . Let them know you care about them. Be aware of their interests, maintaining a close relationship, but at the same time, avoid overprotection—what Israeli psychologist Haim Ginott called "helicopter parents," parents who constantly hover over their children, overly worried and controlling, thus hindering their freedom and personal autonomy.   

If you don't let your children grow, fall and get back up, in the end, instead of a strong tree, you'll have a bonsai. Javier Urra, psychologist.

From within the family, one can observe changes in behavior , habits, and daily routines. Continuous observation is the best tool for detecting drug use, but it shouldn't be a police-like approach. Searching their belongings can provoke resistance and anger. It's important not to rush to conclusions; the issue should be addressed calmly and without alarmism, with concern, but with a collaborative and thoughtful attitude, avoiding confrontation.

What should we do if we notice our child using cannabis?

• Try to remain calm by facilitating a climate of communication.
• Do not judge, reproach, or dramatize.
• To understand the circumstances and reasons that led to consumption.
• Do not bring up the subject if we suspect that he has used drugs.
• To express our opinion on this matter openly.
• Don't make hasty decisions.
• Offer to collaborate and seek specialized professional advice.
• Maintain a firm attitude; do not convey an attitude of failure or defeat.

What topics can we talk about?

• Regarding their consumption pattern.
• Regarding when consumption began.
• The reasons for starting to consume.
• If friendships also consume.
• If you consider the risks of consumption.

Drugs are not a problem. They are a bad solution to a problem. Juan Antonio Marina, philosopher.

Early detection of drug use is crucial. We know there are some indicators, some clues, that can guide us if we suspect our children are smoking marijuana. It's essential to maintain a broad, observant approach . Some signs are typical of adolescence, but if several occur simultaneously, we need to be vigilant.

Physical warning signs:

• Eye redness
• Dilated pupils.
• Dry mouth.
• Sweating.

Warning signs of behavior:

• Changes in behavior or habits in their daily activity.
• Loss of interest in activities that were previously enjoyed (hobbies, sports, etc.).
• Decreased school performance.
• Secrecy and changing friends.
• Affected mood (apathy, lack of initiative…).
• Family arguments (aggression, threats, nervousness...).
• Sudden mood swings.
• Failure to comply with schedules.
• Expenditure or receipt of money without apparent explanation.
• If he gets angry when talking about drugs.
• Changes in diet.

The vast majority of cannabis users stop using it by adolescence or only occasionally in adulthood. Only a small minority of adolescents progress to other habitual and problematic substance use.

When these signs are present, it is essential not to rush to conclusions and to try to establish bridges of dialogue with our son and daughter to understand the whole situation.

The two main predictors of psychoactive substance use and many other risky behaviors are academic failure and lack of integration into the school environment. Alfonso Ramírez de Arellano, psychologist.

If the goal is simply to determine whether or not cannabis has been used, various drug tests are currently available at most pharmacies, medical and health product stores, and even online. There are different detection methods: urine, blood, or sweat.

However, if we suspect it, this doesn't seem to be the best option . The American Academy of Pediatrics (AAP) also doesn't recommend this method; our child may feel intimidated. Therefore, it should be a last resort if dialogue and our trust haven't allowed us to start a conversation with him about this issue and we have indications that he is using drugs.

Alternative forms of cannabis, such as drops or pills, may offer a dosage more precise and reduce respiratory risks associated with smoking. We understand that this refers to formats sold with CBD (Cannabidiol), a cannabinoid found in specialty stores that has no psychoactive properties but rather anxiolytic and relaxing effects, improves sleep, but can carry some risks, side effects, and interact with other medications being taken.

The school environment is an ideal setting for implementing prevention strategies, as it is one of the key places for the development of personal skills and competencies.

Schools are a key ally in drug abuse prevention. Many schools are implementing protocols for detecting and addressing drug use. These protocols facilitate the identification of risky behaviors and drug-related situations, creating standardized procedures for coordination, communication, action, and joint referral among the various agencies and services involved. They also provide guidelines and educational resources for teachers and families.

Schools provide a suitable setting for implementing prevention programs:

• It allows access to a large number of young people in the maturation process phase in which the intervention of the adult has a great impact.
• The compulsory nature of schooling until the age of 16 implies that all people must go through it during the most important period of personality formation.
• It is an ideal space to detect potential risk factors and situations of vulnerability.
• Teachers, as preventive agents due to their close relationship with students and their educational role, can establish positive emotional bonds by transmitting values such as respect, equality, and solidarity.

There is evidence that universal prevention programs in schools, based on promoting the personal and social skills of adolescents, achieve positive results if they involve teachers and use interactive activities that promote responsibility, autonomy, decision-making, and awareness of the consequences of substance use and abuse.

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These interventions should be ongoing, rather than isolated, reactive actions. The teaching staff must have the necessary training, materials, and resources to do so.

There must be communication channels with family prevention to generate a unified and coherent prevention model.

Protective factors in the school environment

• Positive relationships with teachers and the school.
• Clear norms and rules of conduct.
• Student participation in school tasks and activities.
• Motivation and reinforcement of students in the culture of effort.
• Family relationship and school monitoring.

In the latest ESTUDES 2021 Survey, students considered that of the measures that could be implemented to alleviate the drug problem, the most effective would be education in the school environment.

The psychological impact of cannabis use is particularly significant, given that it is primarily used by young people. It causes difficulties in studying by impairing attention, concentration, abstract thinking, and memory, thus hindering learning. It can cause acute anxiety reactions and, in predisposed individuals, lead to the development of mental disorders.

