"Take 5" Adolescents and Cannabis Use: Evidence-based, Primary Care Guidelines for Screening on Cannabis Use in Canada

Canadian youth have the highest rates of cannabis use compared to their peers in other developed countries [2]. Primary care providers (PCPs) have an important role to participate in meaningful conversations about cannabis use with adolescents. Also, PCPs should be advocates for the protection, regulation, and education related to cannabis use among adolescents (ages 10-19). 

 With the recent proposal for the national legalization of cannabis, PCPs should have current, and peer-reviewed clinical practice guidelines. Specifically, guidelines on screening for adolescents cannabis use in primary care settings. 

“Take 5” is a bite-sized, e-learning module about adolescents and cannabis use. Each section takes about 5 minutes to complete. The goal is to improve your awareness of why screening should be part of your practice, and how to screen for cannabis use in adolescents. 

Note that these recommendations are mainly aimed at non-medical cannabis use.

START HERE: Pre-course Assessment and Introduction - You can't diagnose what you don't know!

Adolescents' and Cannabis Use in Canada

Adolescents' and Cannabis Use in Canada

     Is cannabis use harmful or not? This question remains to be a subject of heated debate. The Federal government proposed restricted access to cannabis on youth. Still, youth under 18 years of age would be allowed up to five grams of dried legal cannabis [14]. This is an alarming health issue because youth are already using cannabis despite it being an illicit, and potentially harmful drug. In fact, Canadian youth have the highest rates of cannabis use compared to their peers in other developed countries [19]. Moreover, within Canada, cannabis use among youth aged 15 to 19 (21% or 426,000) is more prevalent than among adults aged 25 or older (10% or 2.5 million) [16].

    With the proposed legalization of cannabis, it is a responsibility for PCPs to stay up to date with the current research on non-medical cannabis use.

Why PCPs should Screen for Cannabis use in Adolescents?

Adolescents and Primary Care 

Given that adolescence can be a dynamic phase of both discovery and development, many tend to rely on first-hand knowledge (e.g. peers), or internet sources to inform their decisions on cannabis use [2]. However, the research evidence suggests that adolescents at-risk for cannabis use are just as likely to discuss substance use during check-ups with their PCP as adolescents without problems [17]. Moreover, adolescents’ perceptions of primary care were more positive when “sensitive” topics (e.g. substance use) were discussed with their PCP [2].

Youth want to have Meaningful Conversations with PCPs around Substance Use! [2]

 Thus, it is up to PCPs to address several commonly-heard assertions: “I have tried marijuana several times and nothing bad has happened to me; it is less harmful than alcohol” regarding cannabis use      [2] - p.3.  

Which of the following statements about cannabis are correct?

  • 1. According to a 2013 UNICEF office of research report, Canadian youth are the most common users (28%) of cannabis in the developed world.
  • 2. There are no implications for adverse health outcomes when initiating cannabis before the age of 16.
  • 3. One in five students (20%) who drive say they have driven within one hour of using cannabis.

Terminology Notes

Terminology Notes

The following terms are based on the fifth editions of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR and DSM-5, respectively; American Psychiatric Association, 2013, p.511) 

Addiction 

"Generally applied to patterns of heavy, compulsive use of psychoactive drugs and an inability to stop substance use, even though it is leading to severe, clinically relevant problems in multiple domains of a person’s life(e.g., when such use becomes physically hazardous; causes failure to fulfill obligations at work, school or home; or creates legal, social or interpersonal problems)."

Substance Dependence 

"Also referred to as drug or alcohol dependence, substance dependence constitutes a cluster of cognitive, behavioural and physiological symptoms indicating continued substance use despite the occurrence of severe substance-related problems. In DSM-5, the diagnosis of substance dependence has been combined with that of substance abuse (see below) and both have been replaced by the single term “substance use disorder,” underscoring the fact that a substance use disorder is not synonymous with physical dependence. In DSM-5, the severity that was previously captured by the diagnostic label substance dependence is now captured by specifying current severity (e.g., substance use disorder, severe)."

Substance Abuse 

"Also known as drug or alcohol abuse, this term refers to a maladaptive pattern of substance use resulting in recurrent and significant adverse consequences. It is a pattern of use under hazardous circumstances and involves neglecting one’s external obligations, legal problems and interpersonal problems. It has also been replaced by the term substance use disorder, but is indicative of a disorder of mild severity."

