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Wednesday, August 11, 2021

ARNALDO CRUZ IGARTUA, MD Specialist in General Psychiatry

and Addictions

MARITZA SALCEDO, MD Specialist in Pediatrics; Addiction Medicine Fellow


Substance use disorders represent a serious public health problem throughout the world. The effects on the life of an individual with a substance use disorder without scientific prevention or treatment can be catastrophic and irreversible, both in the area of ​​physical and mental health, as well as in the social and spiritual areas.

The abuse of tobacco, alcohol and illicit drugs represents an annual cost in the United States of about 740 billion dollars, mostly related to the loss of labor productivity, medical services, and crime. It also has indirect costs: it is estimated that for each person with addictions and without adequate treatment, 3-4 family members are usually negatively affected. The risk of developing an addiction in adolescence is much higher than in adulthood because brain maturation is still incomplete. 74% of people between the ages of 18 and 30 in substance use disorder treatment programs started using substances on or before the age of 17.

Adolescence (12-17 years) and young adulthood (18-21) are periods of great vulnerability as the areas of the brain that govern judgment and impulse control are still under development. Exposure of the brain to substances at this stage can negatively affect decision-making and impulsivity. At these ages, the development of other mental disorders and cognitive impairment could also be triggered. Under the influence of substances, adolescents are at greater risk of engaging in dangerous behaviors such as driving under the influence of substances, risky sexual behaviors (including sexually transmitted diseases), suicide, delinquency, school dropouts, addictions, and even death.


Statistical reports from NIDA (National Institute on Drug Abuse) of the prevalence of substance use in 2019 in adolescents in the 4th year of high school, shows the following percentages of use (in the previous 30 days): 31% electronic cigarettes, 29% alcohol, 24% illicit substances, 22% marijuana, 6% cigarettes, 4% prescription drugs.2 Marijuana was the most widely used illicit substance (35.7%) and its daily use increased significantly in 8th and 10th-grade students.

In the survey (Youth Consultation) - carried out in Puerto Rico in the period 2015-2017 by the Administration of Mental Health and Anti-Addiction Services (ASSMCA) and Carlos Albizu University to students aged 10 to 19 from public and private schools -, it was found that in adolescents between grades 7 and 12, the most used substances at some time in life were alcohol (44.5%), marijuana (12.1%) and tobacco (8.9%). 15.7% of the students reported having used some other substance at some point in their life; the most commonly reported were synthetic cannabinoids (5.0%; misnamed “synthetic marijuana”), non-prescription pills (4.2%), and inhalants (3.9%). This is the first time since 1990 that smoked marijuana ranks second among the most used substances in these consultations.


Alcohol is the substance most abused by adolescents; In Puerto Rico, its use is not legal in adolescents, but in adults over 18 years of age (in the United States the minimum age is 21 years). Alcohol works by depressing the central nervous system, initially producing euphoria and excitement followed by depression and sleepiness, which can progress to coma and death. 15.2% of people who start drinking at age 14 may develop alcohol abuse or dependence, compared with 2.1% for those who wait until age 21.21 Untreated alcoholism is an often progressive and fatal chronic disease with a genetic predisposition in 50% of cases. Of the substances of abuse, alcohol is the most harmful to the fetus, with fetal alcohol syndrome being the most common cause of preventable mental disability.

When alcohol is mixed with marijuana, the risk of a car accident is greater and when it is mixed with cocaine it increases the risk of arrhythmias, which can be fatal. Since 1988, the minimum age for drinking alcohol has been 21 years in the United States and, today, in Puerto Rico it is 18 years.

In the United States, the percentage of fatal automobile accidents between the ages of 16 and 20 due to alcohol use decreased from 61% in 1982 to 31% in 1995, showing a very clear cause and effect relationship between the minimum age for drinking alcohol and fatal car accidents.27


In Puerto Rico, there is great misinformation regarding marijuana, including its long-term negative effects, its real composition, and the possible therapeutic effects of some d

e its processed derivatives.

First, the terms "medical marijuana", "medical cannabis" or "recreational cannabis" are not scientific, but legal and industrial expressions to market their products. This commercialization allowed by law carries the wrong message to children and adolescents, leading them to think that marijuana is harmless or medicine, or a means of recreation, which is known as “normalization”.3 The perception of harm associated with its use of Marijuana among high school students has steadily declined in the United States between 2007 and 2018, from 54.8% to 26.7%, (NIDA;

Marijuana is the common term for the dried cannabis Sativa plant that contains 525 known components. When it is exposed to heat (more than 200º F), it changes chemically and produces 4 types of addictive substances (9THC, 8THC, CVN, THCV). This decarboxylation makes it an addictive polysubstance that contains about 110 phytocannabinoids and about 150 terpenes. Tetrahydrocannabinol (THC) is one of the best-known addictive substances, responsible for psychoactive effects such as palpitations, red eyes, euphoria, poor judgment, incoordination, anxiety, and hallucinogenic effects.

