ST. LOUIS — Dr. Daniel Mamah, a Washington University psychiatrist, runs a local clinic that helps adolescents and young adults experiencing early signs of psychosis.
Through his work, Mamah has seen firsthand how serious psychiatric disorders are often associated with early and frequent marijuana use.
“Very, very often, we have people that come in, and we ask them, ‘When did your symptoms start?’ And they would link it to ‘When I started using weed’ or ‘When I started to increase my doses,’” said Mamah, director of the , which opened two years ago.
On Nov. 8, Missouri voters will be asked whether to approve Amendment 3, which would remove bans on marijuana sales, consumption and manufacturing for adults 21 and older.
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While the debate on the measure has focused on how criminal records will be cleared and who will be able to get into the business, are urging voters to consider the potential health impacts when they head to the polls.
“With marijuana there is still a lot to be studied,” Mamah said. “People think it is just this wonder drug that cures all or it’s purely natural. … But the reality is it has risks, different kinds of risks.”
Because it would change the Missouri Constitution if passed, Amendment 3 can only be altered by another statewide vote. Efforts by state legislators or public health officials to impose new restrictions or add safety measures would have to conform to the language of the constitutional amendment.
Amendment 3 supporters say legalization will allow the state to regulate the quality of marijuana products and make it harder for children and adolescents to obtain them. Opponents counter legalization will normalize marijuana, encouraging use by adolescents and contributing to impaired driving, addiction and accidental overdoses.
The , which represents and advocates for more than 140 hospitals across the state, is among those opponents. In a recent statement, the association warned, in part, that the public health costs, including emergency room visits and “treatment for psychological and addictive disorders,” likely would outweigh any increase in state revenues from taxes on cannabis products.
The hospitals also warned the increased availability of legal marijuana for adults would “inevitably” lead to increased cannabis use by adolescents.
What about the kids?
Concern about children and adolescents is not unfounded. The teen brain is still rapidly developing and will continue to develop until around age 25. Marijuana use during this time period can have permanent effects, .
Approximately 1 in 10 people who use marijuana will become addicted, . When starting before age 18, the rate of addiction rises to 1 in 6.
“That’s where initiation is,” said , a Washington University endowed psychiatry professor who studies genetic and environmental influences that lead to addiction. “We often see the people coming into treatment or having problems when they are in their late 20s, 30s or 40s, but it really is a childhood disorder.”
Mamah, with the early recognition clinic, points to studies showing an association between , a serious and lifelong mental disorder that typically begins in early adulthood and results in extremely disordered thinking and behavior.
While young people who overuse marijuana can experience temporary psychosis with hallucinations or paranoia, Mamah said, “they also tend to have schizophrenia at increased rates, anywhere from two to four or five times as high a rate, depending on how much cannabis has been used.”
Marijuana dulls attention, memory and learning skills. The drug also affects reaction time, movement and coordination, which can impair driving and athletic performance. These effects can last for weeks depending on how frequently it’s used, but more research is needed.
Some studies have linked marijuana use to , but not all studies have reached the same conclusion. It is also difficult to tease out other genetic and environmental factors.
have also associated marijuana use with and increased risk of thinking about and . But again, more research is needed to determine if cannabis or other factors caused the increase.
“I often tell people if you are going to smoke marijuana, wait until you are 30,” Mamah said. “It seems to be safer based on what we know.”
Cannabis is categorized under federal drug laws as a Schedule 1 drug, meaning there is no accepted medical use and has a high potential for abuse, making it extremely difficult to study. President Joe Biden has asked for an expedited review by federal health officials to change the classification.
Bierut said she believes using marijuana use has long-term effects, but some may be simply due to missed learning and social opportunities in high school and college that changed people’s trajectories.
“That’s what we are all really worried about,” she said, “we are worried about the teens.”
Teen use in legal states
, a professor of family and community medicine at Ƶ University and the director of the university’s addiction medicine fellowship, said the amount of marijuana in the state will explode with legalization.
“The pool of available cannabis is going to be much greater, meaning young people are going to find ways to get it, and I’m worried about the floodgates opening,” Rottnek said. “That is where my concern is as a family doc.”
But whether legalizing marijuana increases use among teens remains to be seen.
Since increasing throughout the 1990s to a high of 47% in 1999, the percentage of high school students who had ever used marijuana dropped to 37% in 2019, the latest national (YBRS) data available.
The percentage of high schoolers reporting using marijuana within the past 30 days has also , dropping from a high of about 27% in 1999 to about 22% in 2019.
The more recent annual showed a significant decline in the percentage of eighth, 10th and 12th grade students who reported using marijuana within the past year. After over the past decade, the number dropped to less than 18% in 2021.
In and , the first states to legalize marijuana in 2012, large-scale state surveys of high school students also show slight reductions in past 30-day marijuana use since legalization.
In Colorado, the rate of juvenile marijuana arrests decreased by 42% between 2012 and 2019, . And reported disciplinary incidents in schools due to drugs have not increased. High school dropout rates have also not been impacted.
