Thank you very much for the opportunity to comment on Bill C-45, an act respecting cannabis and to amend the Controlled Drugs and Substances Act, the Criminal Code and other acts. As a developmental behavioural pediatrician and a researcher in the field of adolescent substance use, I'm concerned about the potential impact of these changes, specifically on the health of children and adolescents.
I've served as the chair of the American Academy of Pediatrics' national committee on substance use and prevention, and I've been the director of the adolescent substance abuse program at Boston Children's Hospital since its inception in 2000. Over the past 17 years, I've evaluated and treated hundreds of teens with substance use disorders, and while many of my comments have already been said in one form or another, I'd like to speak from personal experience.
Cannabis is an addictive drug that's particularly harmful to developing adolescent brains. Teens that consume cannabis have poorer life outcomes on a number of measures. They have more mental health disorders, including depression, anxiety, and psychosis. As a group, they complete less school and are more likely to be unemployed or underemployed than are their peers. These harms are distinctly different from the harms of use of other substances, such as tobacco, alcohol, and opioids, but they're no less serious or consequential.
As the director of an adolescent substance use disorders program serving youth aged 12 to 25, I work regularly with children and young adults who use cannabis. In fact, more than 90% of patients we see in our program have a cannabis use disorder. While almost all of them started their drug use histories with cannabis, few stick to one drug alone. Almost all of our patients in treatment for heroin addiction first used cannabis, and most use it very heavily.
We've treated a number of teen cannabis users who've developed schizophrenia right in front of our eyes, and who will never be able to care for themselves or live independently. We don't know what would have happened to them if they hadn't used cannabis, but the science and the statistics made us wonder if they might have had a different life had it not been for a completely preventable risk factor.
More commonly, we see again and again adolescents whose cannabis use more subtly impedes them. Two patients with similar histories paint a very clear picture of cannabis addiction. Both were good students in high school and were accepted to elite universities, where they began using cannabis heavily and ended up failing out. Both blame their changing academic status on heavy cannabis use. All four of their parents have been devastated. One of the fathers confided about adjusting his own hopes and expectations for his son. A few short years ago, he had envisioned his son becoming a successful professional. Now, he simply hopes he'll be able to function well enough to support himself.
The list goes on and on, with many adolescents that I care for falling short of their own educational goals, being underemployed, and struggling with mental health disorders while their families watch and wonder about their future.
Bill C-45 would prohibit the sale or marketing of cannabis to adolescents and young adults under the age of 18, and legalization is often proposed as a mechanism to reduce youth access by taxing and regulating cannabis, raising the price, eliminating the black market, and making shop owners gatekeepers. This approach has failed with other substances in the past. Marketing restrictions have historically been of limited utility when tested against the potential for substantial profits. While it's illegal for tobacco companies to market cigarettes to children, the familiar story of Joe Camel is a good example of how pernicious advertising can be.
In the U.S., the experience in Colorado, which was one of the first two states to legalize cannabis, is instructive. The number of teen users in Colorado increased by 20% in the two years immediately following legalization, while falling by 4% in the rest of the country. As a developmental pediatrician and also the parent of two teenaged children, I do not find these findings at all surprising. The retail sale of cannabis serves to normalize use. Teens are very responsive to cultural trends. When cannabis use is condoned, teens are more likely to use it. To argue otherwise is simply unreasonable from a developmental perspective.
In the U.S., evolving cannabis policies have resulted in changes to cannabis itself. The concentration of THC, the main active ingredient in cannabis, has increased dramatically over the past three decades, exposing users to higher levels of this drug than ever before. That's one of the reasons the science has been so tricky to pin down, because the product is actually changing. New edible products, including cookies, candies, and sodas have appeared on the market and are sold under the umbrella of marijuana.
Now, this market expansion is to be expected, because creating new and improved products is a tried-and-true technique for boosting sales, constantly inviting new users to try, and old users to add, new products to their repertoire.
Dabbing, a newly popular way of using cannabis, results in extremely high blood levels of THC. Higher THC exposure produces more euphoria and also causes more medical problems. In our clinical practice, kids are coming in with new problems that we rarely saw 10 years ago. Cannabis hyperemesis syndrome, which causes recurrent vomiting, was once rare but is now quite common in our practice. Psychiatric symptoms and complaints have also increased. Many of our patients have heard voices, experienced delusions, or become anxious and paranoid with cannabis use. In a study that our group is currently conducting in our primary care centre, more than 25% of cannabis users report that they've hallucinated while using cannabis, and more than 30% report having been paranoid.
As a pediatrician, I find these numbers terrifying. While there's been limited study of these questions in the past, our clinical experience suggests that these rates are increasing, just as would be expected with ever-increasing drug exposure.
Drawing from my experience as both a researcher and a clinician, I'd like to offer the following suggestions. First off, I recommend delivering clear messages to youth that avoiding cannabis use is best for their health. The American Academy of Pediatrics and the Canadian Paediatric Society both oppose marijuana legalization, and encourage parents, health care providers, teachers, and other adults to give clear and unambiguous guidance to children.
Campaigns that educate the public in an attempt to prevent use or delay initiation could be beneficial. For example, the Truth Initiative campaign that targeted tobacco use was remarkably successful in shifting the public perception of tobacco from glamorous to repulsive. Rates of tobacco use plummeted over the past 20 years with the stigmatization of smoking. Cannabis is well known as a psychoactive substance that's particularly detrimental to developing adolescent brains. Although misconceptions that cannabis is “healthy because it's natural” or “safe because it's legal” have cultural traction, they're false. They require ongoing strong messaging of evidence to the contrary.
Age restrictions are effective at reducing youth substance use. In the U.S., the enactment of the National Minimum Drinking Age Act, which effectively raised the drinking age to 21 in all 50 states, resulted in a 16% reduction in motor vehicle accidents. This was as a direct result of lower alcohol consumption. Canada, which has a lower drinking age, also has the highest rate of problem alcohol use in the Americas. These facts support higher minimum age limits as a good public health strategy.
Innovations to cannabis-based products are public health risks, particularly for adolescents. It may be that addictive substances need completely new policy approaches. Novel regulatory schemes that control or eliminate profits, control prices, and conduct surveillance at both the individual and population level should be considered. This type of approach would be expensive and would require unprecedented collaboration between branches of government and other sectors of society. History and current evidence suggest that simply legalizing cannabis and giving free rein to the industry that it will engender would be to entrust private industry with safeguarding the health of the public, a role that industry is not well designed to handle.
Finally, we need more clinicians trained to treat adolescents with cannabis addiction. This will require financial support. With the legalization of marijuana in Canada, there will be a pressing need for health care providers specialized in youth addictions and treatment of adolescent substance use disorders. I am pleased to report that the first physician to acquire specialized training in pediatric addiction medicine in all of North America is a Canadian. They are currently training at Boston Children's Hospital. Much more support and many more funded training spots and training programs are needed.
Thank you for listening and for the opportunity to address this panel.