1. Marijuana and the Teen Brain: What parents need to know Leslie Green, LICSW Clinical Social Worker Shannon Mountain-Ray, LICSW Clinical Director of Social Work Adolescent Substance Abuse Program (ASAP) Division of Developmental Medicine Boston Children’s Hospital

2. Objectives Recent findings from MWHS Describe adolescent brain development Explain why we call addiction a “brain disease” Present the impact of marijuana use on the developing adolescent brain and other risks associated with adolescent marijuana use

8. 8 Source: US News & World Report, 2005 The Teen Brain What is going on in there?

9. 9 Adolescence is a critical period in brain development. The brain is still developing until approximately age 24 or 25 What We Now Know Slide courtesy of Ken Winters, PhD.

10. Critical Period Is a “window” in brain development when a part of the brain: develops rapidly is highly sensitive to being shaped by environmental experiences 10

11. Brain cells (Neurons)

12. 12 BLOSSOMING : Until about ages 10-12, the brain undergoes rapid growth, including: Neuron numbers increasing Neurons getting bushier Neuron connections increasing Construction Ahead Slide courtesy of Ken Winters, PhD.

13. 13

14. 14 Around age 12, neuronal growth starts to undergo pruning, following the principle of “use it or lose it.” Construction Ahead Slide courtesy of Ken Winters, PhD.

16. 16 Construction Ahead Slide courtesy of Ken Winters, PhD. Along with pruning, myelin starts to cover axons and then thicken. The myelin sheaths help action potential travel 100 times faster.

17. 17 The Brain’s Info Superhighway: Myelinated axons = White Matter Tracts Source: Gordon J. Harris, PhD.

18. 18 Result of Pruning and Myelination: Fewer but faster connections in the brain. Construction Ahead Slide courtesy of Ken Winters, PhD.

19. 19 Parietal Lobe Frontal Lobe Occipital Lobe Cerebellum Temporal Lobe Brain Stem BackFront How the Brain Develops Prefrontal Cortex Nucleus Accumbens Amygdala Hippocampus

20. Prefrontal Cortex (matures late adolescence or early adulthood) Impulse control Decision-making Organizing and planning Abstract thought, rational thinking Attention, focus Working memory Brain Maturation Nucleus Accumbens (highly active in adolescence) Pleasure center Active during pleasurable activities, including feeding, sex, and drug use Plays a major role in addiction

21. Addiction is a Brain Disease

22. The Reward Pathway Ventral-Tegmental Area Source: NIDA

23. The Common Pathway to Pleasure Dopamine, a neurotransmitter, works in the pleasure center in the middle of your brain. Once you’ve had a “feel good” experience, your brain builds new paths or a shortcut.

24. marijuana

25. Key Points 1.Adolescence is an important “window” of opportunity and sensitivity for the brain, particularly for developing brain connectivity. 2.How the brain is used during adolescence, and what it is exposed to, will have life-long effects.

26. Key Points 3. Due to the stage of brain development in adolescence, teens are more susceptible to the addictive effects of substance use.

27. 27 Marijuana and the Teen Brain

28. 28 What is in Marijuana? Contains many cannabinoid chemicals: delta-9-tetrahydrocannabinol (THC) delta-8-tetrahydrocannabinol cannabidiol cannabinol cannabichromene cannabigerol Etc. Source: Mechoulam R, Hanus L, The cannabinoid system from the point of view of a chemist. In Marijuana and Madness. ed. Castle, Murray. Cambridge University Press, 2004

29. The Brain’s “Endocannabinoid” System “Endo” means “within”

30. Endocannabionoid System Functions The neuron’s “volume control” system: dials down neuron activity when too strong Regulates levels of neurotransmitters that affect pleasure, mood, pain, appetite, motivation, memory (e.g., dopamine, glutamate, endorphins, serotonin, GABA)

31. Source: NIDA

32. With Marijuana: With Anadamide: Dopamine release

33. THC vs. Anandamide Both dial down neuron activity to change neurotransmitter release THC has a MUCH STRONGER, LONGER effect than anandamide on brain cells THC interferes with cell function and growth

34. 34 THC Binding Sites Source: NIDA Front Back

35. Marijuana Effects on Teen Memory and Thinking

36. Hippocampus

37. Source: Meier et al. Proceedings of the National Academy of Sciences. 2012. Available at: www.pnas.org/cgi/doi/10.1073/pnas.1206820109 Marijuana Use and Change in IQ

38. The Dunedin Study (New Zealand) (N=1,037) 1 2 3 4 5 Assessment ages 13 yrs (Pre-initiation) 18 yrs21 yrs32 yrs38 yrs Source: Meier et al. PNAS, 2012

39. Never used marijuana Used marijuana 3+ years Average IQ at Ages 13 to 38 by Marijuana Use

40. Never used marijuana Used marijuana 3+ years

41. Source: Lynskey et al. Addiction, 2003. Marijuana Use and School Drop-out

42. Increased Odds of Dropping Out of HS by Age of Starting Weekly MJ Use

43. Marijuana and Mental Illness

44. 44 Studies show regular marijuana use during adolescence risk 2 to 7 times of developing psychosis, schizophrenia, anxiety, and depression. Source: Malone DT et al. Adolescent cannabis use and psychosis: epidemiology and neurodevelopmental models. Brit J Pharmacol. 2010;160:511-522

45. 45 The Brain’s Info Superhighway: Myelinated axons = White Matter Tracts Source: Gordon J. Harris, PhD.

