The most popular illicit drug in college students is, perhaps not surprisingly, marijuana [1]. In fact, college attendance is considered a risk factor for the use of marijuana, with rates of college students using the drug steadily increasing [2]. So, how does one talk to a college student about marijuana and mental health?
It is important to keep in mind, however, that while daily marijuana use has been increasing in college, the level in non-college young adults is two to three times that of their college peers [3]. Marijuana smokers are also more likely to smoke cigarettes.
As vaping, dabbing, [4] and legalization spreads across the country, and more synthetic cannabinoids emerge, these rates will only continue to grow [5, 6]. This is because with these cultural and legal changes comes a shift in public opinion on marijuana’s dangerousness. Now, less than 20% of young adults (aged 19-22) consider marijuana use harmful [7].
In my college and graduate student patient population, marijuana use is something that comes up quite regularly. The conversation often starts on an initial interview like this:
Me: “Do you use any other substances, other than alcohol?”
Student: “No. I don’t do drugs.”
Me: “Do you smoke Marijuana?”
Student: “Oh yeah. Of course.”
This further illustrates that marijuana is viewed as more like alcohol than any other illicit substance and must separately be asked when screening for substance use in college students. After a positive screen, I will then attempt to quantify amount (nearly impossible for them to describe), manner of use (smoking vs. edibles), strain (if they know it), and frequency (this one they will know and will probably minimize).
Depending on their answers, I will attempt to formulate an argument a student will most listen to about their use. It is easier to have a conversation, instead of a lecture.
Therefore, I always come from a stance of motivational interviewing—helping them to see how marijuana is interfering with their lives and their other mental health disorders–and harm reduction. In other words, I do not broach the subject as “they need to quit and quit now” and will even explain this stance to students upfront.
Doing so seems to decrease their guarded posturing and disengaged statements and prevents them from shutting down and ignoring the conversation entirely. I feel like it makes me seem like not just a doctor telling them what to do, but someone who is genuinely curious and both listening to and trying to help them.
I often start the conversation by asking students what marijuana does for them. I ask what they like about it and how they feel before and after use.
I think of this as similar to what I might ask someone who self-harms. This answer helps me not only think of ideas of how they might get that feeling from something else (like a skill) but also helps me to understand their beliefs about its effect on their day-to-day lives.
If students do not offer any perceived effects, particularly to their mental health, on their own, I will specifically ask if they notice it does anything to their anxiety, mood, or sleep.
Students typically respond that they have not noticed it affects these areas or state that it treats their mood, anxiety, or sleep conditions (some strains specifically are sold as treatments, as well). No matter which response they give me, I will then transition to discussing the potential negative effects on their college lives and their mental health. I won’t always talk about all of these, but they are all part of my arsenal of potential conversation points.
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Side Effects of Marijuana Use:
Worsening Anxiety:
When discussing the potential for worsening anxiety with students, I first define rebound anxiety, or a temporary return of greater anxiety symptoms after withdrawal of use than was experienced before use, and describe the risk for it with marijuana. I will particularly emphasize this in students who think marijuana is treating their anxiety by asking them if they notice that they feel better at the moment, but after they stop smoking, they feel their anxiety worsens to the point that they may even feel the need to smoke again to fix it.
Worsening Sleep:
I will discuss rebound insomnia with students, which, like rebound anxiety, is worsening insomnia after use (sometimes days later) than experienced prior to using. Sleep is often highly valued in college students as they do not often get enough of it and when they have time to sleep, they want good sleep. This can be a good symptom for them objectively to measure in themselves as well.
Potential for Addiction:
Despite student belief to the contrary, there is clear evidence of marijuana addiction or dependence as well as a marijuana withdrawal syndrome [8]. Like for early cigarette smoking or drinking, early and regular marijuana use predicts marijuana addiction liability. People who begin to use marijuana in adulthood have a lower incidence of addiction than those who begin in adolescence. On the basis of current statistics and data, NIDA’s Director Volkow estimates that 9% of those who experiment with marijuana will become addicted [9]. I have seen multiple patients in my outpatient clinic that are addicted to cannabis, and unfortunately, there are currently no treatments specifically for these patients.
Risk for Depression:
Cannabis use is a risk factor for the development of depression [10]. I will discuss this with students, particularly those who are already depressed and will also discuss their motivation to do things. Marijuana often has a “syndrome” associated with it called amotivation syndrome [11], which looks a lot like depression (or can lead to worsening of depression). Basically, students just want to stay home and smoke and not do anything else. This effect on their day-to-day lives is often hard for students to acknowledge, particularly that their smoking might be worsening their depression (or causing it) and not simply be independent of it. However, if the lack of motivation has begun affecting their grades, the argument often becomes easier.
