The American Academy of Pediatrics (AAP) has updated its position on the benefits and risks of marijuana use and the effects of legalization and decriminalization on children.
As of December 2015, medical marijuana is legalized in 23 states and
the District of Columbia, and in 4 of those states along with in the
District of Columbia, marijuana is legalized for recreational use.1
Residents in more states will be voting on the legalization of
marijuana in 2016, and local governments are increasingly
decriminalizing possession of small amounts of marijuana for
recreational use.
Recognizing the potential for changes in legal status of marijuana to
impact use among minors and that pediatricians may be sought out by
legislators and parents for advice about marijuana legalization, the
American Academy of Pediatrics (AAP) undertook an update of its 2004
policy statement, “The impact of marijuana policies in youth.” The updated policy statement and an accompanying technical report were both published online in January 2015 and in print in the March 2015 issue of Pediatrics.2,3
This article summarizes the policy statement recommendations and
features excerpts from an interview with Seth Ammerman, MD, who is lead
author of the policy statement and technical report and clinical
professor of pediatrics and adolescent medicine, Stanford University
School of Medicine, Stanford, California. He spoke to Contemporary Pediatrics
about the development of the updated AAP Policy Statement and Technical
Report, highlighted some of its major elements, and offered key
messages for practicing pediatricians.
Recommendations
In the 2015 policy statement, the AAP makes 10 recommendations relating
to its positions on marijuana use and decriminalization; actions to
protect children residing in states where marijuana is legalized for
medical or recreational purposes; the development of pharmaceutical
cannabinoids; and research on the benefits and risks of marijuana.
In its recommendations, the AAP opposes:
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Marijuana use by children and adolescents (aged through 21 years) given evidence on the negative health and brain development effects.
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Medical marijuana use outside the regulatory process of the US Food and Drug Administration (FDA), although it recognizes it may be an option for children with life-limiting or severely debilitating conditions for whom current therapies are inadequate.
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Legalization of marijuana because of the potential harms to children and adolescents.
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Use of smoked marijuana because smoking causes lung damage.The policy recommendations also support/encourage:
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Research and development of pharmaceutical cannabinoids and changing the US Drug Enforcement Administration (DEA) classification of marijuana from Schedule I to Schedule II to enable this research.
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Decriminalization of marijuana use for minors and young adults.
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Pediatricians’ efforts to advocate for laws preventing harsh criminal penalties for possession or use of marijuana.
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A focus on treatment rather than criminal penalties for adolescents with marijuana use problems.
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Further research of the effects of legalization on adolescent use and to reduce such use.
To protect children in states where marijuana is legalized, the AAP recommends:
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Strict enforcement of rules and regulations that limit access and marketing and advertising to children and adolescents.
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Regulation of the sale of marijuana products, with a minimum age of 21 years for purchase, strict penalties for offenders, and use of revenue from offender penalties to support research on marijuana health risks and benefits.
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Distribution of marijuana in childproof packaging.
The AAP discourages marijuana use by adults in the presence of minors
considering that adult role modeling can influence child and adolescent
behavior.
The technical report on the impact of marijuana policies on youth
provides evidence that served as the foundation for the updated AAP
policy. Its contents review the known and potential effects of marijuana
use on health and development (Table).2
In addition, the
technical report provides information on the epidemiology of marijuana
use among children and adolescents; presents definitions of
cannabinoids, marijuana, and related terms (tetrahydrocannabinol, hemp);
reviews cannabinoid therapeutics; presents background and issues
relating to marijuana legalization and decriminalization; compares
marijuana-related issues with those involving alcohol and tobacco; and
addresses society and social justice considerations.
The AAP also has developed a “speaking points” document to assist
pediatricians in talking about marijuana. It is accessible to AAP
members through the organization’s website, www.aap.org.
In addition, an AAP clinical report is forthcoming that will provide
specific counseling guidelines and tips for pediatricians as they speak
to parents and patients about marijuana use in the current era of its
legalization.
Q. When did the AAP committees
begin their work revisiting the topic of the impact of marijuana on
youth, and what prompted this undertaking?
A. The effort began in 2011 and was based on
recognition that the marijuana landscape had changed significantly since
the first AAP policy statement was released in 2004. More and more
states were legalizing medical marijuana, and we knew legalization of
recreational use of marijuana by adults was coming.
Considering the
potential for the changing legal status of marijuana to affect
prevalence of youth use, the AAP felt that it was very important for
pediatricians to be informed and have a voice in the discussion.
The entire process took about 3.5 years to complete. There was a
spectrum of opinions about a variety of issues among the individuals
involved in developing the policy statement. The final recommendations
represent a consensus based on the best available evidence.
