Age-dependent association of cannabis use with risk of psychotic disorder

Prevalence Rates, Perceptions of Risk, and Motivations for Nonmedical Cannabis Use in Pediatric Pain

Importance

Characterizing cannabis use (CU) rates in pediatric pain is critical as adolescence is a period of increased substance use and risk for negative outcomes. Youths with chronic pain may engage in CU to cope with symptoms.

Objective

To examine CU rates, risk perceptions, and motivations for use among treatment-seeking youths with diagnosed pain disorders.

Design, Setting, and Participants

Cross-sectional survey study conducted from September 2021 to May 2024 at a pain treatment clinic at a pediatric hospital in the Northeast United States. Participants were 251 adolescents receiving treatment for diagnosed pain conditions. Of 312 approached, 40 did not complete the survey; 17 were excluded.

Exposures

Validated self-report measures assessing demographics, pain, and substance use.

Main Outcomes and Measures

CU rates, motivations for use, and perceived risks.

Results

Of 245 adolescents providing complete data (mean [SD] age 16.9 [1.4] years; 168 [68.6%] female; 1 [0.4%] American Indian, 3 [1.2%] Asian, 3 [1.2%] Black, 19 [7.8%] Hispanic or Latino, and 201 [82.1%] White), 62 (25.3%) endorsed lifetime CU, with a mean (SD) age at first use of 15.3 (1.9) years. Among those endorsing CU, past-year prevalence was 90.2% (56 of 62 participants) and past-month prevalence was 64.5% (40 of 62 participants). The CU group was older (mean difference, 0.9 years; 95% CI, 0.5 to 1.2 years; P < .001), included fewer female participants (difference, -14.0%; 95% CI, -32.6% to -2.9%; P = .03), and reported greater pain interference scores (mean difference, 2.7; 95% CI, 0.8-4.6; P = .01) and depressive symptoms scores (mean difference, 6.2; 95% CI, 2.8-9.5; P < .001) compared with the no CU group. The no CU group perceived cannabis as riskier (odds ratio, 2.37; 95% CI, 1.28-4.39; P = .01). Among youths endorsing CU, 48 of 62 (77.4%) endorsed instrumental use (IU) to alleviate psychological or physical symptoms (primarily pain, sleep, and anxiety), representing an overall IU prevalence of 19.6% (48 of 245 participants). Youths reporting IU were younger (mean difference, -0.7 years; 95% CI, -1.3 to -0.1 years; P = .04) and reported greater functional disability scores (mean difference, -8.4; 95% CI, 2.1 to 12.6; P = .01) compared with the no IU group.

Conclusions and Relevance

In this cross-sectional study, approximately 25% of treatment-seeking youths with chronic pain reported CU, with more than 75% using cannabis instrumentally to treat symptoms despite limited evidence supporting cannabis for pain, sleep, or anxiety. Given CU rates in this population, education about the risks of self-medication and the development of alternative coping strategies are needed.

Cannabis or Cannabinoids for the Management of Chronic Noncancer Pain: Best Practice Advice From the American College of Physicians

DESCRIPTION

The American College of Physicians' Population Health and Medical Science Committee (PHMSC) developed this best practice advice to inform clinicians about what is currently known about the benefits and harms of cannabis or cannabinoids in the management of chronic noncancer pain and to provide advice for clinicians counseling patients seeking this therapy.

METHODS

The PHMSC considers areas where evidence is uncertain or emerging or practice does not follow the evidence to provide clinical advice based on a review and assessment of scientific work, including systematic reviews and individual studies. Sources of evidence included a living systematic review on cannabis and cannabinoid treatments for chronic noncancer pain and a series of living systematic reviews and primary studies.

BEST PRACTICE ADVICE 1A

Clinicians should counsel patients about the benefits and harms of cannabis or cannabinoids when patients are considering whether to start or continue to use cannabis or cannabinoids to manage their chronic noncancer pain.

BEST PRACTICE ADVICE 1B

Clinicians should counsel the following subgroups of patients that the harms of cannabis or cannabinoid use for chronic noncancer pain are likely to outweigh the benefits: young adult and adolescent patients, patients with current or past substance use disorder, patients with serious mental illness, and frail patients and those at risk for falling.

BEST PRACTICE ADVICE 2

Clinicians should advise against starting or continuing to use cannabis or cannabinoids to manage chronic noncancer pain in patients who are pregnant or breastfeeding or actively trying to conceive.

BEST PRACTICE ADVICE 3

Clinicians should advise patients against the use of inhaled cannabis to manage chronic noncancer pain.

Comorbid Cannabis Use and Mood Disorders Among Adolescents

Adolescence is a unique developmental period marked by increased exploration and risk-taking, as well as important brain development milestones. Many people who use substances will begin using during adolescence, and cannabis is the most commonly used illicit substance among adolescents. For adolescents with mood disorders, cannabis use (and, by extension, cannabis use disorder) is even more likely, and the associated consequences are even more significant. In this review, we explore the assessment of cannabis use disorder among adolescents, the impact of cannabis use on mood symptoms, level-of-care recommendations for adolescents with comorbid cannabis use and mood disorders, and effective treatment options.

