Counselling adolescents and parents about cannabis: A primer for health professionals

---

The Canadian Paediatric Society gives permission to print single copies of this document from our website. For permission to reprint or reproduce multiple copies, please see our copyright policy.

Both parents and adolescents are concerned with the effects and potential harms of cannabis and other psychoactive substances ^[1][2]. Many adolescents consider health professionals reliable sources of information on psychoactive substances and expect them to talk about usage or risk during health care visits ^[3]. As facilitators and knowledge brokers, health care providers (HCPs) can effectively engage with youth and families.

This practice point reviews sound, evidence-based tools to help HCPs focus their skills when addressing non-medical (recreational) cannabis use with adolescents in everyday practice. This guidance reflects best practice in adolescent health ^[4][5] as well as perspectives from Canadian and international experts on adolescent substance use ^[6][7]. This document also builds on current knowledge of harms associated with adolescent cannabis use, which are described in a Canadian Paediatric Society statement ^[8] and other resources ^[9][10]. It also advocates for a coherent, practical approach to counselling.

Why health professionals should talk about cannabis

In a recent Canadian survey, 44% of youth aged 16 to 19 reported using cannabis within the previous year ^[11], despite its potential adverse effects on brain development and mental health. Now that cannabis use has been legalized in Canada, and with various cannabinoid products and modes of delivery increasingly available, it is critical that HCPs speak to adolescent patients regularly about cannabis ^[8][12].

Current psychosocial assessment tools such as HEADSSS, SSHADESS ^[13][14], and THRxEADS ^[15] all emphasize the importance of routinely addressing psychoactive substances—including cannabis—with young people during medical visits. Unfortunately, only a limited number of clinical encounters with youth include conversations about cannabis ^[3]. Specific groups, such as adolescents with chronic medical conditions, often go completely unscreened for substance use ^[16].

The 8 As for addressing cannabis with adolescents

Although HCPs may have developed their own approaches to addressing cannabis use, the scientific literature advises using standardized instruments to address and evaluate adolescent cannabis use. As a guide, the authors have adapted a common tool used by physicians for tobacco ^[17].

The ‘8 As’ (Box 1) allow HCPs to screen for problematic cannabis use and assist in early intervention. The tool also addresses several barriers known to hinder in-clinic efforts to discuss psychoactive substance use with adolescents, such as insufficient time or lack of knowledge ^[18]. Similar stepwise approaches have gained recognition in effectively addressing substance use among youth ^[19][20].

Box 1. The 8 As for addressing cannabis use with adolescents Assure patient privacy and confidentiality Ask about cannabis use, after obtaining permission to do so Answer all patient questions, and support healthy choices Assess the impacts of cannabis use, by applying a screening tool Appraise patient willingness to change or reduce cannabis use Assist with specific goal-setting and a realistic time frame Arrange for a follow up within weeks, and regularly thereafter Acknowledge parental needs and concerns, when these arise

Assure privacy and confidentiality: Setting the stage for conversation

History-taking is pivotal when working with adolescents. However, a parent’s presence or involvement can sometimes impede an HCP’s ability to elicit information about risky behaviours, especially when parents are not comfortable with the physician speaking to their child or youth one-on-one. Advise patients and parents that at a certain point (e.g., at age 12, or possibly earlier if developmentally appropriate/relevant), they will start to meet with children alone for at least part of their appointment ^[4]. Reinforce that meeting alone with adolescents is standard of care. Adolescents need private space and have a right to confidentiality. The primary risk of not ensuring patient confidentiality and privacy is that adolescents will not feel comfortable about confiding or being upfront about their own concerns or behaviours ^[21].

Be sure to review the definition of confidentiality and how it applies in your jurisdiction. Address any concerns with the patient, and review their understanding of this important issue, clarifying if any help is required ^[4]. Let them know that you will be asking some personal questions so that you can provide the best care.

Ask about cannabis use and answer all patient questions

Ask the adolescent’s permission to discuss cannabis use and related issues, putting your query into context (Box 2). While requesting permission may seem counterintuitive, it shows respect and invites discussion. You are also letting the adolescent know that they are in control, and that your questions, even when they are personal, serve a specific purpose. For most symptoms reported frequently by youth (e.g., fatigue, sleep problems, low mood), cannabis may be a contributing cause or directly implicated (e.g., when the adolescent is using cannabis to self-medicate (Box 2)). Therefore, even if cannabis use is not the initial cause for consultation, it is a relevant concern and indicates a pertinent question in most situations.

