Systematically Testing the Evidence on Marijuana

Discussing Cannabis Use with Young Adults

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Discussing Cannabis Use with Young Adults

By: Jason R. Kilmer, PhD and Devan Kansagara, MD MCR

Background

In 2023, over a quarter of young adults in the US reported using cannabis in the past 30 days.1 Both college students and their young adult peers not in college use cannabis at similar past year and past 30-day rates, though rates of daily or almost daily use (20 or more days per month) are almost double for young adults not in college (11.6% for non-college young adults and 6.3% for young adults in college).1 For young adults who make the choice to use cannabis, there can be a range of unwanted outcomes and serious risks, particularly for those under the age of 25 as the brain is still developing. Clinicians should be prepared to discuss cannabis use with their young adult patients. 

Evidence Highlights

Young adults who use cannabis are at risk for addiction, adverse mental health outcomes, cognitive issues, and cannabis withdrawal, particularly in those who use high-potency products and with daily or near daily use.

Cannabis use disorder

  • The risk of cannabis use disorder (CUD) is 2 to 3 times higher among 18–25-year-olds than among adults over 25.2
  • CUD is common among young adults with mood disorders and is a marker for adverse mental health outcomes and increased mortality in this population.3
    • In a large population-based cohort study, 13.9% of young adults with mood disorders had been diagnosed with CUD.3
    • CUD was associated with higher rates of psychiatric hospitalizations and emergency room visits, non-fatal self-harm, fatal unintentional drug overdose, homicide, and all-cause mortality in this population.3

Psychotic spectrum disorder

  • In a systematic review of longitudinal cohort studies, cannabis use was associated with a 40% increased risk of future psychotic symptoms and a dose-response effect was observed.4
  • Individuals who use high potency cannabis (≥10% THC) daily have up to 5 times greater odds of developing a psychotic disorder than those who never used.5
  • In a meta-analysis, the average age of onset of psychosis was 2.7 years earlier among those who used cannabis compared to those that did not.6
  • The risk of psychotic symptoms is substantially elevated among individuals who use cannabis and are genetically predisposed to schizophrenia.7

Cannabis withdrawal syndrome

  • Cannabis withdrawal is common among young adults who use cannabis regularly.8
    • In population-based settings, the prevalence of cannabis withdrawal syndrome among young adults is between 12.5 and 29%.8
    • In outpatient settings, that prevalence is as high as 43.5 to 68%.8

Cognitive concerns

  • Cannabis use is associated with poorer academic performance in college settings, including more skipped classes, lower grade point average, and delayed graduation. The more frequently a student reports use, the more pronounced these relationships are.9-12
  • Cannabis use is associated with decreases in attention, verbal learning, and memory (including verbal working memory), although these can improve with abstinence. Some improvement may be seen within 2 weeks, but improvement of attention issues can take 4 weeks or more.13-16

High potency products

  • High potency products (≥10% THC) have become widely available and used and pose a clear risk for young adults.
  • In the 1970s, THC levels in smokeable flower were 1 to 1.5%. By the mid-1990s, THC levels were around 4%, and by 2010, THC levels routinely exceeded 10%. Now, flower typically ranges from 20 to 30% THC, and concentrates typically range from 60% to 90% or higher in states with legal cannabis.17
  • A cohort study comparing young adults using high-potency cannabis to those using low-potency products found that use of high-potency products was associated with a four-fold increased rate of problematic cannabis use and a two-fold increased rate of anxiety disorder.18 

Clinical Considerations

  • Consider screening for cannabis use with your patients or clients. Although there are formal screening measures (e.g., the Cannabis Use Disorder Identification Test-Revised [CUDIT-R],19 available in the Appendix and from the Washington Recovery Helpline20), even asking if patients have used cannabis in the past year can get the conversation started. Review the following suggestions to guide your conversation with patients or clients.
    • There has been a push toward using the term “cannabis” over “marijuana,” but many young adults may not use this term nor know what it means. You may want to define this term (e.g., “When I say cannabis, I mean marijuana, weed, and so on”).
    • The many ways in which people use cannabis have changed. If you ask, “have you smoked marijuana?”, someone who vapes or uses edibles can honestly say no and their cannabis use may go unaddressed. Consider different ways to ask, such as “do you use marijuana?” or “have you used marijuana?”
    • Rather than leading with the “problems” or “concerns” they have had, consider first asking about the good things about cannabis use for them and only then explore the “not-so-good” things. Asking about what they like communicates empathy and acknowledges the value they see in their use; asking about the not-so-good things avoids labels and judgment, and frequently elicits a longer list than many would expect.
  • Raising the issue with young adults can make a difference. Brief interventions utilizing motivational interviewing with a harm reduction focus have demonstrated success in reducing cannabis use and consequences among college students.21 While abstinence may be an ideal goal, reducing the frequency of use and the potency of cannabis used can be more realistic targets that may nevertheless mitigate harms.
  • Some of the very reasons young adults report using cannabis (e.g., it relieves anxiety, relieves depression, helps them sleep, improves appetite, reduces headaches) are also symptoms of cannabis withdrawal.22 Counsel patients about these symptoms so they are not mistakenly using cannabis to treat symptoms that are actually related to withdrawal.

Bottom Line

People with developing brains are at higher risk for adverse effects from regular use of cannabis, particularly from high-potency cannabis. As a clinician, your input and feedback on cannabis use can go a long way towards helping young adults make better decisions. For example, it could be essential to delaying the onset of psychotic or mood disorders or avoiding impairment in cognitive abilities (or other outcomes with elevated risk) for those under 25 years of age. Identifying possible CUD and/or the possibility of withdrawal symptoms that emerge on days your patient or client does not use cannabis could provide the opportunity for a brief intervention. Finally, if you are ruling in or out a diagnosis, be aware of ways in which cannabis use can exacerbate or even cause the very issues someone is seeking assistance for (including anxiety, sleep difficulties, attention challenges, and more).

Suggested citation: Kilmer JR, Kansagara D. Discussing cannabis use with young adults. The Systematically Testing the Evidence on Marijuana Project; December 2024. Accessed (Month DD, YYYY). https://www.cannabisevidence.org/clinician-resources/clinician-briefs/discussing-cannabis-with-young-adults.

Author affiliations: Dr. Kilmer is affiliated with the University of Washington School of Medicine and Dr. Kansagara is with the VA Portland Health Care System and Oregon Health & Science University.

Acknowledgements: Thank you to Mohini Ranganathan, MD and Sarah Feldstein Ewing, PhD for critically reviewing this document.

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References

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