Does Cannabis Use Contribute to Schizophrenia? A Causation Analysis Based on Epidemiological Evidence

Cannabis abuse has been linked to acute psychotic symptoms as well as to the development of schizophrenia. Although the association has been well described, causation has not yet been investigated. Therefore, we investigated whether cannabis or cannabinoid use is causal for the development of schizophrenia, conducting a systematic literature review according to the PRISM guidelines. Epidemiological studies and randomized clinical trials investigating the links between cannabis and psychosis-like events (PLE) and schizophrenia were identified (according to PRISM guidelines), and relevant studies were included in a Forest plot analysis. Confounder analysis was performed using a funnel plot, and the Hill causality criteria were used to estimate causation. A total of 18 studies fulfilled the search criteria; 10 studies were included in a forest plot. All studies reported an increased risk for PLE or schizophrenia, and nine of the ten studies, a significant increase; the overall OR was calculated to be 2.88 (CI 2.24 to 3.70), with a twofold-higher risk calculated for cannabis use during adolescence. Confounder effects were indicated by a funnel plot. The Hill criteria indicated a high likelihood for the contribution of cannabis to schizophrenia development. Cannabinoids likely contribute to chronic psychotic events and schizophrenia, especially if taken during adolescence. This effect likely increases with a high cannabis THC concentration and increased frequency of cannabis use, and is stronger in males than in females. This points to the possibility of a selective cannabis toxicity on synaptic plasticity in adolescence, as compared to adult cannabis use. Cannabis use should be regulated and discouraged, and prevention efforts should be strengthened, especially with reference to adolescence.

The Complex Relationship Between Cannabis Use and Mental Health: Considering the Influence of Cannabis Use Patterns and Individual Factors

The relationship between cannabis use and mental health is complex, as studies often report seemingly contradictory findings regarding whether cannabis use results in more positive or negative treatment outcomes. With an increasing number of individuals using cannabis for both recreational (i.e., non-medical) and medical purposes, it is critical to gain a deeper understanding of the ways in which cannabis may be helpful or harmful for those diagnosed with psychiatric disorders. Although cannabis is composed of hundreds of compounds, studies assessing the effects of "cannabis" most often report the impact of delta-9-tetrahydrocannabinol (d9-THC), the primary intoxicating constituent of the plant. While d9-THC has documented therapeutic properties, negative clinical outcomes commonly associated with cannabis are generally related to d9-THC exposure. In contrast, non-intoxicating cannabinoids such as cannabidiol (CBD) show promise as potential treatment options for psychiatric symptoms. In this article, findings from studies and reviews examining the relationship between mental health conditions (mood, anxiety, psychosis, and post-traumatic stress disorder [PTSD]) and cannabis use are summarized to highlight critical variables that are often overlooked, including those associated with cannabis use patterns (e.g., frequency of use, amount used, cannabinoid exposure, product choice, and route of administration). Further, this article explores individual factors (e.g., age, sex, genetics/family history) that likely impact cannabis-related outcomes. Research to date suggests that youth and those with a family history or genetic liability for psychiatric disorders are at higher risk for negative outcomes, while more research is needed to fully understand unique effects related to sex and older age.

Cannabinoids for treating psychiatric disorders in youth: a systematic review of randomized controlled trials

BACKGROUND

Cannabinoids have been of increasing interest mainly due to their putative efficacy in a wide array of psychiatric, psychosomatic, and neurological conditions.

AIMS

This systematic review aims to synthesize results from randomized placebo-controlled trials regarding the efficacy and the dosage of cannabinoids as therapeutics in psychiatric disorders in children, adolescents, and young adults.

METHODS

All publications up to June 30th, 2024, were included from PubMed and Embase. Eligibility criteria in accordance with the PRISMA-guidelines was applied. RCTs providing pre- and post-treatment parameters on cannabinoid therapies for mental disorders in comparison to controls in an age range from 0 to 25 years were included. Effect sizes were calculated as Hedges' g for primary outcomes, and a multilevel random-effects meta-analysis was conducted to account for dependent outcomes from same study populations.

RESULTS

We identified 7603 records, of which 8 independent clinical trials (reported in 9 publications) met the pre-established eligibility criteria, comprising 474 unique participants (245 treatment, 229 control). Analysis of 13 primary outcomes (of 7 clinical trials) revealed a modest positive overall effect for symptom improvement or normalization of brain physiology (Hedges' g = 0.308, 95% CI: 0.167, 0.448). Autism spectrum disorder studies showed the most consistent evidence (g = 0.264, 95% CI: 0.107, 0.421), while other conditions showed wider confidence intervals. Age-stratified analysis showed that adult populations (mean age 23.3 years, n = 5 outcomes) demonstrated higher effect sizes (g = 0.463, SD = 0.402) compared to pediatric populations (mean age 11.8 years, n = 8 outcomes; g = 0.318, SD = 0.212). Whole plant preparations (g = 0.328, 95% CI: 0.083, 0.573) and pharmaceutical cannabinoids (g = 0.292, 95% CI: 0.069, 0.515) showed comparable effects. CBD dosages ranged from 17.5 mg to 600 mg per day, with no significant correlation between dosage and effect size (ρ = -0.014, p = 0.963). Mild to moderate side effects were reported, but no serious adverse events. Risk of bias assessment ranged from low (n = 3) to high (n = 5).

CONCLUSION

While meta-analysis of effect sizes for primary outcomes revealed modest positive effects, particularly for autism spectrum disorders, the current evidence remains insufficient to broadly recommend cannabinoids for treating mental disorders in youth populations. Larger, controlled studies with standardized outcomes are needed to establish definitive clinical recommendations.