Box 2. Discussing cannabis in different contexts During a routine visit: “To get a sense of your overall health, I will be asking questions about different areas of your life, including school, friends, and substance use. Is that ok with you?” Patient presents with specific symptoms, such as low mood or fatigue: “Before asking more questions about your (insert symptom), I may also need to ask about substance use. Is that ok with you?”

With younger adolescents, consider asking whether (and how) their peers talk about cannabis, or if their friends are “experimenting” with use. Some patients may not know what “cannabis” refers to, either because they are accustomed to more colloquial terms or words that refer to a specific product type or mode of use. It is useful to determine what kind of language the adolescent is using (Box 3). This task can be part of your first round of questioning about substance use.

The literature suggests that adolescents prefer sharing information about their use of psychoactive substances using written or computer-assisted tools as opposed to responding directly to questions from a health professional, so this may be one approach to consider ^[22]. Regardless of method, asking open-ended questions about frequency of use and dose per use rather than closed questions focused on use or abstinence is more likely to elicit helpful information and to normalize experimentation without minimizing effects ^[23]. Questionnaires such as the S2BI and the BSTAD ^[24][25] approach substance use in this way, tracking use over the previous year and including cannabis among other commonly encountered substances.

Box 3. Characterization of non-medical (recreational) cannabis use Type of cannabis product Marijuana (pot, weed, grass, buds, dope) Hashish (hash, kief) Extracts and concentrates (oils, butane hash oil (BHO), shatter, wax) Mode of use Combustion (joint, spliff, pipe, bong, hookah) Vaping Edibles (food, beverages, capsules) Frequency of use Intensity of use Quantity Money spent History of onset Context of use Alone With friends/relatives Risk-related (drug-impaired driving, sports) Motives for use Experimentation Enhancement, pleasure Social cohesion, peer-pressure Coping, self-medicating

When young patients have not yet experimented with cannabis, offer positive reinforcement (Box 4). Always ask whether they have questions about cannabis. While youth rely primarily on information online or from peers and parents, they also value health information presented clearly, factually, without bias or judgment. Uncertainty remains around many cannabis-related issues, particularly when several factors have to be taken into account. Harm reduction and promoting safer behaviours should always be at the forefront when counselling young patients. For example, regarding drug-impaired driving, it is crucial to communicate that although there is no consensus about how much cannabis can be consumed before it is unsafe to drive, or how long a driver should wait to drive after consuming cannabis, avoiding the practice at all costs may be life-saving. Alternatives for getting home safe, as a driver or as a passenger, should be explored.

Box 4. For the patient who has not used cannabis “I know you haven’t tried cannabis yet. This is a wise decision because cannabis affects how the brain develops and we know that your brain will continue developing until you are about 25 years old.” Depending on the situation, you may want to add: “I also know that you’ve struggled with depression/anxiety in the past. Using cannabis can actually make it more likely that you’ll become depressed/anxious again. We know this from studies.”

Assess the impacts of cannabis use

When adolescents report cannabis use, the next step is to screen for problematic use. Problematic use includes a broad range of situations, ranging from conflicts with peers to cannabis use disorder ^[26]. It is important to inquire about age of onset and/or frequency of use, because these indicators (i.e., using before age 14, and using at least monthly) are strongly associated with adverse health impacts. Physicians must also ask about the possible effects of cannabis use on life domains (e.g., family, social, school, work). Review indicators of impact on physical and mental health (e.g., sleep, cough, stress/anxiety, mood).

One of every six youth who experiments with cannabis will develop problematic use ^[27]. Several standardized clinical questionnaires can help identify youth who are at risk for adverse effects. Some ask directly about cannabis (e.g., The Cannabis Use Disorder Identification Test – Revised (CUDIT-R) ^[28] and the Cannabis Abuse Screening Test (CAST) ^[29]). Others, like the CRAFFT and the Severity of Dependence Scale (SDS), are framed to suit all substances ^[30][31]. Using a short questionnaire helps HCPs explore the issue efficiently, and responses can be included in the patient’s chart as an objective assessment. The most recent version of the CRAFFT, for example, consists of six questions, is available in several languages, has proven validity with adolescents, and includes vaping among the diverse modes of use ^[32]. The clear clinical thresholds specific to this questionnaire can guide subsequent discussion with patients.

