Addressing issues related to addictive behaviors and diagnoses
Cannabis, often referred to as marijuana, is the name of a variety of plants from the hemp family that contain tetrahydrocannabinol (THC), a psychoactive substance (National Institute on Drug Abuse [NIDA], 2018g). Use of cannabis is particularly harmful to teenagers because during this time the brain undergoes a period of rapid and dramatic neurodevelopment (Centers for Disease Control and Prevention [CDC], 2017). Use of cannabis during this period can lead to harmful and potentially permanent negative effects on the brain, including difficulty thinking and problem solving and impaired memory and learning (CDC, 2018).
In a national survey, 45% of 8th to 12th graders reported having used cannabis in their lifetime, and 16% had used cannabis in the past 1 month (NIDA, 2018d). One in 16 high school students in the United States reports daily marijuana use, yet only 29% of high school seniors report that regular cannabis use poses a great risk (NIDA, 2018d). Increasingly, teenagers view the use of cannabis as safe, which may be due to the growing number of states legalizing its use (American Academy of Child & Adolescent Psychiatry [AACAP], 2018). A growing trend is that teenagers are using electronic cigarette devices, also called vaping, to administer cannabis, which studies have shown can lead to increased concentrations of THC (Spindle et al., 2018; Trivers, Phillips, Gentzke, Tynan, & Neff, 2018). Vaping cannabis can be difficult to detect because there is no smoke, minimal odor, and the vapor produced dissipates rapidly; thus, it can be used in schools or homes without detection (Budney, Sargent, & Lee, 2015). Cannabis is increasingly the first substance teenagers try. More than 50% of teenagers will try cannabis before they try cigarettes or alcohol for the first time (Keyes, Rutherford, & Miech, 2019).
Why Do Teenagers Use Cannabis?
Reasons teenagers use cannabis include to relieve boredom, satisfy curiosity, experiment, feel good or feel better, and fit in (Dow & Kelly, 2013; NIDA, 2014). Teenagers who have relationships with other individuals who use substances have a greater chance of using substances themselves (Marschall-Lévesque, Castellanos-Ryan, Vitaro, & Séguin, 2014). Gender differences also play a role. It is thought that, in general, males are more likely to use substances for the positive reward, or the high experience, whereas females use substances to avoid a negative feeling or to cope or self-medicate (Bobzean, DeNobrega, & Perrotti, 2014). Risk factors for cannabis use in teenagers include genetics; parental substance use; early exposure to substances; having another mental health disorder, such as depression or anxiety; and a history of trauma or stress (NIDA, 2018e).
Impact of Cannabis on the Teenage Brain
When cannabis is ingested, either by smoking, vaping, or eating (i.e., in food), the THC attaches itself to receptors in the brain that influence pleasure, memory, thinking, concentration, movement, coordination, and sensory and time perception (NIDA, 2018b). In addition, THC activates the brain's reward system, which increases the pleasure neurotransmitter dopamine in key areas of the brain, including the ventral tegmental area, nucleus accumbens, and prefrontal cortex (NIDA, 2016). When dopamine levels are elevated due to substance use, the brain attempts to maintain balance by responding with decreased dopamine production and downregulation of dopamine receptors, which cause negative changes in emotion and behavior (NIDA, 2018a). Using cannabis early in life is associated with developing a substance use disorder (SUD) later in life, as studies show that early exposure to cannabis decreases the reactivity of brain dopamine reward centers later in adulthood (NIDA, 2018c).
Cannabis use in teenagers is also associated with structural and functional changes in the brain, altered connectivity, and reduced brain volume (NIDA, 2018e). The results from several studies have suggested a link between cannabis use and functional impairment in cognitive abilities, including lower IQ scores (NIDA, 2018f). However, some studies suggest that neurocognition may improve in teenagers if they stop using cannabis (Schuster et al., 2018). Smoking cannabis has a negative impact on the lungs because it is a respiratory irritant and can lead to decreased lung volume (Loflin & Earleywine, 2015).
Using cannabis in the teenage years is particularly problematic because the brain is undergoing a time of rapid learning with a developmental focus on learning and mastering new skills to gain independence (Unicef, 2018). During this time, teenagers have increased sensitivity to stressors, such as biological stressors from hormonal changes; population stressors in society, including crime and war; and social stressors, including peer pressure (Unicef, 2018). This period has also been described by Erikson to be that of identity versus role confusion (Learning Theories, 2014). During this time, teenagers will either successfully develop a sense of healthy identity and mastery over skills to gain independence through an upward, positive spiral, or they may develop in a negative spiral and have a sense of role confusion, exhibiting a problematic pattern of behavior that includes substance use (Unicef, 2018). Using substances during the teenage years and the subsequent impact on the brain's reward system can result in teenagers developing a false sense of the need to master substance use rather than life skills to build independence.
In addition, teenagers who use cannabis have a significantly increased incidence of developing a mental health disorder such as depression, anxiety, or schizophrenia (CDC, 2018; Gage et al., 2017). Teenagers who use cannabis have a one in six chance of developing a cannabis use disorder, and early substance use is tied to the development of a SUD later in life (CDC, 2018). Another issue to consider with cannabis use in teenagers is the risk related to driving while under the influence (Durkin, 2014). In Colorado, more than 17% of all arrests for driving under the influence involve cannabis, and 55% of cannabis users said they believed it was safe to drive under the influence of cannabis (Colorado Department of Transportation, 2018).
What Can Be Done About Cannabis Use in Teenagers?