Several academic studies have found no link. An , which looked at YBRS data, found through 2019 that legalizing recreational weed was also not associated with current use or frequency of use among adolescents.
A found no changes in marijuana use among those ages 12 to 20 in states that had legalized weed prior to 2017. And a , 33 conducted in the U.S., also found no evidence of change in cannabis use among adolescents and young adults following legalization.
But with surveys showing fewer teens perceive marijuana as harmful coupled with increased marketing, exposure to adults using marijuana and more high-potency products, some fear it is only time before trends change in legal states. Or that cannabis use among teens .
Bierut said she expects to see a gradual normalization of marijuana use, but hopefully education and safety measures come sooner than they did with tobacco and alcohol.
“With legalization, that means big business is going to get involved, and the purpose of big business, and rightfully so, is to sell its product and have more consumers,” she said. “When I think of substances that cause more deaths in the United States than any other substance, those substances are the legal substances — tobacco and alcohol.”
Pregnant women
Pointing to the latest data showing an increase in the percentage of pregnant women using marijuana in the past 30 days — going from 5% in 2019 to 8% in 2020 — partly blames underlying assumptions that because cannabis is legal, it is safe.
Kottenstette is an assistant professor of family and community medicine at SLU whose research and work includes helping women enter pregnancy as healthy as possible.
“A lot of people base their decisions on prior experience: if someone used before, and their child was fine or their friend’s child was fine,” she said. “Women don’t see that as potential harm, so they continue to use.”
The while pregnant and breastfeeding, because its chemicals can build up in breast milk. Yet, women often seek information from peers and online groups.
Cannabis retailers have also touted the drug as a safe way to manage pregnancy symptoms, and show more pregnant women report using marijuana in states where it is legal.
Kottenstette said many women are unaware that studies show using marijuana during pregnancy place women at twice a greater risk of having a stillbirth (the loss of a fetus after 20 weeks).
Marijuana use with increased risk of miscarriage, premature birth and having a low-birthweight baby, especially with frequent use.
Some animal studies and human research found babies exposed to cannabis in-utero show signs of neurological development problems, such as high-pitched cries and trembling. Some school-age children exhibit problems with memory and attention.
“However, much more research is needed to tease out some of these associations,” Kottenstette said.
She said it’s important for women to be honest with their providers about their drug use, and for providers to be prepared to educate their patients about the risk of marijuana use.
“Because there is so much unknown,” Kottenstette said. “People assume a level of safety.”
The grown-ups
Legalization efforts have greatly increased the number of adults who use marijuana — more than doubling from 22.6 million in 2008 to 45 million in 2019, federal data shows. The number of nearly daily users almost tripled from 3.6 million to 9.8 million during the same time period.
Young adults have the highest rates. The proportion of adults ages 19 to 30 who reported past-year marijuana use , up from 29% a decade ago. About 11% use cannabis daily.
The results have been involving cannabis, and for heart problems (marijuana can make the heart beat faster and blood pressure higher after use) and hyperemesis (nausea, vomiting and dehydration) associated with chronic and higher-potency cannabis.
Researchers at the that found a three-fold increase in marijuana-related ER visits in the four years after legalization.
“With legalization we are going to get all of these things,” Bierut said. “There will be accidental ingestions, there will be ingesting more than people intended because they’re not feeling the effects, so they continue to ingest.”
Worrisome state reports also show — called a dab — are becoming increasingly popular, even among teens. The product is made by extracting the psychoactive compound THC, which gives users the “high,” from cannabis plants. The resin-like substance is usually vaporized and inhaled.
While the typical marijuana joint is about 15% THC, dabs contain concentrations as high as 90%. And the entire amount is inhaled in one breath, delivering extremely large amounts to the body very quickly.
Higher doses of THC are more likely to produce anxiety, agitation, paranoia and psychosis; and increase the risk of addiction. But researchers do not yet fully understand the consequences of “dabbing.”
Only Vermont and Connecticut have laws that include caps on high THC concentrations in their cannabis legalization bills — both at 60% THC. The state of Washington is , and California is considering warning labels.
Rottnek said states are putting the cart before the horse when it comes to the legalization and commercialization of cannabis.
The U.S. Food and Drug Administration regulates the manufacture, packaging and advertising of cigarettes, he points out, but cannabis comes without any harm reduction efforts.
Those who have experienced trauma or are anxious or depressed will be at the highest risk for abuse, Rottnek says, especially when it’s a lot easier to walk into a dispensary than to get an appointment with a doctor.
“Our high-risk populations are going to be young people, it’s going to be poor people, it’s going to be populations that have typically been exploited,” he said. “Very much depends on what we call our social and structural determinants of health: What is going on in the environment you are in, and why do you want to use cannabis when you are 14, or 24 or 44 or 54? What’s it addressing?”
Originally posted at 7:15 a.m. Friday, Oct. 28.