Joey Wahler (Host): It affects many minors, so we're discussing marijuana use. Our guest is Dr. Imran Shakir. He's a dual board-certified psychiatrist, as well as Chief Medical Officer for Silver Oaks Behavioral Hospital. This is Silver Cross Hospital's IMatter Health Podcast, where medical experts bring you the latest information on health topics that matter most to you and your family. Thanks for joining us. I'm Joey Wahler.

Imran Shakir, DO: Hi. Thanks for having me.

Host: Absolutely. I appreciate you hopping aboard. So first, being a child and adolescent psychiatrist, has their marijuana use grown over the past five, ten years?

Imran Shakir, DO: So, the use has certainly gone up. With the legalization of marijuana in a lot of states, it's certainly more prevalent than it ever was. There's malls you can walk into now and walk by a marijuana store. So certainly, the exposure is there and the access is increased now that it's not a crime to have it. And then, along with all of the varieties, it's now available in attractive packages for kids, flavored stuff, edibles, all this stuff. Absolutely, we're seeing use go up in kids.

Host: So, there's a notion that marijuana is completely safe as a substance. Is that true? And can it be addictive?

Imran Shakir, DO: So, THC is psychoactive. And there's no psychoactive substance that's without its risk. And with any psychoactive substance, there's risks and there's benefits involved, and there is certainly a perception that, "Hey, this comes from a plant, it's safe," or there's a perception that the reason it's been illegal so long is because of the alcohol lobby or the tobacco lobby. And so, you know, finally, we have access to it. And there's this almost feeling that we've beaten the bad guys. And certainly, there's been a more greater acceptance of marijuana, which has led to this belief that this is a totally safe thing and that maybe I don't have to worry about any health risks associated with it.

Host: We'll talk about some of those risks and negatives in just a moment. But first, what exactly are minor marijuana users medicating for? What's their attraction to it? And do you find from your experience that it's any different than older people using?

Imran Shakir, DO: So, I think our youth-- and we all went through this, right? They're intensely social creatures. It's just where their brain is at in their development. Social reward is very important to them. Acceptance is very important to them. And so, you know, it's that age-old peer pressure conversation, combining peer pressure, which has always existed along with an increase in availability and acceptance of the drug. That's leading to a lot more use. So, kids are seeing their friends use it, so they get it offered to them sometimes on the school bus, sometimes in the hallway, sometimes at a gathering that they have later in the day. And I think that's really propelling a lot of this perception that, "Hey, everyone's using it, so why can't I?"

Host: Let's talk about some of those negatives we alluded to. For instance, does marijuana have a negative impact on the brain, especially those still developing in minors?

Imran Shakir, DO: Yeah, absolutely. You know, a lot of brain development is managed and mediated by the system called the endocannabinoid system, right? And so, these are endogenous cannabinoids that modify how our brain grows. We have short windows of development in childhood, these bursts of development where there's a lot of changes happening in the brain.

There's addition to things and development to things, but there's also pruning of things, meaning getting rid of things that perhaps aren't as important as originally when we were born, maybe these are structures and parts of the brain that require a little bit of fine tuning, so that process is called pruning, and our brain is constantly snipping away things that maybe get in the way of our efficiency. And then, adding things to increase our efficiency, whatever brain region that might be. And that's just development, that's maturation. And so, we are finding that exogenous cannabis use, so exogenous cannabinoids affect the system. It certainly don't help it. And any disruption to that system, interference in that system is resulting in cognitive deficits and even things you can like see. You can do fMRIs and actually see areas of the brain that aren't developing as maybe swiftly as you would otherwise expect.

Host: And staying with that cognitive theme, how about marijuana use, especially on the heavy side, being able to cause or worsen mental health conditions like, say, psychosis?

Imran Shakir, DO: Yeah. And since the legalization of marijuana, we're seeing significant increases in the incidence of psychosis in the emergency setting. The first state to do it was Colorado. And when they first legalized marijuana, they found an increase in the presentation of people presenting with paranoia, hallucinations, whether the auditory or visual and other disruptions in perception and reality, perception and testing. And that incident went up hundreds of percent, so significantly greater than we were seeing before. Now, was it causal? We have a hard time proving being caused, but does it correlate? Probably. And we've continued to see that trend kind of move in that same direction. The incidence of psychosis in youth is going up, and that is mirroring pretty closely the use, not only the use of marijuana, but also the potency of marijuana.

Host: Certainly eye-opening information there. So, moving from the brain to the lungs, how about marijuana increasing respiratory risks?

