Pediatric Annals

Special Issue Article 

Cannabinoids and the Adolescent Patient: A Pragmatic Guide for Pediatric Practitioners

Gregg Joseph Montalto, MD, MPH; Elizabeth G. Cius, MD; Maria H. Rahmandar, MD

Abstract

Primary care and emergency medicine practitioners frequently care for adolescents with acute or chronic effects of cannabinoids. Cannabinoid epidemiology and pharmacology are changing as new laws and regulations, new products, and new means of delivery are rapidly developed. A grasp of basic cannabinoid terminology, which is also constantly shifting, helps clinicians obtain histories and discuss diagnoses, treatments, and outcomes with their patients. The ability to identify and treat cannabinoid-associated illnesses such as cannabinoid hyperemesis syndrome, withdrawal syndrome, and acute intoxication with synthetic cannabinoids can reduce morbidity. Research on neurodevelopmental, cognitive, and psychological effects of adolescent cannabinoid use helps clinicians to have informed conversations with their patients, while providing anticipatory guidance. This article is designed with busy clinicians in mind and highlights the practical information necessary to provide care to their adolescent patients. [Pediatr Ann. 2021;50(2):e57–e64.

Abstract

Primary care and emergency medicine practitioners frequently care for adolescents with acute or chronic effects of cannabinoids. Cannabinoid epidemiology and pharmacology are changing as new laws and regulations, new products, and new means of delivery are rapidly developed. A grasp of basic cannabinoid terminology, which is also constantly shifting, helps clinicians obtain histories and discuss diagnoses, treatments, and outcomes with their patients. The ability to identify and treat cannabinoid-associated illnesses such as cannabinoid hyperemesis syndrome, withdrawal syndrome, and acute intoxication with synthetic cannabinoids can reduce morbidity. Research on neurodevelopmental, cognitive, and psychological effects of adolescent cannabinoid use helps clinicians to have informed conversations with their patients, while providing anticipatory guidance. This article is designed with busy clinicians in mind and highlights the practical information necessary to provide care to their adolescent patients. [Pediatr Ann. 2021;50(2):e57–e64.

The cannabinoid landscape is ever-changing with new means of delivery, changes in potency, and new regulations. Societal acceptance of cannabis use has grown faster than knowledge of its effects on adolescents. Cannabinoid research is often hindered by regulatory constraints, difficulties accessing products, funding challenges, and disparate methodologies.1 Nevertheless, it is incumbent on practitioners who care for adolescents in outpatient and hospital settings to understand how to efficiently screen for use, identify clinical signs and symptoms of use, and effectively provide care and education.

This article will focus on scenarios familiar to primary care clinics, emergency departments, and inpatient units, covering the epidemiology of adolescent cannabinoid use, describing the mechanism of action of various psychoactive cannabinoids including delta-9-tetrahydrocannabinol (THC) and synthetic cannabinoids, and discussing how these substances are used. The article will review screening strategies, provide blueprints to address common clinical scenarios, and discuss the relationship of cannabinoid use with adverse mental health outcomes. An important list of definitions is in Table 1.2

Definition of Cannabinoids and Clinically Important Cannabinoid Subtypes

Table 1.

Definition of Cannabinoids and Clinically Important Cannabinoid Subtypes

Epidemiology

According to the 2019 Youth Risk Behavior Survey, 21.7% of high school students used marijuana in the past 30 days and 7.3% used synthetic cannabinoids.3 Among these students, 18% used marijuana more than 40 times in the past 30 days, 23.5% used 10 to 39 times, 21.8% used 3 to 9 times, and 36.7% used 1 to 2 times.3 Although lifetime usage decreased between 2013 and 2019 from 40.7% to 36.8%, marijuana use in this population is still quite high.3 Prevalence was essentially equal among all racial groups, but higher among youth who identify as LGBTQ+ (lesbian, gay, bisexual, transgender, queer) than their heterosexual peers.3 Prevalence increased over grade levels.3

New means of delivery, particularly vaping, are impacting adolescent cannabis use.4 Although overall annual use of cannabis by any means did not increase in 2019, there was a large increase in cannabis vaping.5 Early-onset occasional and regular cannabis use increase the risk for nicotine dependence, and both early- and late-onset occasional and regular cannabis use increases the risk for misuse of alcohol and illicit drugs by age 21 years.6