Cannabidiol (CBD, which is not cannabis or marijuana) is a decarboxylated phytocannabinoid to which some therapeutic effects such as analgesic, anticonvulsant or antiemetic have been attributed. CBD is a component for the production of which the plant is subjected to a standardized scientific process of heat and purification where this component is extracted, isolating it from THC and other toxic substances.

Raw-dried marijuana to be smoked (or inhaled by evaporation), whether sold on the street or in a dispensary, is not medicine but a toxic polysubstance not only for the uncertain content of 4 addictive variants of THC but also for more than 4000 toxic substances produced by combustion.4,5,6 On the other hand, the lack of standardization for the production of CBD products makes it impossible to know their purity, the precise doses, and how safe it is to use them, thus preventing their medical use.

Unlike commercial CBD, the FDA-approved cannabidiol product (Epidiolex) is standardized and indicated for specific cases of epilepsy, such as Dravets syndrome. Unlike CBD that is sold without a prescription, the quality, purity, and dosage of this product is scientific and precise, using oral doses standardized by weight of the patient. Its possible adverse effects (such as liver irritation) are scientifically known as well as the laboratory tests indicated to prevent them.

When marijuana is smoked, it generates about 4,000 substances, of which about 20 have been identified as carcinogens. When it is vaporized and inhaled, it generates more than 100 substances, some of them irritating to the respiratory system. Tobacco smoke and marijuana smoke have been found to contain similar toxic and carcinogenic substances.7

Some of the possible negative effects related to the use of smoked or inhaled marijuana described in the scientific literature are: Substance use disorder, depression, anxiety, violence, psychosis, decreased cognitive ability, low learning level, and cancer of the lung. 8-14

The negative effects of marijuana on a teenager can originate from the womb. There is scientific evidence associating the use of cannabis during pregnancy with low birth weight and long-term neurological problems.17 THC is excreted in human milk and studies in animals suggest that exposure to cannabinoids through breastfeeding has sequelae in neurodevelopment similar to in utero exposure.18 The use of smoked cannabis affects a mother's ability to care for a baby and increases the risk of neglect, the type of abuse that causes the most deaths. Some of the effects on neurodevelopment in babies exposed to cannabinoids during pregnancy have been identified in the medical literature: aggressiveness and attention problems as early as 18 months of age, and difficulty with verbal and visual reasoning in preschool age. 19-20

Since the legalization of marijuana in the state of Colorado, there has been a 65% increase in its use among young people (National Survey on Drug Use and Health, 2006-2017). The percentage of adolescent suicide victims who tested positive for marijuana increased (Colorado Department of Public Health & Environment; CDPHE, 2017). As the legalization of marijuana use in Colorado progressed to full legalization in 2012, deaths from opioid use increased from 110 deaths in 2000 to 536 in 2017 (CDPHE).

Tobacco and Vaporizers

The psychoactive substance that forms a habit in tobacco is nicotine. This acts in the brain as a stimulant increasing alertness, l

attention, and decreasing appetite. Its use in adolescents can increase the effects of gratification and addiction to other drugs, making it a potential contributor to other substance use disorders.

Smoking is one of the significantly more preventable causes of death and disability. In 2000, there were an estimated 4.83 million premature deaths globally attributable to smoking. The leading causes of death were cardiovascular disease, chronic obstructive pulmonary disease, and lung cancer.22 Half of new smokers in 2013 started smoking before age 18 (2013 National Survey on Drug and Health). Studies have shown that starting smoking on or before the age of 17 increases the risk of mortality.23 Cigarette use has been declining due to new options for the use of nicotine such as electronic cigarettes (known as vaping) and an inhaler device known as hookah.

The prevalence of cigarette use in 4th-year students in the United States in 2019 was 6% compared to 31% for any type of vaporizer and 22% for marijuana.2 E-cigarettes are devices that produce an aerosol when heating a liquid that usually contains nicotine, flavors, and other harmful ingredients such as ultrafine particles (diacetyl benzene, a chemical associated with serious lung disease and past metals).24 More than 85% of users of flavored e-cigarettes are in the ages 12-17.24 These devices can also be used to inhale marijuana and other illicit substances.

Currently, in the United States, there is an alarming increase in lung damage and deaths among users of electronic vaporizers/inhalers (“vaping”). More than 77% of the people in this crisis reported having used products containing THC with or without nicotine, 36% THC alone, and 16% nicotine exclusively.25 As of February 2020, 2,807 cases of patients hospitalized for lung damage were reported to cause vaping in the United States and its territories, and 68 confirmed deaths in 29 states.26 The CDC does not recommend the use of vaping products, especially those with THC.

Early Detection Tools for Teen Substance Use

Due to the great vulnerability of adolescents and the new wave of “medical marijuana” propaganda in Puerto Rico, today more than ever the early identification of substance use in children and adolescents is important. In all the states of the United States, it is mandatory to provide all Medicaid participating children with screening for physical and mental illnesses, including substance use (Early Periodic Screening, Diagnosis, and Treatment; EPSDT). The American Academy of Pediatrics, the World Health Organization, and the National Institute of Health, among others, recommend tools for early detection of substance use in adolescents.