46. Similar altered white matter structure found in the brains of people dx with schizophrenia and teen marijuana users Bava S, Frank LR, McQueeny T, Schweinsburg BC, Schweinsburg AD, Tapert SF. Altered white matter microstructure in adolescent substance users. Psychiatry Research Neuroimaging. 2009;173:228-237.

47. Corpus callosum damage in daily marijuana users Source: Arnone D, Barrick TR, Chengappa S et al. Corpus callosum damage in heavy marijuana use: Preliminary evidence from diffusion tensor tractography and tract-based spatial statistics. NeuroImage, 2008; 41:1067-1074 Non-user Daily user

48. STUDIESCognitiveBrain StructureBrain Function Effects Meier et al., 2012  IQ Pope et al., 2003  IQ Ehrenreich et al., 1999  attention Huestegge et al., 2002  visual search Fontes et al., 2011  executive functioning Solowij et al., 2012  executive functioning Churchwell et al., 2010  prefrontal cortex volume Gruber et al., 2011  impulsivity  white matter integrity in prefrontal cortex Lopez-Larson et al., 2011  prefrontal cortex thickness Wilson et al., 2000  total gray matter, Becker et al., 2010a  prefrontal cortex activity during working memory task Gruber et al., 2012  anterior cingulate activity during inhibition task Jager et al., 2010  prefrontal cortex activity during in working memory

49. Marijuana and Driving

50. Brain regions affected by THC Source: NIDA

51. Marijuana and Driving Studies of performance show that THC impairs attention, working memory, coordination, reaction time, and visual perception Source: Castle D, Solowij N. Acute and subacute psychomimetic effects of cannabis in humans. In: Castle D, Murray R, eds. Marijuana and Madness. Cambridge, UK: Cambridge University Press; 2004:41-53.

52. What else is affected by marijuana?

53. Reproductive/Growth Hormones Marijuana affects glands, organs and hormones involved in overall growth, pubertal development, and energy levels Source: Wenger T, Croix D, Tramu G. The effect of chronic prepubertal administration of marijuana (delta-9-tetrahydrocannabinol) on the onset of puberty and the post-pubertal reproductive functions in female rats. Biology of Reproduction. 1988;39:540-545. Can lower fertility of males and females through lowered sperm count and egg damage Increases risk for testicular cancer

54. Avg. % THC Content among Confiscated Cannabis Products in U.S. (1993-2012)* *Source: ElSohly MA. Potency Monitoring Project Quarterly Report #123. U of Mississippi, 2014 <4% 14%

55. THC Content Increase = > Increase in Adverse Effects: Paranoia Anxiety and panic Hallucinations Hyperemesis Erratic mood swings Aggressive behavior Source: National Drug Abuse Warning Network, 2011

56. First death in Colorado after legalized recreational marijuana 19 year-old Levy Thamba-Pongi, college student visiting on Spring Break Died March 11, 2014 Jumped out 4 th floor hotel window after eating cookie with 65 mg of THC

57. Perceived Risk of Harm and Marijuana Use, U.S. 12 th graders: 1975-2011 39.5 % 22.7% Source: National Monitoring the Future Survey, 2013 Perceived risk is at a nearly historic low!

58. Percent of 12 th Graders Reporting Using Substance in Lifetime, 2000-2013 Marijuana Source: National Monitoring the Future Survey, 2013

59. Source: http://www.governing.com/gov- data/safety-justice/state-marijuana-laws-map- medical-recreational.html Marijuana Legalization (2014) (18 states) (2)

60. Percent Using Marijuana in Past Month, Ages 12-17, by State States with Legalized Marijuana Source: National Survey on Drug Use and Health, 2010-2011

61. 61 Take-Home Points 1.The teen years are a time of tremendous opportunity and risk for the brain 2.The endocannabinoid system is important for maintaining brain health and proper development, and THC interferes with its proper functioning! 3.Regular marijuana use in adolescence may have lasting effects on memory and IQ

62. 62 Take-Home Points 4. Today’s marijuana is a much more potent than 20 years ago 5. Marijuana use increases risk for car crashes 6. The risk of serious mental illness is 2-7 times greater for those starting marijuana use during adolescence 7. It is not safe in any capacity – out of the home, in the home, etc.

63. © Boston Children’s Hospital 2012. All Rights Reserved. For permissions contact SBIRT project manager at www.CeASAR.org. Thank you Funding provided by the American Medical Foundation Healthy Living Grants Program

64. Acknowledgements John Knight Sharon Levy Ximena Sanchez- Samper Patricia Schram Miriam Schizer Wesley Boyd Susan Kiley Shari VanHook Leslie Green Julie Hansen Lon Sherritt Marianne Pugatch Celeste Wilson Roman Pavlyuk Sion Harris Rosemary Zeimnik

65. Q & A