Imran Shakir, DO: So, marijuana can be introduced to our system in many ways. Most commonly, we think about smoking. And whether that's actually smoking flower directly or using some kind of device like a vape or an ionizer. You're introducing smoke into the lung, right? That's never been good. And the same is true for marijuana use.

So, we're seeing that bronchitis is going up. You remember not too long ago, nicotine vapes got into big trouble because of the popcorn lung they were causing. Now, we've since moved away from a lot of those emollients that they were using to carry the nicotine, however, that risk persists. Again, smoke in our lungs is never a healthy thing. So, users can avoid it by using the edible versions, ingesting it. However, the vast majority of its users are still smoking marijuana and their products.

Host: Is it safe to drive under the influence of marijuana?

Imran Shakir, DO: I get that question a lot. "Hey, doc, is this driving under the influence if I'm using marijuana?" Absolutely. Yes, it does. And so if you look at the risk associated with it, and we've actually looked at it, I always tell everybody, marijuana and driving certainly doesn't mix. There's certainly a higher chance that you're going to get into a car accident. Data already supports that. And that's no surprise, right? When we use marijuana, our ability to perceive things and stimuli, whether positive or negative, changes, usually in the wrong direction. Our reaction to things also change, meaning maybe we don't as quickly or intensely respond to a threat in the environment. Obviously, that's not something you want on the road.

Now, if you look at the data and like level of impairment, it's certainly eclipses texting while driving. So, meaning it's worse than texting while driving, which we all freak out about, right? And take very seriously. But maybe it's not as impairing as having a blood alcohol level of 0.08. It's somewhere in between there. Is that going to change as we gather more data? Probably. But there's no doubt that it impairs their ability to drive.

Host: Gotcha. Switching gears a little bit, medical marijuana, is that safe?

Imran Shakir, DO: You know, you're talking to a doc who's very much pro at the use of marijuana in a therapeutic way. And so, there are certainly places where marijuana belongs. And look, at the end of the day, THC is a psychoactive medication. It's a medicine. And just like any other medicine, like I said before, it carries risks and it carries benefits.

And so, when you're selecting a treatment, marijuana being one of those treatments, you compare it to other treatments. So, let's say, for instance, we're considering managing someone's pain with marijuana. So, you're putting marijuana up against opioids, right? Like Norco and Vicodin and morphine and fentanyl.

Now, it's no contest. Marijuana tends to be a better tolerated substance and has less risks associated with it than long-term or chronic pain pills, anxiety drugs like Xanax and Ativan and Valium. Marijuana is well-studied for the use in the management of anxiety disorders and panic attacks and PTSD. If I compare marijuana against Xanax, the side effect profile for marijuana is far more favorable because Xanax and Valium and Ativan, which we use far too much, carry a much greater risk of substance dependence. And then also, the withdrawal from those substances is fatal. None of those things are true for marijuana. So whenever you consider a treatment, you're comparing it against alternatives. And so, there are certainly parts in conditions that marijuana is more favorable than other treatments that are available, so, pain, anxiety, glaucoma, terminal cancer. It certainly has a place in treatment.

Host: Is the marijuana of today's stronger and more dangerous than in years past? And what's the basic difference between the strains, sativa, indica, and hybrid?

Imran Shakir, DO: So, human beings make progress, right? And we've made a lot of progress in agriculture. That's why we're able to grow so much food with so much less resources. And that's true for marijuana too, right? We've made a lot of progress in not only understanding how marijuana works. And through that understanding, targeting, "Well, how do I make it better for my use?" And that use tends to be the after effect, the high that we seek. It's hard to quantify. So, there's no doubt that marijuana now is more potent than it ever has been. Some people have suggested up to 80 or 100, even 200% stronger than the stuff that people were smoking when marijuana was really cool in the '70s when that movement happen.

We have gotten really good at selecting the psychoactive part, so not as just THC, CBD and making sure that we're growing strains that are more plentifully producing those kinds of substances. And that has an effect on its potency and the side effects associated with it. So, the short of it is, absolutely, it's way more potent, probably twice, maybe even three times as potent as it was in the past.

Host: Wow. Certainly eye-opening numbers there. A few other things. You alluded earlier to devices. So, what are the dangers of marijuana pens, for instance?

Imran Shakir, DO: So, pens in and of themselves, obviously that smoke risk that we talked about. But the thing that is probably the most alarming about vapes and devices is how accessible they are. In the past, you couldn't really smoke marijuana at work or at school. You couldn't really sneak away and get away from the really strong odors that are associated with it.