Beginning in late elementary school, children should receive education about the harmful effects of cannabis (ASCAP, 2018). Results from a meta-analysis on substance use prevention programs indicate that age-specific strategies should be used when teaching children about substance use prevention (Onrust, Otten, Lammers, & Smit, 2016). For elementary school–age students, teaching social skills, self-control, problem-solving skills, and healthy behaviors can help reduce substance use (Onrust et al., 2016). For early adolescents, norm-focused discussion groups, feedback regarding peers' actual and perceived substance use, the use of role models, parent involvement, and decision-making skills can reduce substance use (Onrust et al., 2016). For middle adolescents, cognitive-behavioral therapy strategies and teaching students to cope with stress and anxiety reduces substance use (Onrust et al., 2016). For late adolescents, social influence, refusal skills training, and education about the interference of substance use with personal goals has been shown to reduce substance use (Onrust et al., 2016).
One evidence-based approach that can be used in schools is life skills training (LST), which has programs geared toward elementary, middle, and high school–aged children. Components of LST include drug resistance skills, personal self-management skills, and general social skills (Botvin Life Skills Training, n.d.). In addition to education about the risks of substance use, the program promotes healthy alternatives to risky behaviors through activities designed to help students resist social use of drugs, develop greater self-esteem and self-confidence, cope with stress, and enhance cognitive and behavioral competency (Botvin Life Skills Training, n.d.). LST is effective in reducing substance use by up to 41% and is cost effective, with $15 being the average cost per student (Crowley, Jones, Coffman, & Greenberg, 2014; Spoth et al., 2017).
As the science evolves on the prevention and treatment of SUD, ongoing, up-to-date, and evidence-based education is needed for teenagers, teachers, and parents. Teenagers who are in recovery and health care professionals who work with teenagers who have SUDs are ideal speakers at schools for students, teachers, and parents. In addition, teenagers, teachers, and parents should have access to community resources for any teenager in need of treatment.
Nurses should take steps to keep up to date on the latest advances in the prevention and treatment of SUDs through ongoing education, attending conferences, and conducting literature reviews. An organization for nurses with a focus on SUDs is the International Nurses Society on Addictions (IntNSA; n.d.), which also publishes the Journal of Addictions Nursing. Nurses who specialize in substance use treatment can be excellent resources for health care professionals, teachers, parents, and teenagers.
As cannabis use increases, nurses are in a prime position to play a role in implementing screening and intervention (Durkin, 2014). Screening brief intervention and referral to treatment (SBIRT) is an evidence-based approach that can be used with teenagers and includes universal screening with standardized instruments, brief intervention using motivational interviewing strategies, and referral to treatments when indicated (Levy & Williams, 2016). The American Academy of Pediatrics (AAP; 2016) recommends universal SBIRT for all teenagers. A quick screening instrument for substance use in teenagers is the CRAFFT, which is an acronym for screening for driving a car while using, using to relax, using alone, use causing one to forget, family or friends voicing concern, and using causing trouble (Knight, Sherritt, Shrier, Harris, & Chang, 2002). Two online screening tools from NIDA for use with teenagers are the Brief Screener for Alcohol, Tobacco, and other Drugs (BSTAD) and Screening to Brief Intervention (S2BI) (NIDA, 2017). Brief intervention using motivational interviewing involves a short, structured conversation designed to take a nonjudgmental approach with the goal of enhancing patients' self-efficacy to change rather than persuading them to change (Levy & Williams, 2016).
Another way nurses can play a role with teenagers who use cannabis is to take steps to identify teenagers' strengths and weaknesses in areas associated with increased recovery rates from SUDs, including quality of life, self-efficacy, and spirituality (Worley, 2017). The 14-item Health-Related Quality of Life measure developed by the CDC (2016) measures physical and mental health perceptions, health risks and conditions, functional status, social support, and socioeconomic status. The Drug Avoidance Self-Efficacy Scale (DASE) is a 16-item instrument that measures self-efficacy, or confidence, in relation to how likely an individual is to avoid or resist the urge to use drugs (Martin, Wilkinson, & Poulos, 1995). The Faith and Belief, Importance and Address in Care (FICA) Spiritual Assessment Tool is an 11-item instrument that measures items in five categories: faith, belief, meaning, importance, and influence (Puchalski & Romer, 2000).
Moreover, keeping teenagers occupied in school, employment, sports, clubs, or other activities with healthy peers and role models could be protective (Worley, 2017). Because teenagers may use substances to positively enforce the high feeling, it may be beneficial to promote activities that lead to a natural high or reward, such as sports and other activities, including bowling, sledding, and comedy. Because self-medicating or using substances to avoid negative emotions is a reason for substance use, all teenagers should be screened and treated for underlying mental health disorders.
Cannabis use in teenagers is common and particularly harmful due to the detrimental effect on the rapid development in the brain during that time. Increasingly, teenagers are not recognizing the dangers of using cannabis. Steps should be taken to provide teenagers with education and other prevention and intervention strategies to reduce the use of cannabis and other substances. This information can be provided in schools or other community centers by individuals who are knowledgeable of the current science on the topic, including nurses and individuals who have experienced SUDs in their lives. Ways to prevent and identify cannabis use in teenagers should include universal screening and other approaches that are developmentally focused. Identifying and treating underlying mental health disorders in teenagers and providing them opportunities for natural stimulation of the brain's reward center are also important. Goals for teenagers are healthy brain development and a positive sense of identity and mastery over life skills needed for impending independence.
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