The Problem With Our National Dialogue on Cannabis

The dialogue that we’ve had around substance abuse in this country for the last 30 years has been lacking in sophistication and nuance. The echoes of Reagan-era messages to “just say no” and that all drugs of abuse are equally deleterious have imperiled the credibility of these messages among young people. The increasing acceptance of cannabis for purported medical uses has given this ancient drug the appearance of safety among young people. 

An obvious harm of substance use is death, and the data on this outcome with regards to cannabis are clear: it is prescription medications (usually opiates), alcohol, cocaine, and heroin that kill more Americans than any other group of drugs (1). 

Cannabis doesn’t even show up on this list of deadly drugs, which makes sense, because a lack of cannabinoid receptors (the target for both endogenous cannabinoids such as anandamide and for exogenous cannabinoids such as THC) at the brain stem means that when Johnny smokes a lot of pot, it may make him intoxicated, but won’t cause him to stop breathing (2). 

However, this relatively low risk of lethality, coupled with the increasing societal acceptance of cannabis (52% of Americans surveyed in 2013 now support legalization of cannabis) (3) has led many young people to believe that cannabis is a safe drug. The average age of cannabis initiation is 17 (4), and 44% of regular adolescent cannabis users now say that cannabis presents “great risk” in the 2012 survey, down from 55% ten years ago.

This, however, couldn’t be farther from the truth. While cannabis presents fewer risks to the adult brain, the dangers it poses to the developing brain of an adolescent are increasingly clear. Early, heavy use of cannabis before the end of adolescence increases the risks of psychotic illness, psychiatric hospitalization, decreased IQ, and in young women, anxiety and depression (5-11). 

Harm reduction techniques recognize that abstinence is not appealing to all substance users (12, 13), that no use is ideal, but that less use is better than more use. In addition, harm reduction recognizes that the use of lower potency substances is better than higher potency substances. Following the tenets of this approach, it is clearly less risky to use cannabis as an adult than as a teenager. 

So I pose this question to the readers of my blog: how do we craft a realistic, honest message to young people about cannabis? How do we convince young people to hold off on using cannabis until they are older and the risks are decreased? Clearly, the blanket message that “all drugs are bad all the time for all people,” has failed. Yet, in the absence of a clear statement about the attendant risks of cannabis, young people will continue to assume that this increasingly ubiquitous drug is safe for them. Harm reduction efforts need to focus on encouraging adolescents to hold off on using cannabis until they are older, if they are going to use at all.   How can we, as psychiatric clinicians, become the standardbearers for honest, nuanced information about this drug? 

References

1.Peek 04/23/2013 Popular Science https://www.popsci.com/science/article/2013-04/which-drugs-actually-kill-americans 

2. Inaba DS et al. Uppers, Downers, All Arounders: Physical and Mental Effects of Psychoactive Drugs. 7th ed. Medford, OR: CNS Productions, Inc.; 2011. 

3. Pew Research Center, 4/4/13 https://www.people-press.org/2013/04/04/majority-now-supports-legalizing-marijuana/ 

4. SAMSHA (2012) Results from the 2012 National Survey on Drug Use and Health: Summary of National Findings https://www.samhsa.gov/data/NSDUH/2012SummNatFindDetTables/NationalFindings/NSDUHresults2012.pdf

5. Patton GC et al. BMJ. 2002;325(7374):1195-1198. 

6. Andreasson S et al. Lancet. 1987;2(8574):1483-1486. 

7. Fergusson DM et al. Addiction. 2005;100(3):354-366. 

8. Henquet C et al. BMJ. 2005;330(7481):11. 

9. Moore TH et al. Lancet. 2007;370(9584):319-328. 

10. Schubart CD et al. Acta Psychiatr Scand. 2011;123(5):368-375. 

11. Meier, et al (2012) PNAS 109(40). 

12. Miller W et al. Motivational Interviewing: Preparing People for Change. 2nd ed. New York, NY: Guilford Press; 2002. 

13. Denning P. Practicing Harm Reduction Psychotherapy: An Alternative Approach to Addictions. New York, NY: Guilford Press; 2000.

Andrew Penn was trained as an adult nurse practitioner and psychiatric clinical nurse specialist at the University of California, San Francisco. He is board certified as an adult nurse practitioner and psychiatric nurse practitioner by the American Nurses Credentialing Center. Currently, he serves as an Assistant Clinical Professor at the University of California-San Francisco School of Nursing. Mr. Penn is a psychiatric nurse practitioner with Kaiser Permanente in Redwood City, CA, where he provides psychopharmacological treatment for adult patients and specializes in the treatment of affective disorders and PTSD. He is a former board member of the American Psychiatric Nurses Association, California Chapter, and has presented nationally on improving medication adherence, emerging drugs of abuse, treatment-resistant depression, diagnosis and treatment of bipolar disorder, and the art and science of psychopharmacologic practice.

The views expressed on this blog are solely those of the blog post author and do not necessarily reflect the views of Psych Congress Network or other Psych Congress Network authors. Blog entries are not medical advice.