Federally, cannabis remains a Schedule 1 drug, yet regulations around medical and recreational marijuana are made at the state level, and are inconsistent from state to state.7 As of early 2020, 11 states and the District of Columbia have legalized recreational marijuana for people age 21 years and older, and 33 states permit medical marijuana.8 Many states have decriminalized small amounts of cannabis for personal use.9 There is limited evidence that legalization of recreational cannabis is associated with increased use.10 Perception of harm due to cannabis has decreased markedly in recent decades.11 It has been difficult to accurately determine the effects of adult medical and recreational cannabis legislation on adolescent cannabis use.10,12

Forms and Pharmacology

Although there are more than 100 active cannabinoids in the Cannabis sativa plant, the primary psychoactive substance is THC. THC and other cannabinoids are agonists at cannabinoid receptor 1 (CB1) and cannabinoid receptor 2 (CB2). The high felt after using THC includes feelings of euphoria and relaxation, although anxiety and nausea are often reported. Cannabidiol (CBD) binds to the same CB1 and CB2 receptors as THC. Although it does not produce the same psychoactive effects, CBD may modulate the effects of THC. Synthetic cannabinoids (SCs) often have a much stronger affinity for cannabinoid receptors, and have varying neuropsychiatric and physical effects, often quite different from THC, including acute psychosis and cardiovascular events. The main psychoactive properties are mediated via the CB1 receptors in the brain. Tolerance and withdrawal can be seen after chronic activation of the CB1 receptor.2

Cannabinoids are lipophilic, and sequestration in adipose tissue leads to a long half-life, measured in days, which is why even after abstinence THC can be found in a urine drug screen for weeks after frequent, heavy use. They are metabolized via the cytochrome P450 system, and metabolites are excreted in both feces and urine.13

There are four main preparations of THC: (1) marijuana, made from the dried tops and leaves of the plant; (2) hashish, dried resin and flowers; (3) sensimilla, unfertilized (seedless) flowers; and (4) hash oil, dabs, and wax, extracted THC from hashish or marijuana.2

THC concentration of Cannabis sativa products increased from 4% in 1995 to 12% in 2014, and the THC to CBD ratio increased from 14 to 80 over a similar time period.14 In Washington state in 2016, shortly after legalization, the THC concentration in cannabis flowers was over 20%.15 Dabs can have as much as 90% THC concentration.2 These higher-concentration forms of THC are increasingly popular, and adolescents who use them may be more impacted by acute and chronic adverse effects, including psychosis and an increased dependence liability.16

Cannabis can be inhaled or ingested, with a more rapid onset and intensity of psychoactive effects when inhaled, but a longer duration when ingested.2 There are myriad means to use cannabis, with usage patterns rapidly evolving with the ubiquity of electronic delivery systems (Table 2 and Figures 17).

Common Methods of Using Cannabis

Table 2.

Common Methods of Using Cannabis

A cannabis grinder used to break up marijuana into small pieces that are easier to ignite. Used with permission from Joseph Montalto, BA.

Figure 1.

A cannabis grinder used to break up marijuana into small pieces that are easier to ignite. Used with permission from Joseph Montalto, BA.

Pipe used to smoke marijuana or other cannabinoids. Used with permission from Joseph Montalto, BA.

Figure 2.

Pipe used to smoke marijuana or other cannabinoids. Used with permission from Joseph Montalto, BA.

A bong where marijuana or other cannabinoid “herbs” are placed in the bowl and lit. Used with permission from Joseph Montalto, BA.

Figure 3.

A bong where marijuana or other cannabinoid “herbs” are placed in the bowl and lit. Used with permission from Joseph Montalto, BA.

A gravity bong where marijuana is lit in the bowl while the smaller bottle (which fills with smoke) is slowly lifted out of the water. Used with permission from Joseph Montalto, BA.

Figure 4.

A gravity bong where marijuana is lit in the bowl while the smaller bottle (which fills with smoke) is slowly lifted out of the water. Used with permission from Joseph Montalto, BA.

A THC (delta-9-tetrahydrocannabinol) pen in which cartridges are filled with THC concentrates. Used with permission from Joseph Montalto, BA.