Definitions of "Adolescents", "Youth", and "Young People"

For the purpose of this module, we have defined "Adolescents", "Youth", and "Young People" as the following:

Adolescents 

Individuals 10-19 years of age (defined by the World Health Organization). 

Youth

Individuals 15-24 years of age (defined by the United Nations). 

Young People

Individuals 10-24 years of age (defined by the World Health Organization). 

T/F: Emerging Trends in Cannabis Research

  • Cannabis is a harmless drug.
  • Canadian adolescents (ages 10-19) are 2x more likely to use cannabis than adults.
  • Cannabis can be highly addictive.

T/F: Cannabis Use may be...

  • Associated with adverse changes on respiratory functions (e.g. cough, wheeze, and phlegm production, airway inflammation) [9]
  • Associated with adverse changes on behavior, and central nervous systems function (e.g. memory, executive functioning) [9]
  • Associated with mental health problems (e.g. bipolar disorder, depression and anxiety) [9]
  • Associated with motor-vehicle accidents during the period of acute psychoactive effects from cannabis use [18]

CAUTION: Did you know...

Youth Perceptions on Cannabis Use

Clinical Vignette 1: Steve

What would you do?

Clinical Vignette: Steve (Canadian Center on Substance Abuse, 2015, p. 25)

Clinical Vignette 2: Melinda

What would you do?

Clinical Vignette: Melinda (Canadian Center on Substance Abuse, 2015, p. 43)


Insights from a Multi-site Qualitative Analysis of Young People's Harm Minimization Strategies (Jenkins et al., 2017, p.4-8)

The City, The Valley, The North - 

Learning objective: to take an ethnographic approach to primary care

As PCPs, it is vital to implement harm reduction strategies within a culturally, socially, and geographically responsive framework. Jenkins et al. (2017) addresses substance use in the context of three communities (urban, suburban, and rural geographies) in British Columbia, Canada. Themes across and within each research site were complied from individual interviews (n=86) with young people aged 13-18.

The following section highlights themes across the three communities. Please refer to Jenkins et al. (2017) for a detailed qualitative data collection. 

Reflection

- How can you deliver patient-centered, and culturally sensitive health care? 

CAUTION: Before you tell, ask!

  • Effective communication skills lead to better patient health outcomes, and satisfaction for both you and your patient [13].

  • In a landmark study, physicians were found to interrupt their patients after given 23 seconds to speak [13].


Common Reasons Why Youth Use Cannabis (Canadian Center on Substance Abuse, 2017, p.17-19)

1. Social Influences - Common Reasons Why Youth Use Cannabis

[2] 

(For e.g. Family Members) 


2. Availability and Acceptability - Common Reasons Why Youth Use Cannabis

[2]

3. The Beliefs about Health Enhancing Properties of Cannabis - Common Reasons Why Youth Use Cannabis

Shown above: Adolescents believed that cannabis could help with the following diseases and conditions [2]

Practical PCP-administered Screening Tools for Youth

Introduction

Screening Tools 

Screening for substance use is critical in the early detection of cannabis use problems among adolescents [2]. Studies suggest that adolescents at-risk for cannabis use are likely to discuss substance use during check-ups [17]. Moreover, adolescents’ perceptions of primary care were more positive when “sensitive” topics (e.g. substance use) were discussed with their PCP [17].

You will be introduced to two clinician-administered screening tools that are highly referenced in the literature:

  • CRAFFT Questionnaire
  • Brief Screener for Tobacco, Alcohol and other Drugs (BSTAD)

CRAFFT and BSTAD 

"The advantages of CRAFFT include its ease of use as a mnemonic and its assessment of high-risk, substance related factors. It leaves out tobacco use, however, and lacks an assessment of substance use quantity. BSTAD, on the other hand, does include tobacco use as well as a detailed assessment of the frequency of use of each substance, but does not include some aspects of substance-related risk. As well, it assesses both patient and peer or friend substance use,with additional questions regarding the quantity of substances used in the past year." [2, p.68] 

"One possible method for combining the attributes of these screening tools is a staged screening process, beginning with brief questions about the use of any substances in the past year, followed by a more detailed assessment of the quantity and associated risks of each substance identified. This staged approach was found to be effective in a recent trial among adolescents presenting for routine outpatient care. A single screening question on past-year frequency of use for eight categories of commonly used substances was followed by a substance-associated risk assessment derived partly from the CRAFFT questionnaire. Delivered electronically, this approach was deemed valid in assessing clinically relevant risk categories of adolescent substance use." [2, p.69] 

CAUTION: Knowing the Common Barriers to Screening

FAST FACT!