Q. What is new in the 2015 policy statement recommendations?
A. There are a few significant differences. First,
however, I think it is important to point out that the AAP’s position
against legalization of marijuana did not change. That is because the
AAP wanted to take a cautious stance at a time when marijuana
legalization is increasing in states nationwide, given the concerns and
unknowns about both the potential harms to children and adolescents and
how the prevalence of marijuana use in this population could be impacted
by legalization. In addition, we also felt it will be important to see
if, with legalization, regulations will be enacted providing for youth
education, prevention and early treatment, and then to see what does and
does not work.
Right now recreational use of marijuana by adults is legalized in
Alaska, Colorado, Oregon, Washington, and the District of Columbia. In
2016, it will almost certainly be on the ballot in California where it
is likely to pass, and that will be a major development considering the
size of the population and the influence events in California can have
elsewhere in the nation.
As the first state to legalize recreational marijuana for adults,
Colorado is now starting to gather data to understand its impact.
However, it will take some time until we know how it is affecting use by
youth.
In terms of major changes, the recommendation strongly supporting
decriminalization is entirely new as decriminalization was not addressed
in any way in the 2004 policy statement.
It was very clear, however, in
reviewing information for the update that criminalizing minors for
marijuana possession has a hugely negative impact on them
psychosocially, academically, and at other levels. It is absurd for
actions on possession of small amounts of marijuana to fall under the
purview of the criminal justice system and to penalize kids with harsh
measures that can adversely affect them their entire life. Rather, the
members of the committees developing the policy statement felt strongly
that addressing marijuana possession is a public health issue.
Thus, the
recommendation supports decriminalization and encourages that kids who
have problems with marijuana use will get the help they need so that
they ultimately can lead happy, healthy, and productive adult lives.
The recommendation to change the DEA classification from Schedule I to
Schedule II is another major change in the updated policy. In this
regard, I want to point out that “medical marijuana” is a misnomer.
When
it comes to pharmacologic effects, what we are really talking about are
the cannabinoids, which are the active ingredients in the cannabis
plant. So far, about 200 such compounds have been identified, but we
know little about most of them. The 2 most notable exceptions are
tetrahydrocannabinol, which is the primary psychoactive agent, and
cannabidiol, which does not have psychoactive effects but is being
investigated as a treatment for intractable seizures in children.
The point is that some cannabinoids may have therapeutic or medical
benefits, but their Schedule I classification has significantly limited
research. Rescheduling to class II should facilitate that research and
development of a compound with the necessary data pertaining to
efficacy, safety, dosing, and purity that will be able to go through the
FDA approval process.
The statement about considering “medical marijuana” for use in children
with life-limiting or severely debilitating illnesses is also new in
the 2015 policy statement. We recognized there may be a role for
marijuana in those situations, but only after standard treatments have
been tried and found inadequate.
Q. How should pediatricians in the community implement the information in the AAP policy statement into patient care?
A. Pediatricians need to be up-to-date on this topic
and understand the concerns about marijuana because screening for
substance abuse, including marijuana, is a standard of care as part of
anticipatory guidance given at annual visits or at any visit where there
is suspicion of substance use.
The vast majority of pediatricians think that any drug use by
kids—whether tobacco, alcohol, marijuana, or others—is not healthy. In
the general public, however, there is a sense that marijuana, especially
for adults, is a relatively benign substance. In fact, marijuana is
often cast in a positive light by individuals who compare it with
alcohol, saying alcohol causes more problems for individuals and
society. While there may be some truth to those arguments in terms of
adults, we know there may be some serious consequences when marijuana is
used on a regular (10 to 19 times/month) or heavy (20 or more
times/month) basis by youth in terms of effects on brain development and
mental health as well as academically and psychosocially.
Therefore, pediatricians should be emphasizing to parents and their
patients that marijuana is not necessarily a benign substance; that it
can be addicting and cause problems; and that children, teenagers, and
young adults need to be making healthy choices, including not using
marijuana on a regular basis.
Q. What other take-home messages do you have for pediatricians?
A. In both the policy statement and technical report,
we are definitely advocating for pediatricians to get involved with
decriminalization efforts. Decriminalization occurs at the state and
local government levels, and with the AAP being divided into state
chapters and districts, it is our hope that members of those groups will
take an active role in advocating for decriminalization of marijuana
possession for kids.
Q. More than a decade passed
between publication of the first AAP policy statement on marijuana
impact on youth and the update. Do you foresee that this topic will be
reexamined sooner than before?
A. The landscape is changing rapidly now, and the AAP
may well revisit its advocacy position and/or the policy statement
sooner, depending on what information emerges on the impact of
legalization of medical marijuana and recreational marijuana. So far,
looking at states where medical marijuana is legalized, it looks as if
youth use rates have not significantly increased. That is an encouraging
trend, but it is still too early to reach any conclusions, and we have
no data yet on how legalization of marijuana for recreational use by
adults will affect use among youth.
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