Figure 5.

A THC (delta-9-tetrahydrocannabinol) pen in which cartridges are filled with THC concentrates. Used with permission from Joseph Montalto, BA.

This “do-it-yourself” sploof uses a toilet paper roll, a rubber band, and dryer sheets to reduce the odor after exhalation. Used with permission from Joseph Montalto, BA.

Figure 6.

This “do-it-yourself” sploof uses a toilet paper roll, a rubber band, and dryer sheets to reduce the odor after exhalation. Used with permission from Joseph Montalto, BA.

(A) Cannabis concentrates, (B) resin with a dab tool, and (C) honey butane wax, one of the most concentrated forms of THC (delta-9-tetrahydrocannabinol). From the US Drug Enforcement Administration43 (in the public domain; permission is not required).

Figure 7.

(A) Cannabis concentrates, (B) resin with a dab tool, and (C) honey butane wax, one of the most concentrated forms of THC (delta-9-tetrahydrocannabinol). From the US Drug Enforcement Administration43 (in the public domain; permission is not required).

Illicit “joints” and “blunts” can be dipped in other psychoactive substances, such as phencyclidine or cocaine, making it difficult to predict physical and psychotropic effects. Legal cannabis does not have tightly enforced regulations on product content, so chemical composition and combinations may vary widely.7

Screening for Cannabis Use in Clinical Settings

The American Academy of Pediatrics encourages the use of brief screening tools, such as Screening to Brief Intervention (S2BI) and Brief Screener for Tobacco, Alcohol, and Other Drugs (BSTAD) in a medical home setting.17,18 The US Preventive Services Task Force recommends screening questions for unhealthy drug use in patients age 18 years and older, but states the evidence is insufficient to recommend routine screening in patients younger than age 18 years.19 Both S2BI and BSTAD only take a few minutes to complete and can be administered confidentially in a variety of settings, including a clinic or emergency department. These screening tools may be more sensitive at identifying cannabis use than urine drug screens, especially for intermittent or infrequent use.

S2BI begins by asking about tobacco, alcohol, and marijuana use (Table 3). Any answers other than “never” prompt four additional questions about misused prescription medications, other illegal drugs, inhalants, and novel psychoactive substances (including synthetic cannabinoids). When compared with criteria for substance use disorder (SUD) per the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5),20 “never” and “once or twice” correlate with no SUD, “monthly” with mild or moderate SUD, and “weekly or more” with severe SUD.17

Intervention Screening Questionsa

Table 3.

Intervention Screening Questions

Screening is most useful when there are the means to intervene, optimally at the time of screening. Clinics should advocate for needed resources and give clinicians the time and training needed to have sensitive discussions with their patients. Many different health professionals, including therapists, social workers, nurses, and independent practitioners (physicians, nurse practitioners, physician assistants), can actively participate in the screening, brief intervention, and referral to treatment model.

It may be useful to ask “do you use to get high with your friends, or do you use to get through the day?” The answer to this simple question can quickly guide a clinician's intervention. Adolescents who do not have cannabis use disorder (CUD) and use infrequently and socially may benefit from exploring how cannabinoid use may affect educational or employment prospects. Harm reduction strategies, such as designated sober friends for transportation, should be discussed. Those with more frequent use may benefit from referral to substance use treatment or close medical home follow-up. Many adolescents use cannabis to self-medicate for anxiety-based disorders, including posttraumatic stress disorder (PTSD).21 Clinicians should address the underlying psychiatric disease, and discuss the relationship among cannabinoid use, depression, and anxiety.

Physical Effects of Cannabinoids

Adolescents often display untoward effects of cannabinoids, possibly connected to increasing rates of daily use, more potent THC products, changing ratios of THC to CBD, or the popularity of synthetic cannabinoids. Cannabinoid hyperemesis syndrome (CHS), cannabis withdrawal, and acute toxicity from synthetic cannabinoids are frequent presentations to emergency departments, and recognizing these clinical presentations can help to avoid unnecessary delays in diagnosis and treatment.