Using a standardized questionnaire to assess for negative impacts on life avoids the difficulty of establishing a purely clinical diagnosis of problematic substance use ^[33]. Understanding the products that have been used, the mode and motivation for use, and the context of consumption (as shown in Box 3) can orient counselling and prompt youth to ask for guidance to prevent adverse effects. Choosing a questionnaire that also addresses other substances – particularly tobacco – appears sound, because tobacco use often co-exists with cannabis use ^[34].

Appraise patient willingness to change

When an adolescent is experiencing negative impacts from cannabis use, or when screening reveals an at-risk profile, the next step should be to appraise willingness to change. Adolescents are often most interested in their physician’s information and support when discussing current cannabis use. One study showed that regardless of whether or not primary care physicians had specialized training to deliver a brief intervention to young patients, simply having a conversation with them about substances was associated with reducing excessive use ^[35]. For example, HCPs can open the discussion with: “Some adolescents I meet have thought about cutting down on their cannabis use, because while they like the feeling the substance brings, they don’t like (…). Have you ever felt that way? Have you ever thought you might like to cut back?” Box 5 summarizes key elements ^[36] to include in subsequent discussion.

Box 5. Key elements to include when discussing cannabis use with adolescents The HCP’s office is a safe place to find factual information, answers to personal questions, and support for changes they may wish to make. The best way to prevent negative impacts that cannabis can have on health is to avoid use. Some individuals should avoid cannabis use completely (e.g., due to young age, a medical condition (specifically heart, lung, and mental health conditions and treatments), a family or past history of psychosis and depression, or pregnancy). The negative impacts of cannabis use reported most frequently by adolescents include relationship and family difficulties, respiratory symptoms, and academic challenges. One in six adolescents who experiments with cannabis goes on to misuse it, especially if they use frequently. Different modes of consumption present different risks. Because the effects of ingesting cannabis take longer to peak, inexperienced edible users may end up in the emergency department because of overdose. Vaping, once considered a safe alternative to smoking, is not without risks [36]. Safety comes first: Never consume cannabis and drive.

When an adolescent asks for help to reduce or stop using, motivational interviewing techniques ^[6] are the cornerstone therapeutic response and can be initiated immediately. Cannabis is the substance for which young people most commonly consult addiction rehabilitation centres for help ^[37]. In cases of severe dependency, rehabilitative stays can last several weeks and will integrate several therapeutic components. Unfortunately, compared with other substances, there is no clear evidence to support using medications to manage withdrawal symptoms or help adolescents with cannabis use disorder decrease use or quit ^[38][39]. Health professionals should be familiar with local support resources and treatment centres. Many treatment options for youth, both outpatient or rehabilitative, are accessed through self-referral only, underscoring the need to assess and support willingness to change. HCPs who need support managing cannabis-dependent youth should reach out to more experienced colleagues, including specialists in adolescent medicine or child and adolescent psychiatry, when available. Drug Free Kids Canada has lists of local resources and centres across Canada (see appendix).

Interventions are only effective when adolescents are willing to voluntarily address substance use and commit to therapy. An adolescent who is reluctant to envision change despite clear evidence of problematic cannabis use is challenging to manage. In this situation, consider these two approaches:

1. To envision change, a patient needs to be ready, willing, and able to do so. Short-term goals are about more than “cutting down” or quitting. Specific goal-setting should be developed based on each individual’s objectives and capacities. Start with what they identify as important (e.g., comments from parents or peers) and one change they believe is achievable (e.g., not using cannabis early in the morning). Goal-setting can also take the form of a first consultation in a specialized setting, “just to see what’s on offer.”  
2.  At some point, the HCP needs to clearly express patient-specific clinical concern and offer personalized options for improving the adolescent’s health and well-being.

By this stage of management, it is often helpful to include parents, but only after negotiating their involvement with the adolescent. A first step might be to plan a follow-up visit, with the explicit aims of obtaining more specific information, exploring options, and discussing parental involvement. Such a visit should be scheduled within the next few weeks. Some situations are urgent. For example, prompt intervention is warranted when: adolescents are younger; social services are involved; treatment is court-mandated; or when a patient’s social, family, or academic life is being significantly affected by their cannabis use.

