Baking Young Minds: Scientific Concerns for Cannabis on Kids

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Joe Selvaggi talks with professor of psychiatry Dr. Ryan Sultan about the findings of his recently released study on the effects of cannabis on the mental health of American adolescents. Dr. Sultan’s work shows a substantial correlation between cannabis use and negative mental health outcomes.


Dr. Ryan S. Sultan is an Assistant Professor of Clinical Psychiatry in the Department of Psychiatry at Columbia University Irving Medical Center/New York State Psychiatric Institute. Dr. Sultan is an expert in the areas of ADHD and cannabis use. His research focuses on the interface of electronic databases, epidemiology, and evidence-based treatments with common psychiatric disorders. Currently, he is using big data to investigate cannabis and other substance use in teens. His past research includes antipsychotic treatment of ADHD and psychopharmacology trends in youth. His work has been published in academic journals and presented nationally and internationally.

Dr. Sultan completed his training as a physician at Emory School of Medicine, New York-Presbyterian Weill Cornell Medical College, and the Columbia University Irving Medical Center. Dr. Sultan has been featured in Time Magazine and on NPR’s Morning Edition. Dr. Sultan is also director of Integrative Psych, providing individualized evaluation and ongoing treatment for adults, youths and families. He specializes in psychotherapy and psychopharmacology for individuals with ADHD and substance use.

This is Hubwonk. I’m Joe Selvaggi. Welcome to Hubwonk, a podcast of Pioneer Institute, a think tank in Boston. A century after becoming the first U.S. state to criminalize recreational cannabis, Massachusetts voters chose to legalize it in a 2016 referendum. This decision, now joined by 20 other states, has evolved on a backdrop of a societal view that casual cannabis use is benign and poses no risk. In this light, the cannabis industry has harnessed its new legitimacy to better refine and market ever more potent versions of cannabis, offering modern consumers options for smoking, vaping, and eating. But while adult users seem inured to the effects of getting high on cannabis, little is known about the effects of cannabis on developing minds, those of adolescents who may perceive the new ubiquity of cannabis as tacit approval for its use. But can cannabis harm kids? Despite the paucity of research on cannabis effects on adolescents, new studies on the risks to kids suggest a strong correlation between use and serious psychiatric disorders, along with a raft of risks for poor long-term life outcomes. How large are the risks for teen cannabis use? And how might policymakers and cannabis industry leaders work together to craft better guidance and regulations that protect potential young users, particularly as newer, more potent versions of the drug emerge? My guest today is Dr. Ryan Sultan, assistant professor of clinical psychiatry at Columbia University and coauthor of the recently released study entitled Non-Disordered Cannabis Use Among U.S. Adolescents, which studied nearly 70,000 teenage Americans to measure the correlation between cannabis use and adverse mental health outcomes. The study found that teens who use cannabis recreationally were at risk for poor grades, truancy, and trouble with the law, and were two to four times as likely to develop psychiatric disorders such as depression or suicidal ideation than teens who didn’t use cannabis at all. Dr. Sultan was shared the details of his study and discussed his views on ways in which society and public health leadership can use the study’s observations to better craft cannabis regulation to reduce the risk of cannabis use to vulnerable, maturing adolescent minds. When I return, I’ll be joined by Columbia professor and psychiatrist, Dr. Ryan Sultan. Okay, we’re back. This is Hubwonk. I’m Joe Selvaggi. I’m now pleased to be joined by Columbia University assistant professor of clinical psychiatry, psychiatrist Dr. Sultan. Welcome to Hubwonk, Dr. Sultan.

Dr. Ryan Sultan: Happy to be here.

Joe: All right, I’m pleased to have you join me to talk about a topic about which there’s a great deal of opinion, but in my view, very little factual understanding, and that we’re going to talk about the effects of marijuana on the human mind, particularly amongst young minds, adolescents whose brains are still developing. But before we discuss the findings of your recent paper, I want our listeners to know something about your expertise in your clinic. You’re professor of psychiatry at Columbia. What do you teach? And then I’d like to hear a little bit about your practice. I teach a psychotherapy course. I also teach a number of young mental health practitioners in our residency program as they move through and supervise them. I concentrate a lot on addiction, social media, and ADHD in my research and in my clinical practice.

Joe: And so, you have a clinical practice in New York City, I think it’s called integrative psychiatry. What’s the focus of that particular practice? If you want to make a plug for our listeners?

Ryan: Yeah, we do. We have a wonderful practice with a number of clinicians down here.

One of the reasons that I call that integrative is that for many years, the world of mental health exists in these silos. And each silo thinks that they have the kind of best treatment for something and the only treatment for something. And in reality, when you look at the scientific evidence, the best way to treat people is combination treatments, where you kind of hit it with a multi-pronged approach. So, we really concentrate on looking at what we know from our experience and the scientific evidence to create an action-packed, multi-pronged approach that really maximizes how quickly people get better, how much they get better, and how long they stay better.

Joe: Worthy goals. Now, we’re going to be talking about your study about the effects of cannabis on young minds. Before we go into the details of this study, what made you focus on this? Again, your specialty is mental health, particularly amongst adolescents. What made you focus on the use of cannabis in your time?