Suboptimal screening practices can fail to identify drug problems among adolescents. In one study, although 14% of the patients scored ≥2 on the CRAFFT screening tool, PCPs only identified 4.8% of the patients with problem use [8].

PCP Perceptions on Screening

The following PDF file "barriers_facilitators to screening" was adapted from Sterling et al. (2012). The table in the PDF highlights the top barriers that PCPs felt when diagnosing for adolescent drug use. The survey was based on the web-based response of 437 PCPs practicing in pediatric health-care settings [17]. 

barriers_facilitators to screening

1. Car, Relax, Alone, Forget, Family or Friends, Trouble (CRAFFT)

CRAFFT questionnaire [5]

 Each yes answer scores 1 point; a total score of 2 or higher indicates a need for additional assessment.

C—Have you ever ridden in a car driven by someone (including yourself) who was high or had been using alcohol or drugs?

R—Do you ever use alcohol or drugs to relax, feel better about yourself, or fit in?

A—Do you ever use alcohol or drugs while you are alone?

F—Do you ever forget things you did while using alcohol or drugs?

F—Do your family or friends ever tell you that you should cut down on your drinking or drug use?

T—Have you ever gotten into trouble while you were using alcohol or drugs?

CRAFFT_English

2. Brief Screener for Tobacco, Alcohol and other Drugs (BSTAD)

Why BSTAD? [11]

“Providers are extremely busy and need a quick and valid screening measure for identifying teens who use substances,” says Dr. Kelly. The BSTAD was developed to overcome tight time constraints of PCPs. [15] 



BSTAD

[11, p.21]

Cannabis Withdrawal Symptoms (National Cannabis Prevention and Information Centre, 2016, p. 4)

Cannabis Withdrawal Syndrome-NEW

Summary

By the end of this module you should have an understanding of...

By the end of this module you should have an understanding of...

  • The adverse health consequences associated with non-medical cannabis use
  • The importance of patient-centered, and culturally-sensitive practices
  • Current, and peer-reviewed clinical screening tools (CRAFFT; BSTAD) for cannabis use in adolescents
  • Some online resources about Canadian youth and cannabis use

Final Tips

Tips on working with adolescents (Turner et al., 2014, p. 806)

Tips on working with adolescents [19]

The following are tips on how to work constructively with adolescents who use cannabis:

Establish rapport—this is the most important aspect of the encounter

Clarify confidentiality (e.g, “What is said in this room, stays in this room, unless there is a serious risk to you or another young person”)

Encourage self-efficacy by eliciting the adolescent’s thoughts, goals, and motivation for change. Highlight his or her strengths and previous successes

 Roll with resistance. Do not lecture or judge. Attempt to eliminate discrepancy between the adolescent’s goals and values and the choices he or she is making

Ask permission to address the subject at another time if the adolescent is not ready to change

References and Further Reading Materials

References and Further Reading Materials 

[1] - American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.

[2] - Canadian Centre on Substance Abuse. (2015). The effects of cannabis use during adolescence. Retrieved from http://www.ccdus.ca/Resource%20Library/CCSA-Effects-of-Cannabis-Use-during-Adolescence-Report-2015-en.pdf

[3] - Canadian Centre on Substance Abuse. (2017). Canadian youth perceptions on cannabis. Retrieved from http://www.ccdus.ca/Resource%20Library/CCSA-Canadian-Youth-Perceptions-on-Cannabis-Report-2017-en.pdf

[4] - Canadian Centre on Substance Use and Addiction. (n.d.). Addictions treatment helplines in Canada. Retrieved from http://www.ccdus.ca/Eng/Pages/Addictions-Treatment-Helplines-Canada.aspx

[5] - Center for Adolescent Substance Abuse Research. (2009). The CRAFFT screening interview. Retrieved from http://www.ceasar-boston.org/CRAFFT/pdf/CRAFFT_English.pdf

[6] - Drug Free Kids Canada. (n.d.). Get help - Resources. Retrieved from https://www.drugfreekidscanada.org/get-help/get-help-resources