Cannabinoid Hyperemesis Syndrome

CHS is characterized by current cannabinoid use, uncontrolled vomiting, and abdominal pain that may be relieved by hot showers. Little is known about the pathophysiology of CHS, although most theorize dysregulation of the endocannabinoid system. CB1 receptors in the brain, which have antiemetic functions when activated, may be down-regulated with chronic cannabis use. CB1 receptors in the gastrointestinal tract delay gastric emptying, possibly contributing to CHS. THC causes an increase in splanchnic blood flow, which may contribute to nausea and vomiting; this theory is backed by symptom improvement with hot showers, which leads to a cutaneous steal of blood flow and decreased splanchnic flow.22–24 CHS has three phases: prodromal, hyperemetic, and recovery. The prodromal phase can last weeks, with nausea and abdominal pain. Nausea can then drive cannabinoid use, given the potential antiemetic effects.24,25 The hyperemetic effect is difficult to treat.

CHS can mimic infectious and inflammatory processes, hepatobiliary disease, intestinal obstruction, pregnancy, pancreatitis, increased intracranial pressure, and other diagnoses.25 Although CHS is a diagnosis of exclusion, it is on the differential diagnosis list for adolescents presenting with acute bouts of nausea and vomiting. Virtually all patients will have cyclic, severe nausea and vomiting, and the vast majority report abdominal pain, with symptom relief by taking hot showers. Nearly three-quarters of patients report daily or greater than daily cannabis use, and more than 95% at least weekly cannabis use.23

Treatment for CHS focuses on correcting any gastrointestinal, electrolyte, and renal anomalies that follow intractable emesis and dehydration. The only consistently effective treatment is cessation of cannabinoid use, although it may take 1 to 2 days before the hyperemesis phase abates, and relapse rates can be high.25 Standard antiemetic medications are generally ineffective.24 Of the limited research on acute pharmacologic treatment of CHS, benzodiazepines have the most supporting evidence.22 Benzodiazepines should be limited to the hospital setting, and not as a home as-needed treatment, given their addiction liability. Haloperidol has also been used with some success. Capsaicin, a compound in chili peppers, applied to the abdomen, torso, back, and/or upper arms, has shown some promise in the treatment of acute CHS, perhaps via a mechanism similar to hot showers.22,24 Opioids should be avoided in the treatment of abdominal pain associated with CHS.23

Cannabis Use Disorder and Withdrawal

Each year, CUD affects 2.1% of adolescents age 12 to 17 years and 5.9% of young adults age 18 to 25 years.26 CUD is characterized in DSM-520 as problematic use with elements of impaired control, such as using more often or over a longer period than intended, or inability to cut back; impaired social interactions at home, school, or work; or use in risky scenarios, such as while driving, or while aware of clear physical and psychological harms. Chronic cannabinoid use can lead to addiction, and subsequent abstinence to a withdrawal syndrome. Patients with cannabinoid withdrawal may experience irritability, anger, anxiety, depression, insomnia, anorexia, weight loss, restlessness, abdominal pain, headaches, or tremors.20 Symptoms generally begin after 24 hours of abstinence, peak at 2 to 3 days, and can last for 2 to 3 weeks.27 High-potency THC products may be associated with more severe dependence.16 More than one-third of adolescents may exhibit withdrawal symptoms, and those that do are more likely to resume chronic cannabinoid use.28 Symptoms of withdrawal overlap with those of mood disorders and anxiety-based disorders, including PTSD, which may be difficult to differentiate.

Treatment for cannabinoid addiction and withdrawal can involve a multidisciplinary approach, including psychotherapy and supportive interventions. Understanding any physical or psychological comorbidities is essential.29 Asking “do you use marijuana to get through the day?” can provide good insight about underlying pain, anxiety, or addiction.

There are no approved medications for the treatment of CUD or withdrawal, although there are some that show promise in small studies. N-acetylcysteine may lead to a decrease in cannabis use and craving in patients with CUD, and gabapentin has been shown to decrease symptoms of withdrawal.28,29 Mirtazapine may improve sleep early in the treatment course for withdrawal syndrome but does not affect relapse rates. Multiple studies involving anti-depressants, atypical antipsychotics, and mood stabilizers either showed no benefit for the treatment of CUD with withdrawal, exacerbated symptoms, or caused unwanted side effects.29