Ryan: During the pandemic, I, like most of us, had a lot of time to think. And as we were coming out of the pandemic, particularly in New York, I was really struck by the frequency with which I saw people getting high on the street with marijuana. And then how often I was seeing young minds, teenagers doing that. And particularly in the morning, I would go for a run, I’d be walking my dog, and it would be 7:30 in the morning, 8 o’clock in the morning, and there would be these kids getting high before they go to school on a weekday. And I would go and talk to them sometimes. And I just found it very disturbing, because at a minimum, before I even did the study, at a minimum, going to school high, just like you wouldn’t go to school drunk, you just can’t imagine that these young minds are really learning very much.

Joe: Indeed. Now, we’ve seen a lot of changes in attitudes and in laws about the use of cannabis. A lot of cities and states have effectively decriminalized the possession and use of cannabis. I think, you know, I don’t know what’s cause and what’s effect, but it seems to be the received wisdom of society that cannabis is somewhat relatively safe. Are there have others, you know, you’ve studied it. Are there many other studies that look at the, let’s see, the short term or long-term effects of cannabis on the mind?

Ryan: And I just want to add to what you said. When you look at survey data, national survey data, what we’ve seen now is that the vast majority of people perceive cannabis as totally safe. And that is, I think that’s really just wrong. Just like any substance, including alcohol, there are catches that come along with that. And there’s a number of studies that have come out recently. For example, there was a study that came out where they looked at people who do not smoke at all, people who smoke marijuana and people smoke cigarettes. And when they actually looked at their chest X-rays, and I found this shocking, if you would have thought who’s going to have the worst chest X-ray, I would have thought cigarettes for sure, right? We were told for years how bad cigarettes are. The cannabis smokers actually had worse looking chest X-rays. And they’re not exactly sure why, but they were more like mucus plugs and all these things that are risk factors for COPD and emphysema, which are serious conditions, which had been disappearing for many years as we had reduced air pollution and smoking habits in the U.S. But for me, I found it to be really kind of concerning that this actually is a risk factor for that. Another study that I think about a lot comes out of the Scandinavian countries where they have this really great system and they’re able to monitor people forever through their whole life. And if you look at people that are regular cannabis users, a part of their brain called the hippocampus, which is very involved in memory, when you scan their brains, they actually, it’s atrophied, it’s shrunken over long periods of time.

Joe: Well, again, these are great studies beyond the scope of our conversation, but worthy of analysis, we can understand as a correlation, we don’t quite perhaps understand the causation. I want to focus on your particular study. It came out last month in the JAMA Network entitled Non-Disordered Cannabis Use Amongst U.S. Adolescents. You’re looking at both of course cannabis use, but particularly amongst adolescents, people who are young. How are the brains of young people, and effectively we’re talking about young users, different from adults who might also choose to use cannabis. What’s the physiology of it?

Ryan: Yeah, one of the things we’ve learned from neuroscience in the last few decades is that even though when you’re 18, you think of ourselves as an adult, you think puberty is wrapped up, that your brain is still going through many different changes for another seven years. Additional myelination, these things where your brain sort of cuts back on certain nerve connections, it refines them. And that process really moves us towards the more advanced thinking that people are capable of after 25. The things that allow you to sort of think proactively, that reduce your impulsivity, that give more advanced cognitive processes, and that that’s not done until your mid-20s. And so, one of the things that we know around cannabis and substances in general is that exposure to that before that time period seems to do something that primes your brain so that you are less likely to be able to manage your use, meaning in a healthy way as you go forward into adulthood, both with that substance and with other substances.

Joe: Indeed, I always think of the word intoxicant and at the base of that word is toxic, poison, it’s just a matter of dose. But let’s talk about the study. How large in your analysis, how many people were you able to collect data about, let’s say, the effects of marijuana?

Ryan: The total sample is 68,000.

Joe: That’s quite a large study. So, for those of our listeners who aren’t good at sampling and what the inference is, what that means, how many people would that represent in the United States if we were to sort of analyze everyone? How large of a subset is that?

Ryan: I say that is off the top line. I think it’s several million teens. Let me see. I actually have the number right here.

Joe: I thought in your paper, I saw 25 million.

Ryan: 25 million teens. So basically, what’s interesting about this data is that you can take this 70,000 and the way that it’s been sampled is it actually weights this cool epidemiologic thing they do. It weights different groups of people in a way that you can actually generalize the entire U.S. population. So yes, 25 million teenagers.

Joe: So, this is not a small group we’re talking about. This is not a niche topic. This is a lot of people, a lot of young people. You broke your study down into three categories. Again, I’ve read the study my listeners haven’t. I’ll just go through and say, okay, you have non-users. I think we all understand what that is. You have non-disorder users and then you have cannabis use disorders people. How do you define each group? Let’s start there.