[7] - Fischer, B., Russell, C., Sabioni, P., Brink, W. Van Den, Foll, B. Le, & Hall, W. (2017). Lower-Risk cannabis use guidelines: A comprehensive update of evidence and recommendations. Public Health Policy, 107(8), 1–13. https://doi.org/10.2105/AJPH.2017.303818

[8] - Hassan, A., Harris, S. K., Sherritt, L., Hook, S. V., Brooks, T., Carvey, P., ... Knight, J. R. (2009). Primary Care Follow-up Plans for Adolescents with Substance Use Problems. Pediatrics, 124(1), 144-150. doi: 10.1542/peds.2008-2979

[9] - Iede, M. Al, Nunn, K., Milne, B., & Fitzgerald, D. A. (2017). The consequences of chronic cannabis smoking in vulnerable adolescents. Paediatric Respiratory Reviews, 24, 44–53. https://doi.org/10.1016/j.prrv.2016.11.001

[10] - Jenkins, E. K., Slemon, A., & Haines-saah, R. J. (2017). Developing harm reduction in the context of youth substance use: Insights from a multi-site, qualitative analysis of young people's harm minimization strategies. Harm Reduction Journal, 14(53), 1–11. https://doi.org/10.1186/s12954-017-0180-z

[11] - Kelly, S.M., Gryczynski, J., Mitchell, S. G., Kirk, A., O'Grady, K. E., Schwartz, R. P. (2014). Validity of brief screening instrument for adolescent tobacco, alcohol, and drug use. Pediatrics, 133(5), 819-826.

[12] - National Cannabis Prevention and Information Centre. (2016). GP Fact Sheets. Retrieved from https://cannabissupport.com.au/media/4481/gp-factsheets-for-patients-and-gps-2016-combined-version.pdf

[13] - Poole G., Matheson., D H., Cox., D N. (2016). The psychology of health and health care : A Canadian perspective. Toronto, ON: Pearson Canada Inc.

[14] - Rudyk, A. (2017). Ontario's plan to regulate legalized cannabis. Retrieved from https://news.ontario.ca/mag/en/2017/09/ontarios-plan-to-regulate-legalized-cannabis.html

[15] - Sarlin, E. (2015). A rapid teen substance use screening tool for clinicians. Retrieved from https://www.drugabuse.gov/news-events/nida-notes/2015/07/rapid-teen-substance-use-screening-tool-clinicians

[16] - Statistics Canada. (2017). Canadian Tobacco, Alcohol and Drugs Survey (CTADS): 2015 summary. Ottawa, ON. Retrieved from https://www.canada.ca/en/health-canada/services/canadian-tobacco-alcohol-drugs-survey/2015-summary.html

[17] - Sterling, S., Kline-Simon, A. H., Wibbelsman, C., Wong, A., & Weisner, C. (2012). Screening for adolescent alcohol and drug use in pediatric health-care settings: predictors and implications for practice and policy. Addiction Science & Clinical Practice, 7(11), 1-12. doi:10.1186/1940-0640-7-

[18] - Turner, S. D., Spithoff, S., & Kahan, M. (2014). Approach to cannabis use disorder in primary care. Canadian Family Physician, 60(9), 801–808. Retrieved from http://pubmedcentralcanada.ca/pmcc/articles/PMC4162694/

[19] - UNICEF Office of Research. (2013). Child well-being in rich countries: A comparative overview - Innocenti report card 11. Retrieved from https://www.unicefirc.org/publications/pdf/rc11_eng.pdf


What Help is Available?

Canadian Center on Substance Abuse [4]

CCSA does not provide treatment services. Please contact your provincial or territorial helpline for information on available treatment services. Toll free numbers might not work outside of your province or territory, so use the local numbers listed below.