Acute Toxicity from Synthetic Cannabinoids

SCs, marketed as K2, Spice, Black Mamba, Kush, and others, are a wide array of chemicals structurally similar to THC, yet are full agonists with a much higher affinity for the CB1 and CB2 receptors.30 SCs are sprayed onto plant material and sold as incense or herbal blends that are smoked, or as liquids that are vaped. There are dozens of SCs with differing pharmacokinetic and pharmacodynamic properties, and to keep ahead of US Drug Enforcement Agency scheduling, new substances continue to be created. This chemical diversity likely plays a role in the wide array of symptoms from acute SC toxicity.30

Common symptoms of toxicity are altered mental status, agitation, psychosis, panic, and paranoia, often accompanied by a sympathomimetic response with tachycardia and hypertension. Rhabdomyolysis, hyperthermia, ischemic events, and acute kidney injury have been reported.31 Although there are urine assays for SCs, they are not widely available; therefore, a high index of suspicion is needed to identify a patient who presents with acute SC toxicity.

Treatment of acute SC toxicity is generally supportive, addressing fluid and electrolyte derangements, ensuring renal protection due to risk for rhabdomyolysis. Agitation, psychosis, anxiety, or seizures can be treated with benzodiazepines, whereas psychosis and agitation have been treated with neuroleptic medications.31 Because of the varying effects of different known SCs, and because SCs are often used in conjunction with other substances, it is important to closely monitor patients' medical and psychiatric status.

Mental Health and Cannabinoids

Widespread legalization of marijuana in the United States, along with the perceived safety of such products,11 makes it imperative that clinicians be able to speak to adolescent patients about cannabinoid use. Changes in gross brain morphology characterized by cortical thinning, synaptic reorganization or pruning, and increased myelination of white matter tracts make adolescents particularly susceptible to adverse mental health, cognitive, and neurodevelopmental consequences.32 These maturation patterns occur earlier in the amygdala and hippocampus and later in the areas of the prefrontal cortex and the temporal region,33 and are associated with development of harm avoidance, decision-making, inhibition, learning memory, motivation, and reward.34 CB1 receptors are densely located in these regions, and the use of exogenous cannabinoids during adolescence may lead to an alteration in normal brain development and functioning.35

Longitudinal data suggest that persistent cannabis use starting between ages 13 and 15 years is associated with diminished IQ scores, processing speed, and executive function.36 Younger age of onset and more persistent use of cannabis translated into more profound decline.36 These effects were not seen with adult onset cannabis use.36 Additionally, daily use of cannabis prior to age 17 years adversely affected the odds of completing high school compared with adolescents who do not use cannabis.37 The vulnerability of the developing adolescent brain to the effects of cannabinoids should prompt clinicians to counsel patients to abstain or delay cannabinoid use during adolescence.

Epidemiological studies suggest an association between cannabis use and the development of anxiety disorder, depression, and psychosis.38 Perhaps the largest body of evidence supports the association between cannabis use and psychosis. Frequent use prior to age 15 years and using higher potency THC products are independent risk factors for a higher lifetime risk for the development of psychosis.39,40 Additionally, the use of high potency THC is associated with a significant increase in the likelihood of developing an anxiety disorder.41 A recent meta-analysis demonstrated that cannabis use starting in adolescence is associated with a moderately increased risk of developing depression, suicidal ideation, and suicide attempt in young adulthood.42 Although these associations place a person at low to moderate risk, when looking at the high numbers of teenagers using marijuana, this could translate into a much larger public health issue.

Not only can cannabinoids have a negative impact on the developing adolescent brain and increase the risk of future cognitive and mental health issues, but adolescents may also be using cannabinoids to manage depression, trauma, or even poor sleep. For all these reasons it is important for practitioners to screen for and address mental health conditions in patients who present with cannabinoid use.

Summary

The cannabinoid landscape is shifting. Changes in laws, higher potency products, and new cannabinoid delivery methods require that primary care, emergency department, and hospitalist practitioners remain vigilant in their screening for cannabinoid use. Although societal inertia is moving cannabinoids in the direction of acceptance, there are very real physical, psychological, and neurodevelopmental effects on patients, in part influenced by adolescent development. A pediatric practitioner's insight, empathy, guidance, and intervention (Table 4) can make a big difference in an adolescent's life.

Education, Anticipatory Guidance, Screening and Intervention, Coding, and Policy Resources for Patients, Families, and Practitioners

Table 4.