There are several validated tools for the early detection of substances in adolescents, quick and easy to administer that can be used both in medical offices and in emergency rooms: CRAFFT + N2.1 or S2BI, among others (APA NIDA Modified ASSIST Levels 1-2; STAD; PHQ-2 / PHQ-3; PHQ-9A; C-SSRS).

The CRAFFT + N2.1 tool is the most popular for ages 12-26 and is recommended by the American Academy of Pediatrics. This can be administered by electronic questionnaire, on paper, or by interview. It has two parts, the first (part A) consists of 4 questions to determine any use of alcohol, tobacco, and drugs in the last 12 months; Part B has 6 questions about drug and alcohol experiences. The other tool, S2BI (Screening to Brief Intervention), is new, it is validated for adolescents aged 12 to 17 and consists of a single question to identify the frequency of use of tobacco, alcohol, marijuana, controlled medications, illicit drugs, and inhalants. It can be administered by electronic questionnaire, on paper, and by interview. Both are available in Spanish and are free.


In summary; The following measures may help in early detection and intervention for substance use in adolescents and young adults:

-Increase education about substance use for adolescents, parents, and health professionals;

-Increase the offer of prevention and early detection programs for substance use in adolescents and young adults, based on scientific evidence;

-Legislation should be made to increase the age of alcohol consumption from 18 years to 21 years and to prohibit all propaganda/standardization of addictive substances;

-Develop evidence-based interdisciplinary programs to treat substance use disorders (accessible to community physicians);

-Clarification of scientific terms by the medical community and promotion of their correct use.


  1. US HHS, The Surgeon General’s Report on Alcohol, Drugs, and Health. Washington, DC: HHS, Nov 2016.

  2. NIDA. (2019, December 18). Monitoring the Future.

  3. Cruz Igartua A. Cannabis or experimental cannabinoids? Galenus, PR (54), Oct 2015: p.33-34.

  4. Crotenhermen F, Russo E. Cannabis and Cannabinoids, Pharmacology, Toxicology, and Therapeutic Potential. 2002.

  5. The Health Effects of Cannabis and Cannabinoids: The Current State of Evidence and Recommendations for Research. 2017.

  6. NIH and National Institute on Drug Abuse (NIDA). Drug Facts: Marijuana. Revised September 2015.

  7. Moir D, et al. A Comparison of Mainstream and Sidestream Marijuana and Tobacco Cigarette Smoke Produced under Two Machine Smoking Conditions.

  8. The Health Effects of Cannabis and Cannabinoids: The Current State of Evidence and Recommendations for Research, 2017.

  9. Forbes E, et al. Pattern of marijuana use during adolescence may impact psychosocial outcomes in adulthood. J Addiction, 2017.

  10. Ran S, et al. The association between cannabis use and depression. Psychological Medicine. June 2013.

  11. Centennial Institute epidemiologic study; Colorado 2017.

  12. Mammen G, et al. Clin Psychiatry 79:4, July/Aug 2018.

  13. Dugre JR, et al. Persistency of Cannabis Use Predicts Violence Following Acute Psychiatric Discharge, Front. Psychiatry; 2017.

  14. Aldington S, et al. Cannabis Use and Risk of Lung Cancer: a Case Control Study. Eur Respir J. 2008 February.

  15. Cruz Igartua A. Smoked or vaporized dried cannabis. Cannabis-Cannabinoids: Synonyms. Personal Health. Public Health. 2020.

  16. The ASAM Principles of Addiction Medicine 6Th edition.

  17. Porath AJ, et al. Maternal cannabis uses during pregnancy. Ottawa, Canadian Centre on Substance Use and Addiction; 2018.

  18. Fried PA. The Ottawa Prenatal Prospective Study (OPPS). Life Sciences 1995;56(23-24):2159-68.

  19. Huizink AC. Prenatal cannabis exposure and infant outcomes: an overview of studies. Prog Neuropsychopharmacol Biol Psychiatry 2014; 52:45-52. Epub, 2013 Sep 27.

  20. El Marroun H, et al. Intrauterine cannabis exposure leads to more aggressive behavior and attention problems in 18-month-old girls. Drug Alcohol Depend 2011;118(2-3):470-4.

  21. National Institute on Drug Abuse. Principles of Adolescent Substance Use Disorder Treatment: A Research-Based Guide.

  22. Ezzati M, Lopez AD. Estimates of global mortality attributable to smoking in 2000. Lancet 2003; 362:847-52.

  23. Kenfield SA, et al. Smoking and smoking cessation in relation to mortality in women. JAMA 2008; 299:2037-47.

  24. E-Cigarette Use Among Youth and Young Adults. A Report of the Surgeon General. U.S. Department of Health and Human Services.

  25. THC Products May Play a Role in Outbreak of Lung Injury Associated with E-cigarette Use, or Vaping. CDC. September 2019.

  26. Outbreak of Lung Injury Associated with the Use of E-Cigarette, or Vaping Products. CDC.February 25, 2020.

  27. McCartt AT, Hellinga LA, Kirley BB. The effects of minimum legal drinking age 21 laws on alcohol-related driving in the United States. J Safety Res. 2010 Apr;41(2):173-81.

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