And flowers are a lot harder to hide than a very slim USB stick-looking device that you can put anywhere. And we find that, this is especially true for nicotine, right? Initially when vapes came out, we were saying, "Hey, maybe this will help people quit. Maybe this will help people get off of cigarettes." Well, the opposite has been true. So, people who went from cigarette smoking to using vapes now find themselves sitting at home, watching TV, pulling out their vape, taking a few hits and putting it back in their pocket. When in the past, they would've had to get up, put on their jacket, go outside, light up and smoke, right?

And so, that accessibility is something that we really take for granted. So while smoking flower is probably less healthy for our lungs than smoking vapes, but the accessibility usually means that you're using it way more frequently because it's so much easier to do.

Host: What are the signs your child may be using marijuana, and what should you do about it? What's the proper reaction if there is such a thing?

Imran Shakir, DO: Marijuana and the talk around marijuana should start really early. So hopefully, you've already had conversations with your child about drug risk. There are schools that are doing a good job about this. Back in my day, it used to be D.A.R.E., right? D.A.R.E. to keep a kid off drugs and all of that. We've gotten better. So, we found that D.A.R.E. maybe wasn't as effective as other interventions. And so, we've gotten better at introducing kids to the risks associated with substance use, marijuana included now than we ever have. So, those conversations also need to extend into the home, right? And so, you really need to have frank conversations with your kids.

"Hey, kid, you know, son, you're going to be offered marijuana someday. It might be tomorrow in the hallway at school, it might be at a party. It's going to happen. It's not an if thing, it's a when thing. It's a matter of time." And so, really having a very frank conversation about the associated risks and benefits of use and really educating them on what they're signing up for and hoping that they make a healthy decision for themselves, right? We're not going to control our kids despite what parents think and believe, kids are going to be kids. They are going to make their own decision. They're autonomous. All we can do is educate them the best of our ability. So, education is first and foremost.

Now, you're, "What do I look for? How do I know my kid is smoking? You know, the traditional signs and symptoms, right? Red eyes, glassy eyes, a change in their affect. Meaning you're seeing inappropriate smiles, right? You can tell. "Hey, why are you smiling constantly? What's going on?" There's a change generally in their emotional display. They might be slower cognitively, physically. And going further, you know, when use really starts to get concerning, it starts to affect their function. By that, I mean social functioning, academic functioning. Maybe they're not getting the grades that they used to. Maybe they're hanging out with a different subset of kids, who have their own histories behind them. Maybe you're noticing money is missing or items are missing, and they're starting to get desperate to have access to funds to get the marijuana to begin with.

And so, what I always, always, always encourage parents to do is set our kids up to be comfortable bringing these issues to you. Making sure that, "Hey, son, I know you're going to mess up," "Daughter, I know you're going to mess up. And when you do, I'm here and we can talk about it in a constructive and non-punitive way. I'm going to try to help you rather than punish you for something that's out in the environment. And so, that not only extends to just kind of in general, right? That's a tact we should have for our kids, but especially true for substances like marijuana.

Host: And so, piggybacking on that in summary here, Doctor, if you suspect that there's an overuse of marijuana, maybe even an addiction, where's the line as a parent, when should you seek professional help?

Imran Shakir, DO: So, I always say, it goes back to function, function, function. Honestly, certainly, there's not a justification for marijuana use in our youth now, even medically speaking. There's no body, academic body, medical body saying, "Hey, marijuana can be safely used in terminal cancer in kids or autism in kids or anxiety disorders in kids." The risks are far too great and they wipe out any benefit specifically in our kids.

So to that, I say we ought not to wait until the signs of addiction are there. No pun intended. Even if we get a whiff of it, that conversation needs to happen. We need to start early. It's about education, it's about support. It's about trying to find why we're using it, right? Is it simply for fun or is it to belong? Each one of those conversations is going to take you in a different direction, and it's going to modify our approach.

I will say it again. We have to be gentle in our approach. We have to be supportive in our approach. There is certainly room for punishment and learning. However, if we're punitive first and supportive second, the next time this happens, and there will be a next time, your child is far less likely to be open and honest and forthcoming with you. And if that's true, any control that you have over your child's health is gone.

Host: It can be a sticky situation, but it sounds like if parents stick to some of the thoughts and steps that you've covered, it'll be a lot easier to deal with. Well, folks, we trust you are now more familiar with marijuana use among minors. Dr. Shakir, keep up all your great work and thanks so much again.

Imran Shakir, DO: Thanks for having me.

Host: We appreciate the time. So for more information, please visit silveroaksbehavioralhospital.com. If you found this podcast helpful, please do share it on your social media. I'm Joey Wahler. And thanks so much again for being part of Silver Cross Hospital's IMatter Health Podcast.