Education, Anticipatory Guidance, Screening and Intervention, Coding, and Policy Resources for Patients, Families, and Practitioners

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  40. Di Forti M, Quattrone D, Freeman TP, et al. EUGEI WP2 Group. The contribution of cannabis use to variation in the incidence of psychotic disorder across Europe (EU-GEI): a multi-centre case-control study. Lancet Psychiatry. 2019;6(5):427–436. doi:10.1016/S2215-0366(19)30048-3 [CrossRef] PMID:30902669
  41. Hines LA, Freeman TP, Gage SH, et al. Association of high-potency cannabis use with mental health and substance use in adolescence. JAMA Psychiatry. 2020;77(10):1044–1051. doi:10.1001/jamapsychiatry.2020.1035 [CrossRef] PMID:32459328
  42. Gobbi G, Atkin T, Zytynski T, et al. Association of cannabis use in adolescence and risk of depression, anxiety, and suicidality in young adulthood: a systematic review and meta-analysis. JAMA Psychiatry. 2019;76(4):426–434. doi:10.1001/jamapsychiatry.2018.4500 [CrossRef] PMID:30758486
  43. US Department of JusticeUS Drug Enforcement Agency. Get smart about drugs. A DEA resource for parents, educators & caregivers. Accessed January 20, 2021. https://www.getsmartaboutdrugs.gov/
  44. National Institue on Drug Abuse. Screening tools for adolescent substance use. Accessed January 22, 2021. https://www.drugabuse.gov/nidamed-medical-health-professionals/screening-tools-resources/screening-tools-for-adolescent-substance-use

Definition of Cannabinoids and Clinically Important Cannabinoid Subtypes

<list-item>

Cannabinoid: a group of compounds with a structure based on a 21-carbon skeleton; there are more than 100 known cannabinoids found in the Cannabis sativa plant

</list-item><list-item>

Cannabis: the combined phytocannabinoids of the Cannabis sativa plant; cannabis is used interchangeably with marijuana

</list-item><list-item>

delta-9-tetrahydrocannabinol (THC): the primary psychoactive cannabinoid of the Cannabis sativa plant; it is a partial agonist at the cannabinoid receptors

</list-item><list-item>

Cannabidiol (CBD): nonpsychoactive cannabinoid of the Cannabis sativa plant; it has potential medical benefits that are being researched, and many purported benefits that have not been proven. Although it does not have substantial direct psychoactive effects, CBD can modulate the effects of THC

</list-item><list-item>

Synthetic cannabinoids: a group of synthetic chemicals that are structurally similar to THC; many of these are full agonists at the cannabinoid receptors and can have effects that are different than that of THC

</list-item>

Common Methods of Using Cannabis

<list-item>

Joints (hand-rolled marijuana cigarettes)

</list-item><list-item>

Bongs (water pipes used to “filter” combusted marijuana)

</list-item><list-item>

Pipes

</list-item><list-item>

Blunts (hollowed-out cigars filled with marijuana)

</list-item><list-item>

Vape pens, dab pens, dab nails (used for THC [delta-9-tetrahydrocannabinol]) concentrates)

  Concentrated viscous liquid (hash oil)

  Concentrated soft solid (wax, budder)

  Concentrated hard amber solid (shatter)

</list-item><list-item>

Edibles (can be marijuana or concentrated extracts)

</list-item><list-item>

Sploof (device used to hide the smell of smoke)

</list-item>

Intervention Screening Questionsa

<list-item>

In the past year, how many times have you used nicotine/tobacco (including cigarettes, electronic cigarettes, or vapes)?

</list-item><list-item>

In the past year, how many times have you used alcohol?

</list-item><list-item>

In the past year, how many times have you used marijuana (such as smoking, vaping, or edibles)?

</list-item><list-item>

In the past year, how many times have you used prescription drugs that were not prescribed for you (such as pain medication or Adderall)?

</list-item><list-item>

In the past year, how many times have you used illegal drugs (such as cocaine, ecstasy, or molly)?

</list-item><list-item>

In the past year, how many times have you used inhalants (such as nitrous oxide)?

</list-item><list-item>

In the past year, how many times have you used herbs or synthetic drugs (such as salvia, K2, or bath salts)?

