Office Approach to the Adolescent Patient
Adolescents and preteens may be screened for substance use and brief intervention, as recommended in the Screening, Brief Intervention, and Referral for Treatment (SBIRT) policy statement.27 The effectiveness of the SBIRT technique has been documented in adults with alcohol use problems; because of the lack of information in the adolescent population, the US Preventive Services Task Force recently gave SBIRT an “I” rating, stating that there was insufficient evidence to recommend either for or against this technique. However, on the basis of the limited evidence available and the low cost of this brief intervention, the AAP and the National Institute on Alcohol Abuse and Alcoholism both recommend that this technique be used in pediatric practices as part of routine care.
For adolescents who do not use marijuana, motivational techniques may be helpful in eliciting reasons for abstaining from use and resisting peer pressure in a manner that supports their decision to abstain.
Adolescents who use marijuana regularly or heavily are more likely to meet criteria for a substance use disorder. For these teenagers, a brief motivational intervention may be used to target: (1) reducing use and (2) continuing the conversation either with the pediatrician or a mental health or behavioral counselor. Additional advice for gathering information that is helpful to determine the extent and severity of use follows:
Ask the adolescent how much and how often he or she uses marijuana. Also ask about the circumstances (ie, where the marijuana is obtained, if use is with others versus alone, if use is before or during school versus on the weekends) and motivations (when stressed, bored, alone, angry, etc) associated with the decision to use the substance. Although teenagers may use marijuana for the positive euphoric effects or for social acceptance, they also may use marijuana for self-medication, such as to relieve negative moods (ie, stress, anxiety, or depression)28 or for sleep problems. Teenagers who use marijuana for these purposes who meet criteria for a co-occurring mental health disorder may benefit from treatment, including counseling and/or a psychiatric evaluation.
Take a detailed history that includes identifying concerns associated with marijuana use. Criteria in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (see Table 1), can be useful as a guideline in ruling out problematic marijuana use.29
If the adolescent does not report regular use of marijuana and denies any associated problems, offer a “challenge.” Ask the adolescent to quit using the drug for a brief period of time, and see what happens. If the adolescent is able to stop completely, ask whether life was “better, worse, or the same” during the quit period to prompt a discussion of pros and cons of use. If the adolescent was unable to stop completely, explore possible triggers and high-risk situations that were barriers to success. Work with the adolescent to problem-solve and try again. If the adolescent was unwilling to quit, even for a limited period of time, explore the motivations for drug use (see talking point 1) and consider whether any additional interventions or supports may be helpful. Talking points can be introduced as areas of concern but also can be used to trigger engagement and discussion during brief interventions (eg, information about the modeling effect of parental smoking and the current understanding of marijuana effects in teenagers). If there are major concerns for the teenager’s safety or the teenager is considered at high risk of adverse consequences, breaking confidentiality and notifying the parents may be advisable to ensure the patient’s safety.
Talking Points for Parents and Teens: Handout
Marijuana is not a benign drug for teens. The teen brain is still developing, and marijuana may cause abnormal brain development.
Teens who use marijuana regularly may develop serious mental health disorders, including addiction, depression, and psychosis.
There are no research studies on the use of medical marijuana in teens, so actual indications, appropriate dosing, effects, and side effects are unknown. The only data available on medical marijuana in the pediatric population are limited to its use in children with severe refractory seizures.
Recreational use of marijuana by minors and young adults under the age of 21 years is illegal and, if prosecuted, may result in a permanent criminal record, affecting schooling, jobs, etc.
Never drive under the influence of marijuana or ride in a car with a driver who is under the influence of marijuana. Adults and teens regularly get into serious and even fatal car accidents while under the influence of marijuana.
Marijuana smoke is toxic, similar to secondhand tobacco smoke. The use of vaporizers or hookahs does not eliminate the toxic chemicals in marijuana smoke.
For parents: You are role models for your children, and actions speak louder than words. So if you use marijuana in front of your teens, they are more likely to use it themselves, regardless of whether you tell them not to. (See the AAP Healthy Children Web site: www.healthychildren.org/English/ages-stages/teen/substance-abuse/Pages/Drug-Abuse-Prevention-Starts-with-Parents.aspx.)
For parents: It is important to keep all marijuana products away from children. As with other medications and toxic products, containers that are child-proof and kept out of reach should be used. For small children, marijuana edibles and drinks can be particularly dangerous.
For parents: Remember that intoxication and euphoria are predictable effects of using marijuana products. Being “high” from your own recreational or medical marijuana use may alter your capacity to function safely as a parent or to provide a safe environment for infants and children.30
For parents: If your child asks you directly whether you have used marijuana, a brief, honest answer may help the child feel comfortable talking with you about drug use issues. However, it is best to not share your own histories of drug use with your children. Rather, discussion of drug use scenarios, in general, may be a more helpful approach.
Summary and Conclusions
Pediatricians are in a unique position to provide parents and teenagers with accurate information and counseling regarding the consequences of marijuana or cannabis use by children, teenagers, and adults. A number of strategies can be used to counsel families about preventing use and to intervene if marijuana is being used either recreationally or medically by the families for whom they provide medical care.
Sheryl A. Ryan, MD, FAAP
Seth D. Ammerman, MD, FAAP
Committee on Substance Use and Prevention, 2016–2017
Sheryl A. Ryan, MD, FAAP, Chairperson
Pamela K. Gonzalez, MD, MS, FAAP
Stephen W. Patrick, MD, MPH, MS, FAAP
Joanna Quigley, MD, FAAP
Leslie R. Walker, MD, FAAP
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