Alberta (Addiction Helpline, Alberta Health Services)  1-866-332-2322; 780-427-7164 

British Columbia (Alcohol and Drug Information and Referral Service) 1-800-663-1441;              604-660-9382 

Manitoba (Addictions Foundation of Manitoba) Adult services: 1-855-662-6605                         Youth services: 1-877-710-3999; 204-944-6200  

New Brunswick (Addiction Centres, Department of Health) 506-674-4300 

Newfoundland and Labrador (Addictions Services, Department of Health and Community Services) 1-888-737-4668; 709-729-3658 

Northwest Territories (Department of Health and Social Services) 1-800-661-0844; 867-873-7037  

Nova Scotia (Addiction Services Offices, Nova Scotia Health Authority) 1-866-340-6700      (Halifax Regional Municipality) 902-424-8866 

Nunavut (Kamatsiaqtut Help Line) 1-800-265-3333; 867-979-3333 

Ontario (Drug and Alcohol Helpline, ConnexOntario)  1-800-565-8603; 519-439-0174 

Prince Edward Island (Addiction Services, Health PEI) 1-888-299-8399; 902-368-4120 

Quebec (Drugs: help and referral) 1-800-265-2626; 514-527-2626 

Saskatchewan (HealthLine, Ministry of Health) 811 or 1-877-800-0002 or 306-766-6600 

Yukon (Alcohol and Drug Services, Health and Social Services) 1-800-661-0408, Ext. 5777        After hours: 1-800-661-0408, Ext. 8473 867-667-5777

Online Support for Teen Drug Abuse [6]

Here are several additional resources for you to search and get the tools you need to deal with drug related issues

Disclaimer: Inclusion of an organization does not imply endorsement or authorization by Drug Free Kids Canada.  The sources of information listed below are intended only as a partial list of the resources available to viewers of this website. You are encouraged to conduct additional research for resources.

Resources:

Canadian Centre on Substance Use and Addiction www.ccsa.ca Provides help, information and guidance on substance use for parents.

Health Canada Talking with teenagers about drugs The importance of starting the conversation

Centre for Addiction and Mental Health Child, Youth and Emerging Adult Services Provides help to young people with mental health and/or addiction problems.

WebMD Teen Drug Abuse Directory This editorial section of the popular medical site helps parents understand and deal with teen OTC drug abuse.

Canadian Society of Addiction Medicine Addiction Medicine information A resource of scientific and medical information about Addiction - for the general public and professionals.

Families for Addiction Recovery Understanding Addiction

RCMP Drug Awareness Kids and drugs: A parent's guide to prevention

The Centre for Youth Crime Prevention (CYCP)"YOUth have the power to create positive change"A by-youth for-youth web-based program that is operated by the Youth Engagement Section of the Royal Canadian Mounted Police.

ABOVE The Influence http://abovetheinfluence.com/ This site is designed to engage teens in discussions about influence and ways to “stay above it.”

Prevent Teen Drug Use www.preventteendruguse.org This site aims to give parents and teens, facts about today's marijuana and to encourage public discussion about the risks of using this drug.

Kids Now http://www.kidsnowcanada.org/ Kids Now is a national, after school mentoring program that empowers grades 7 and 8 youth, to believe in themselves so they can make positive choices.

Teen Mental Health http://teenmentalhealth.org/ Helping to improve the mental health of youth by the effective translation and transfer of scientific knowledge.

Smart kids don't do drugs www.smartkidz.org Help to fight the battle against drug abuse by our young people.

Kids Help Phone http://www.kidshelpphone.ca To reach a Kids Help Phone professional counsellor, kids, teens and young adults, from any community in Canada, you can call or go online 24 hours a day, 365 day a year.

(USA) The Partnership for Drug free Kids www.drugfree.org Need Help? Get Help! How to talk to your kids. Drug prevention, drug abuse, drug intervention, drug treatment and recovery. Drugfree.org provides answers, guidance, tips and stories.

Get Treatment:

The Family Navigation Project at Sunnybrookewww.sunnybrooke.ca The Family Navigation Project at Sunnybrook is a non-profit program designed to provide expert navigation of the mental health and addictions service system for youth aged 13-26 with serious mental health and/or addictions problems.

Drug Prevention Network of Canada www.dpnoc.ca Provides contacts to each relevant provincial ministry as well as an extensive list of organizations in your province

Centre for Addictions and Mental Health - CAMH www.camh.net CAMH is Canada’s leading addiction and mental health organization, integrating specialized clinical care with innovative research, education, health promotion and policy development. Find out more about CAMH’s programs, locations, and how to contact us.

The Drug & Alcohol Helpline www.drugandalcoholhelpline.ca The Drug and Alcohol Helpline provides information about drug and alcohol addiction services in Ontario. A helpful Information and Referral Specialist will answer your call, email or web chat 24/7. The service is free, confidential and anonymous.

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