Cannabis use poses risks to mental health, both with occasional and continued use. The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) includes the category of Cannabis Use Disorder, classifying it as mild, moderate, or severe based on symptoms and withdrawal criteria. Withdrawal syndrome can occur upon cessation of use after periods of heavy and prolonged consumption, and may include irritability, anxiety, restlessness, insomnia, appetite disturbances, abdominal pain, spasms and tremors, fever, chills, or headache.

The dangers of smoking marijuana during adolescence

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Problematic cannabis use is defined as persistent use of the substance despite harmful effects (social, physical or mental health).

Some risks:

• Memory and learning problems.
• Dependence and addiction.
• Emotional disorders: anxiety, depression.
• Fear and panic attacks.
• Bronchopulmonary diseases.
• Heart rhythm disorders: arrhythmias.
• Certain types of cancer.
• Psychosis and schizophrenia.

It is not yet known with certainty whether cannabis is responsible for the illness or if it merely accelerates the onset of something that was already latent in the user, but the result, in either case, is the same: the manifestation of the mental health problem. The earlier consumption begins, the greater the likelihood of altered neuronal communication and the appearance of cognitive or motivational impairments and psychiatric disorders.

Cannabis use can lead to various types of mental disorders, including psychotic disorders . The relationship between cannabis use and psychotic symptoms has been clearly described in numerous studies. Chronic cannabis users have a higher risk of developing both schizophrenia and other psychotic disorders.

First psychotic episodes and substance abuse

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The earlier and more frequently cannabis use begins, the greater the risk. Some authors suggest that cannabis use may precipitate the onset of psychotic episodes in vulnerable individuals with a predisposing genetic predisposition. However, it is difficult to definitively establish a direct causal relationship between cannabis use and psychosis, as the development of psychotic disorders depends on multiple factors. Smoking cannabis may be a risk factor in people with a family history of psychiatric disorders.

Primary care pediatric teams are in a privileged position for the early detection of cannabis use due to their contact with children in the development and growth phase, and their families.

All interventions should be done in a comprehensive and non-specific manner, taking into account community and specialized resources.

Primary care professionals need basic knowledge and training to screen adolescents for potential substance use. Pediatricians are essential in the prevention and early detection of potential drug use, and in referring patients to specialized centers when necessary.

These professionals should get used to including questions about drug use from the beginning of adolescence, in order to identify potential use as early as possible. There is evidence of the efficacy and effectiveness of early identification and brief intervention programs in cases of drug use.

To detect and initially address cannabis use in 15-year-old adolescents, brief interventions such as validated screening questionnaires like the CAST ( Cannabis Abuse Screening Test ) can be implemented. This is a simple, six-question scale designed to identify patterns or risk behaviors associated with cannabis use in the past year. Easy to administer, it assesses the frequency, dependence, and consequences of cannabis use. Its use in primary care would allow for the identification of young people who may be at risk of developing cannabis use disorder. Furthermore, it can help guide diagnosis and direct individuals to appropriate programs.

The American Academy of Pediatrics recommends annual screening, coinciding with regular physical examinations, although it is important for the family to exercise their role in supervising and monitoring the behavior of their children.

These actions should be carried out in an environment of trust and support , without adopting a punitive approach.

The following article is recommended: Benítez Rubio MR, Medranda de Lázaro MI, Montón Álvarez JL. Primary Care Pediatrician Intervention in the Prevention of Substance Abuse. Rev Pediatr Aten Primaria. 2006; 8 Suppl 3: S91-111.

The role of primary care professionals in addressing drug use is relevant, since they can detect drug use directly or indirectly through their consultations.

If a referral to specialized services is made, it will be done in coordination with them and with accompaniment to the adolescent and the family.

Primary care professionals can also:

• Conduct training and coordination seminars between social and healthcare professionals and educators to analyze case studies and coordinate actions and interventions.
• To set up or recommend devices for young people, where the adolescent can go alone or accompanied by trusted people (friends, partner…) and express their doubts.
• Conduct prevention workshops for family members.
• Carry out preventive activities outside the health center.
• Participate in working groups for the development of prevention plans.
• Development of support materials.

When a teenager mentions cannabis use, it is necessary to create a bond, accepting it unconditionally and creating a climate of empathy and trust, guaranteeing confidentiality.

People with attention deficit hyperactivity disorder (ADHD) experience difficulties with attention and concentration, are easily distracted, tend to procrastinate and abandon tasks, have trouble following instructions, experience emotional instability, have low self-esteem, suffer from anxiety and depression, and make decisions without considering the immediate consequences. They are also more prone to drug use.

An international study conducted by the Psychiatry, Mental Health, and Addictions team at Vall d'Hebron Hospital identified that people with ADHD were almost eight times more likely to use cannabis during their lifetime . This is a common comorbidity, and this association will exacerbate both disorders.

Individuals with ADHD may experience early drug use. Early diagnosis, assessment, and treatment of ADHD can reduce the risk of drug use; however, it is essential that parents establish prevention guidelines and recommendations as previously described. At the same time, it is important to make them aware of their increased vulnerability and cognitive impairment due to substance use and abuse. It is also important to keep in mind that the propensity of individuals with ADHD to use cannabis could be for self-medication to avoid feeling overwhelmed or as a way to alleviate distress caused by difficulties at school, with peers, or within the family.

Children who are diagnosed and treated for ADHD at a young age may be less likely to use substances compared to those who start treatment later or are not diagnosed.

ADHD increases the risk of developing problems associated with drug use, and this association not only exacerbates both disorders but also complicates ADHD treatment and leads to a less favorable outcome. Therefore, preventing drug addiction is a fundamental objective in the management and treatment of children and adolescents with ADHD.

Yes, because he is unable to see the risk of consumption and his own impulsiveness causes him to not perceive that risk or puts him in risky situations