Risk for Psychosis:
Another mental health effect that can be seen is long-lasting or even permanent development of psychotic disorders [12]. Studies suggest that marijuana use can exacerbate the course of illness and that heavier use, greater drug potency, and younger age of use can all affect the disease trajectory (for example, by advancing the time of a first psychotic episode by 2 to 6 years) [13]. In this conversation, we will discuss the family history of psychotic disorders as well as any psychotic experiences while high on marijuana. In those with positive family histories, as I would in those with alcohol use disorder family histories, I tell them, they should not smoke, or they are risking development of schizophrenia. I will also tell my patients stories of patients I saw in the inpatient unit who developed schizophrenia after marijuana use. This is a bit scary, but it seems to be effective.
Worsening School Performance:
Studies in high school students have shown that students who smoked marijuana regularly were more likely to miss assignments, less likely to get good grades, and were less academically competitive [14]. Since marijuana use impairs critical cognitive functions, both during acute intoxication and for days after use, college students may compromise their academic success and may begin to function at a cognitive level that is below their natural abilities [9]. Although acute effects may subside after THC is cleared from the brain, measurable impairments like a decrease in short term memory may be long lasting, particularly among those who started to use marijuana early and often. Students who use are also more likely to drop out of school [9].
Potential for Risky Behaviors and Accidents:
Marijuana like alcohol can cause poor motor performance, judgment errors, and accidents. Marijuana or drugged driving is dangerous and risky and was the most frequently reported illicit drug in connection with impaired driving and accidents, including fatal ones [15]. In fact, one meta-analysis found that marijuana use increases the overall risk of involvement in an accident by a factor of two [16]. Combined with alcohol, accidents are more common than with either alone. In addition to car accidents, altered judgment can also increase the risk of sexual behaviors that could facilitate the transmission of sexually transmitted diseases [9].
After discussing some (usually not all) of these potential negative effects on their mental health, I will also point out a couple of things to keep in mind with their overall use. I highlight the difference in types of cannabis and that edibles are often more highly associated with acute psychiatric symptoms and intoxication than inhaled cannabis [17].
We also discuss how their supply might be laced with other drugs, and so they should not only be sure of the origin of theirs but be aware that this is dangerous and can lead to the development of unexpected serious symptoms [18].
Once I have been able to talk about most of these key points, like what happens in all motivational interviewing, I will ask if they have any desire to cut down. This desire will be higher if through the conversation they notice marijuana is affecting their life (particularly school) and/or is altering their mental health.
I then try to ascertain the likelihood that they will actually cut down and will sometimes make goals for the next time I will see them (decreasing to 2 times a week from 3 times a week). Sometimes, a student will agree to do an experiment where they take a “drug holiday.”
By taking a few weeks off entirely, they can measure and see if anything in their mental health changes tangibly. Sometimes they will do this just trying to prove me wrong in their scientifically minded brains, but getting them to try, no matter the reason, is key.
Even still, sometimes students are not ready to discuss their use. This is not a conversation to only be had once, especially in students with longer term or heavy use. Repetition is important, and at each visit, I will ask about usage and again try to discuss how use interferes with therapy and their medication fully working.
As a psychiatrist working on a college campus, marijuana use is rampant and will only increase. This can lead to risky behaviors, addiction, worsening mental health, and decreased academic performance.
As such, it is important that all providers and parents understand marijuana’s mental health effects and how to have a conversation about marijuana use that is effective in this population. Even if culturally there is a shift in believing it is so, marijuana is not harmless, and students should be aware of the risks and counseled on how to cut down or stop completely.
References:
1. Palmer, R.S., McMahon, T.J., Moreggi, D.I., et al. (2012). College Student Drug Use: Patterns, Concerns, Consequences, and Interest in Intervention. J Coll Stud Dev, 53(1):10. doi: 10.1353/csd.2012.0014.
2. Miech, R.A., Patrick, M.E., O’Malley ,P.M., et al. (2017). The Influence of College Attendance on Risk for Marijuana Initiation in the United States: 1977 to 2015. Am J Public Health, 107(6):996-1002. doi: 10.2105/AJPH.2017.303745.
