5 Questions: Ammerman on pediatrics academy's opposition to legalizing pot

Four states and the District of Columbia have legalized the use of recreational marijuana for adults 21 and older, and 23 others and the District of Columbia allow the use of medical marijuana. As the social and political climates shift, the American Academy of Pediatrics has reiterated that drug laws affect children as well as adults, and issued a new position statement on marijuana Jan. 26.

The lead author of the academy’s statement is Seth Ammerman, MD, clinical professor of pediatrics at the School of Medicine and medical director of the Adolescent Health Van operated by Lucile Packard Children’s Hospital Stanford. He said the position statement includes 10 recommendations that address one fundamental issue: How we can best help make sure our youth are healthy.

Ammerman discussed the academy’s stance on marijuana with science writer Erin Digitale.

Q. Some advocates of marijuana legalization see it as a benign substance. Is marijuana benign for adolescents? What does the scientific evidence show?

Ammerman: No, it’s definitely not benign for adolescents. In the past decade, we’ve learned that human brain development doesn’t finish until the early to mid-20s, and substance use can alter the developing brain. There are a few ways we know this: One, there’s clear evidence that the younger you start using drugs regularly, the more likely you are to become addicted. This is true for alcohol, tobacco and marijuana, among others. For those who put off substance use until their late teens or early 20s, addiction rates are significantly lower.

We also know that the developing brain is very vulnerable to substance use. One in 10 adolescents who use marijuana become addicted. That means that 90 percent won’t — which is the good news — but the problem is we can’t predict which 10 percent will develop addiction.

We also have a lot of research about the adverse effects of marijuana use. Heavy users fare worse in many ways: Their cognitive levels fall, they are less likely to finish high school or attend college, and they tend to suffer more from depression. Most users are not heavy users, but again, we can’t predict who will fall into this category.

Q. Another argument from pro-legalization groups is that kids can already get marijuana anywhere. How did the AAP consider this issue in formulating its position?

Ammerman: It’s true that kids can get marijuana now, but when you start making it much more available to adults through legal means, inevitably adolescents will have more access. And we are concerned not just about access, but also about the marketing that would inevitably follow legalization. If you look at the history of the tobacco industry, we have lots of rules and regulations to try to prevent youth use, but tobacco companies ignore these or have loopholes to get around them. Rather than going the route of tobacco, let’s be more proactive and take a public health-oriented approach.

Q. One of the AAP recommendations is that marijuana possession be decriminalized. If the academy believes using the drug is harmful to kids, why should it be decriminalized?

Ammerman: It’s crazy that marijuana possession and use is a criminal issue; it should be a public health issue. We need to focus on prevention of substance use and on early intervention, getting kids with substance-use disorders the help they need. As the AAP statement points out, there is a significant problem of racial inequity associated with marijuana arrests: Minorities are way over-arrested, and their lives are messed up because of marijuana arrests. It’s a very important step to say we need to help kids, not punish them.

I also think the AAP’s stance in favor of having marijuana reclassified by the federal Drug Enforcement Administration as a schedule-2 drug is important because this would make it somewhat easier for researchers to study cannabinoids’ possible medical benefits. We know from limited research that certain cannabinoids, which are the compounds from the cannabis plant, have some medical benefits. But this area of research is in its infancy. Reclassification and more research could lead to Food and Drug Administration regulation and standardization of cannabinoid-containing products.

Q. As an adolescent medicine physician, what kinds of conversations do you have with your patients about marijuana?

Ammerman: I already get kids and parents coming in who want medical marijuana. Because it’s highly unregulated, “medical marijuana” is really a misnomer. A few cannabinoids have medical purposes, but if I were to recommend them, I couldn’t prescribe a particular dose, how much to use or how frequently, and it’s hard to recommend something based just on anecdotal evidence. I hear patients say, “It helps my depression,” even though it generally worsens depression, or “I study better,” even though most kids study worse with it. Or patients may say, “It helps my pain,” but there are probably other, better, standard pain medications or nonmedical treatments for pain that should be considered first. I ask if they have tried standard treatments, and often they haven’t.

Although there is some research into the use of marijuana for certain conditions in adults — it may help with low appetite, nausea and vomiting in AIDS patients and those receiving cancer chemotherapy, for instance — there are no research studies in children and adolescents. However, the new AAP statement does specify that in situations where standard treatment has failed and a child or teen has a life-limiting or severely debilitating problem, physicians might consider recommending marijuana on a case-by-case basis.

Q. What messages do you suggest for parents who want to talk to their children or teens about marijuana use in light of the country’s trend toward liberalization in marijuana policies?

Ammerman: For parents, I would say: Marijuana is not benign for teens. Even if it’s being used as a medicine, it can have side effects. And without the research background, we really don’t know if it will work or not; it’s hard to recommend it under those circumstances. In addition, parents should not use marijuana around their kids, particularly if they use recreationally, because that’s giving the message, “Hey, it’s fine to smoke,” and if kids start they could end up with serious problems.

We give similar messages to kids: Kids can be addicted to marijuana. Your brains are developing and we don’t want to mess around with that. In young people who use marijuana, their brain patterns shift, as measured by MRI. We don’t know the meaning of that, but it’s not normal, and it is worrisome.