Acknowledge parental or caregiver needs and concerns

When a parent or caregiver’s concern has initiated the consultation, they should be invited to present facts as they perceive them, with a focus on how their child’s or family’s life is being impaired. This conversation can be a springboard for subsequent one-on-one discussions with the adolescent. For example, parents could be asked: “What have you observed that makes you think your child is using cannabis? And, if you think they are using, how does this affect their behaviour at home, at school, or with friends?” Whether a medical encounter starts with or without the youth in question, the aim is to avoid confrontation and judgment. HCPs should explicitly seek and obtain the adolescent’s consent to explore what parents are worried about. “Your parents are concerned that you may be using cannabis. Do you mind if we talk about this?” may be an appropriate way to introduce the subject. The adolescent may not wish to discuss matters further, and they have the right to make that choice. Usually, however, after hearing a parent’s or HCP’s specific health care concerns, adolescents are willing to discuss cannabis use, if only to reassure their parents. Some parents may wish to meet alone with their HCP, in which case the clinician can coach them on how to express concerns to their child in a non-judgmental manner.

Sometimes, parental expectations of the physician’s role need to be reframed. Some experimentation with substance use is common for many youth, and occasional cannabis use is often a transient behaviour ^[40]. This message can be reassuring for some parents. Parents should also be aware that their own behaviours related to cannabis or other substances may affect their adolescent’s behaviour and perception of harms ^[41]. There are useful resources for parents and HCPs on how to approach the topic of cannabis with adolescents (see Appendix).

Conclusion

Adolescents frequently use cannabis, which can have many potential adverse effects on both mental and physical health. The HCP’s approach when addressing adolescent cannabis use should be non-judgmental, factual, and – if problematic use is identified – to initiate a mutually agreed-upon therapeutic plan. Evidence suggests that screening for cannabis use with validated tools is the most efficacious method of identifying youth who require intervention. Resources to help parents and additional avenues for HCPs are in the Appendix. Harm reduction and enabling motivation for change are therapeutic cornerstones when assisting youth to overcome problematic cannabis use.

Acknowledgements

This practice point was reviewed by the Adolescent Health, Community Paediatrics, and Mental Health and Developmental Disabilities Committees of the Canadian Paediatric Society. Special thanks to our colleagues from the Canadian Paediatric Society Cannabis Project Advisory Group, as well as to Francine Charbonneau, Elizabeth Moreau, and Jennie Strickland for their invaluable counsel at diverse stages of the manuscript writing.

Funding: Production of this document has been made possible through a financial contribution from Health Canada. The views expressed herein do not necessarily represent the views of Health Canada.

Potential Conflicts of Interest: Both authors received an honorarium from the Canadian Paediatric Society for their work on the Cannabis Project Advisory Group, which included drafting this practice point. Outside the submitted work, CNG also reports receiving speaker fees from Purdue/Shire, University of Alberta, Queen's University, the Canadian Paediatric Society and the Canadian Association of Paediatric Health Centres. There are no other disclosures. All authors have submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Conflicts that the editors consider relevant to the content of the manuscript have been disclosed.

---

CANADIAN PAEDIATRIC SOCIETY CANNABIS PROJECT ADVISORY GROUP

Members: Richard E Bélanger MD (co-Chair), Christina N Grant MD (co-Chair), Michael Hill MD, Ellie Vyver MD, Robert Milin MD (Canadian Academy of Child and Adolescent Psychiatry), Pierre-Paul Tellier MD (College of Family Physicians of Canada)

Principal authors: Richard E Bélanger MD, Christina N Grant MD

---

Appendix

RESOURCES FOR HEALTH CARE PROVIDERS

Cannabis and Canada’s Children and Youth 
Canadian Paediatric Society
This 2017 position statement discusses health impacts of non-medical (recreational) cannabis use and provides recommendations to protect children and adolescents from the harms associated with recreational cannabis use and dependence.
www.cps.ca/en/documents/position/cannabis-children-and-youth