</list-item>

Education, Anticipatory Guidance, Screening and Intervention, Coding, and Policy Resources for Patients, Families, and Practitioners

• For patients and families
   American Academy of Pediatrics (AAP)/<ext-link ext-link-type="uri" xlink:href="HealthyChildren.org" xlink:type="simple" xmlns:xlink="http://www.w3.org/1999/xlink">HealthyChildren.org</ext-link>
  healthychildren.org/English/ages-stages/teen/substance-abuse/Pages/default.aspx
   National Institute on Drug Abuse
   <ext-link ext-link-type="uri" xlink:href="teens.drugabuse.gov/drug-facts/marijuana" xlink:type="simple" xmlns:xlink="http://www.w3.org/1999/xlink">teens.drugabuse.gov/drug-facts/marijuana</ext-link>
   Partnership to End Addiction
   <ext-link ext-link-type="uri" xlink:href="drugfree.org/" xlink:type="simple" xmlns:xlink="http://www.w3.org/1999/xlink">drugfree.org/</ext-link>
• For practitioners
   Screening to Brief Intervention and Brief Screener for Tobacco, Alcohol, and Other Drugs
   <ext-link ext-link-type="uri" xlink:href="https://www.drugabuse.gov/nidamed-medical-health-professionals/screening-tools-resources/screening-tools-for-adolescent-substance-use" xlink:type="simple" xmlns:xlink="http://www.w3.org/1999/xlink">https://www.drugabuse.gov/nidamed-medical-health-professionals/screening-tools-resources/screening-tools-for-adolescent-substance-use</ext-link>
   National Institute on Drug Abuse
   <ext-link ext-link-type="uri" xlink:href="drugabuse.gov/blending-initiative/cme-ce-simulation" xlink:type="simple" xmlns:xlink="http://www.w3.org/1999/xlink">drugabuse.gov/blending-initiative/cme-ce-simulation</ext-link>
   AAP Committee on Substance Use & Prevention
   <ext-link ext-link-type="uri" xlink:href="services.aap.org/en/community/aap-committees/committee-on-substance-use-and-prevention/" xlink:type="simple" xmlns:xlink="http://www.w3.org/1999/xlink">services.aap.org/en/community/aap-committees/committee-on-substance-use-and-prevention/</ext-link>
   AAP Substance Use/Abuse Coding Fact Sheet for Primary Care Pediatrics
   <ext-link ext-link-type="uri" xlink:href="aap.org/en-us/Documents/coding_factsheet_substance_abuse.pdf" xlink:type="simple" xmlns:xlink="http://www.w3.org/1999/xlink">aap.org/en-us/Documents/coding_factsheet_substance_abuse.pdf</ext-link>
• For advocacy and public policy
   Getting It Right from the Start: Advancing Public Health & Equity in Cannabis Policy
   <ext-link ext-link-type="uri" xlink:href="gettingitrightfromthestart.org/" xlink:type="simple" xmlns:xlink="http://www.w3.org/1999/xlink">gettingitrightfromthestart.org/</ext-link>
Authors

Gregg Joseph Montalto, MD, MPH, is the Associate Division Head, Ann & Robert H. Lurie Children's Hospital of Chicago, Potocsnak Family Division of Adolescent & Young Adult Medicine; and an Associate Professor of Pediatrics, Northwestern University Feinberg School of Medicine. Elizabeth G. Cius, MD, is the Director of Adolescent and Young Adult Medicine, Naval Medical Center San Diego; and an Assistant Professor of Family Medicine, Uniformed Services University. Maria H. Rahmandar, MD, is the Medical Director, Substance Use and Prevention Program, Ann & Robert H. Lurie Children's Hospital of Chicago, Potocsnak Family Division of Adolescent & Young Adult Medicine; and an Assistant Professor of Pediatrics, Northwestern University Feinberg School of Medicine.

Address correspondence to Gregg Joseph Montalto, MD, MPH, Ann & Robert H. Lurie Children's Hospital of Chicago, 225 E. Chicago Avenue, Box 161B, Chicago, IL 60611-2991; email: gmontalto@luriechildrens.org.

Disclosure: The authors have no relevant financial relationships to disclose.

10.3928/19382359-20210120-01

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