3. https://www.drugabuse.gov/related-topics/college-age-young-adults
4. https://www.lung.org/stop-smoking/smoking-facts/marijuana-and-lung-health.html
5. Egan, K.L., Erausquin, J.T., Milroy, J.J., et al. (2016). Synthetic Cannabinoid Use and Descriptive Norms among Collegiate Student-Athletes. J Psychoactive Drugs, 48(3), 166-72. doi: 10.1080/02791072.2016.1186305.
6. Jones, J., Nicole Jones, K., & Peil, J. (2018). The Impact of the legalization of recreational marijuana on college students. Addict Behav, 77, 255-259. doi: 10.1016/j.addbeh.2017.08.015
7. Miller, A.M., Rosenman, R., & Cowan, B.W. (2017). Recreational marijuana legalization and college student use: Early evidence. SSM Popul Health, 3, 649-657. doi: 10.1016/j.ssmph.2017.08.001
8. Livne, O., Shmulewitz, D., Lev-Ran, S., & Hasin, D. S. (2019). DSM-5 cannabis withdrawal syndrome: Demographic and clinical correlates in US adults. Drug and alcohol dependence, 195, 170-177.
9. Volkow, N. D., Baler, R. D., Compton, W. M., & Weiss, S. R. (2014). Adverse health effects of marijuana use. New England Journal of Medicine, 370(23), 2219-2227.
10. Gobbi G, Atkin T, Zytynski T, et al. Association of Cannabis Use in Adolescence and Risk of Depression, Anxiety, and Suicidality in Young Adulthood – A Systematic Review and Meta-analysisJAMA Psychiatry. Published online February 13 2019
11. Lac, A., & Luk, J.W. (2018). Testing the Amotivational Syndrome: Marijuana Use Longitudinally Predicts Lower Self-Efficacy Even After Controlling for Demographics, Personality, and Alcohol and Cigarette Use. Prev Sci, 19(2), 117-126. doi: 10.1007/s11121-017-0811-3.
12. Boutros, N.N., & Bowers, M.B. (1996). Chronic substance-induced psychotic disorders: state of the literature. J Neuropsychiatry Clin Neurosci., 8(3):262-9. doi: 10.1176/jnp.8.3.262.
13. Di Forti, M., Sallis, H., Allegri, F., Trotta, A., Ferraro, L., Stilo, S. A., … & Dazzan, P. (2013). Daily use, especially of high-potency cannabis, drives the earlier onset of psychosis in cannabis users. Schizophrenia bulletin, 40(6), 1509-1517.
14. Karen A. Patte, Wei Qian, Scott T. Leatherdale. Marijuana and Alcohol Use as Predictors of Academic Achievement: A Longitudinal Analysis Among Youth in the COMPASS Study. Journal of School Health, 2017; 87 (5): 310 DOI: 10.1111/josh.12498
15. Brady, J. E., & Li, G. (2014). Trends in alcohol and other drugs detected in fatally injured drivers in the United States, 1999–2010. American journal of epidemiology, 179(6), 692-699.
16. Hartman, R. L., & Huestis, M. A. (2013). Cannabis effects on driving skills. Clinical chemistry, 59(3), 478-492.
17. Monte, A.A., Shelton, S.K., Mills, E., et al. (2019). Acute Illness Associated With Cannabis Use, by Route of Exposure: An Observational Study. Annals of Internal Medicine. doi: 10.7326/M18-2809. [Epub ahead of print]
18. Gottlieb, S., Marks, P., & Woodcock, J. (2018). Statement from FDA warning about significant health risks of contaminated illegal synthetic cannabinoid products that are being encountered by FDA. Food and Drug Administration. Retrieved from https://www.fda.gov/newsevents/newsroom/pressannouncements/ucm614027.htmU.S.
Article Written By:
Jessica (“Jessi”) Gold, M.D., M.S., is an Assistant Professor in the Department of Psychiatry at Washington University in St Louis School of Medicine, specializing in college mental health, medical education, and physician wellness. She writes regularly for the popular press about mental health, stigma, and medical training. Dr. Gold is a graduate of the University of Pennsylvania where she did her undergraduate and Masters in Science in Anthropology and the Yale School of Medicine. She can be found at @drjessigold or drjessigold.com
The opinions and views of our guest contributors, are shared to provide a broad perspective of addictions. These are not necessarily the views of Addiction Hope, but an effort to offer a discussion of various issues by different concerned individuals.
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Reviewed by Jacquelyn Ekern, MS, LPC on May 23, 2019
Published on AddictionHope.com