Talking Pot with Youth – A Cannabis Communication Guide for Youth Allies
Canadian Centre on Substance Use and Addiction
https://www.ccsa.ca/talking-pot-youth-cannabis-communication-guide-youth-allies

Counseling Parents and Teens About Marijuana Use in the Era of Legalization of Marijuana
American Academy of Pediatrics
A concise, well-referenced clinical report covering the paediatrician’s role in medical and non-medical cannabis counselling.  
https://pediatrics.aappublications.org/content/pediatrics/139/3/e20164069.full.pdf

Canada’s Lower-Risk Cannabis Use Guidelines
Canadian Research Initiative in Substance Misuse (CRISM)
Provides 10 recommendations for ways to use cannabis more safely.
https://www.camh.ca/-/media/files/pdfs---reports-and-books---research/canadas-lower-risk-guidelines-cannabis-pdf.pdf

Non-Medical Cannabis Resource (for providers)
Centre for Effective Practice
Helps primary care providers discuss non-medical cannabis with patients. Includes sections on screening, potential harms, and tips for harm reduction.
https://cep.health/media/uploaded/CEP_Non-Medical_Cannabis_Resource_2018.pdf

The Health Effects of Cannabis and Cannabinoids: The Current State of Evidence and Recommendations for Research
National Academies of Science, Engineering and Medicine (U.S.)
Not specific to adolescents and children, but information is broadly insightful.
https://www.ncbi.nlm.nih.gov/books/NBK423845/

Resources in your region
Drug Free Kids Canada
https://www.drugfreekidscanada.org/treatment-recovery/get-help-in-your-region/

RESOURCES FOR PARENTS

Cannabis: What parents need to know
Canadian Paediatric Society
www.caringforkids.cps.ca/handouts/marijuana-what-parents-need-to-know

Cannabis Talk-Kit: Know How to Talk With Your Teen
Drug Free Kids Canada
https://www.drugfreekidscanada.org/wp-content/uploads/pdf/Cannabis-Talk-Kit_EN.pdf

Cannabis Products, Including Edibles
Drug Free Kids Canada
https://www.drugfreekidscanada.org/wp-content/uploads/2020/01/DFK_Info_Cannabis_FINAL.pdf   

Cannabis: What Parents/Guardians and Caregivers Need to Know
School Mental Health Ontario/The Centre for Addiction and Mental Health
https://smho-smso.ca/wp-content/uploads/2019/08/Cannabis-Parent-Infosheet.pdf

Cannabis Use and Youth: A parent’s guide
B.C. Partners for Mental Health and Substance Use Information
Covers terminology, potential harms, common claims, and ways to interact with youth.
www.heretohelp.bc.ca/workbook/cannabis-use-and-youth-a-parents-guide

Do You Speak Cannabis?
Government of Quebec
Information and talking points to allow parents to broach the subject of cannabis with their child.
https://publications.msss.gouv.qc.ca/msss/fichiers/2018/18-236-06A.pdf

Thinking about using cannabis while parenting?
Health Canada
www.canada.ca/en/health-canada/services/drugs-medication/cannabis/health-effects/parents.html

Marijuana: Facts Parents Need to Know
National Institute on Drug Abuse (U.S.)
https://d14rmgtrwzf5a.cloudfront.net/sites/default/files/mj_parents_facts_brochure.pdf

RESOURCES TO SHARE WITH ADOLESCENTS

Cannabis: Important things to know
Kids Help Phone
https://kidshelpphone.ca/get-info/cannabis-important-things-know/

The Blunt Truth: Useful tips about safer ways to use cannabis
Canadian Research Initiative in Substance Misuse, CAMH
http://crismontario.ca/Pages/LRCUG.YouthBrochure.English.Final.pdf

Cannabis: Inhalation vs Ingestion - What happens in the body?
Drug Free Kids Canada
https://www.drugfreekidscanada.org/wp-content/uploads/2020/02/DFK_Cannabis_1Pg_FINAL.pdf

Learn about cannabis
First Nations Health Authority
https://www.fnha.ca/what-we-do/mental-wellness-and-substance-use/non-medical-cannabis-information

---

References

---

Disclaimer: The recommendations in this position statement do not indicate an exclusive course of treatment or procedure to be followed. Variations, taking into account individual circumstances, may be appropriate. Internet addresses are current at time of publication.