Ryan: So non-users for us were anyone who said, I’ve never used cannabis or if they said yes, they said they used it over a year ago and we said, okay, well, those people feel like, let’s just put them in non-use. There’s no recent use. Then we took everyone that said they’ve used cannabis recently and we split them into two groups. The study automatically goes through criteria for anyone that has endorsed cannabis use to see whether they meet the DSM, which is our big psychiatry Bible, to decide whether someone officially meets criteria for an addiction, whether we want to pathologize that. And then we pulled those guys out of the cannabis use group. So now we have those that meet the criteria for disorder, which means that it’s having some negative effect on them. And then we had this other group of people that are endorsing cannabis use, but do not meet the criteria for disorder. And when you look down at the numbers, total, that’s about 13% of teenagers that are endorsing cannabis, about two and a half meet the criteria for an addiction and 10% to 10.5% are endorsing using cannabis, but are not meeting any additional criteria. So, they would be maybe what you consider a recreational or casual cannabis user.

Joe: So that’s a little bit reassuring, some good news in our conversation. That sounds like if I’m back in one in eight teenagers use cannabis, that seems lower than my intuition would suggest. Again, for the benefit, we keep saying cannabis. What is it within a cannabis that makes it an attractive use? What makes you high within that larger substance?

Ryan: Yeah, THC, we’ve been talking a lot about CBD and THC. So, it’s the THC that’s the active compound.

Joe: And your analysis is not looking at someone actually getting high, but rather the long-term, perhaps unintended effects of THC use. You’re not talking about how high one gets, you’re talking about what are the things you don’t plan on having. Described for our listeners, what are some of these negative long-term effects that your analysis is taking account of?

Ryan: You know, and I want to take issue a little bit of the word effect, because it, in fact, to me, implies is a clear causality. And it is difficult to prove causality in science. And this is a cross-sectional study. So we’re not following people in a way where we can really even kind of say that. So, but what we can show is a correlation. We can show that there’s an association going on. And so that association we see is if you split the groups into three, like we said, the non-users, the non-disordered users, the casual users, we’ll call them, and the ones that are meeting criteria for an addiction. And you look at mental health outcomes. So how common is a major depressive episode? How common is it that they’ve had suicidal ideation recently? How common is it that they report cognitive effects, not going to school, low GPA? And what we found is that the ones that are the casual users are two to three times more likely to have those negative associations of the depression, the suicidal ideation, the cognitive effects, the academic effects, and that the addicted individuals, the one they meet the criteria for the disorder, are more like three to four times more likely to have them.

Joe: And you mentioned an important point, which I point out often in other episodes about other topics dealing with science and statistics. And when designing a study, you can never be sure that the sample size is—you are truly taking a cross-section and that there isn’t another confounding factor when selecting non-users and users, meaning it’s not a random person who decides to use cannabis. They already have some sort of characteristics that lead them in that direction. Non-users are different from users before cannabis is used. How do you account for that, those confounding factors, that cannabis users aren’t already different when they start using?

Ryan: Yeah, so there’s several ways. One, when you have a very large sample, one of the advantages of a larger sample is these things just start to cancel them out. The concept you’re talking about is more important the smaller your sample is, because you can imagine that if I just put my hand into two jars of multicolored jelly beans and depending on how many I take out, the likelihood that I get a representation of what’s actually in there is going to be lower the fewer that I take out. So, because we have a large sample size, it’s not as important as it would be with a small sample size. But what we do is we control for things like age, sex, racial and ethnicity, socioeconomic of the family, and if they had another substance use disorder like alcoholism.

Joe: So you’re comparing like with like, you’re not comparing one group to another, you’re saying amongst this group that is somewhat homogenized in large numbers, you can tease out the actual. Again, I’m going to avoid using effects, but the correlation with marijuana or cannabis use, is that right? Okay, all right, good. Now, for the baseline, let’s just start at the beginning and say, okay, we’ve got a group, we’ve got quite, you know, tens of thousands of adolescents. What is the incidence of all these negative symptoms, if you will, in someone, an adolescent with no cannabis use? In fact, aren’t adolescents already prone to all kinds of the negative things that you describe? How do you come up with a baseline?

Ryan: Yeah, absolutely. So, I mean, there’s a huge mental health crisis in the United States, particularly among youth, rates of depression, anxiety and suicidal thoughts have been increasing for years now. Baseline, the numbers that we got are pretty similar to the numbers that have been published otherwise. So, like, maybe around 10% of teens would say that they have had a major, it met criteria for major depressive episode, or suicidal ideation, or had these difficulties with concentrating. And those numbers are pretty similar for academic performance.

Joe: So we’ve got three different groups, the non-users, the, let’s say, less heavy users and very heavy users. Let’s cut to the chase. What are both the major findings and the magnitude of those findings? How much greater was the incidence of these negative characteristics amongst users and then heavy users? Can you sort of put a fine point on that?

Ryan: Yeah, so I think there’s a number of things that we could talk about. So, the first thing that you see is the non-disordered users, the casual users, started using cannabis later than the ones that meet criteria for addiction. Now that’s interesting because one of the questions that comes up from that when you think about this in the world of addiction is, are these casual users, how many of them, how much of this is a predictive factor that they will actually flip over into this fully pathologized version of it? Because their age is already a little higher, about a year higher. And then when we’re thinking about these different events, you want to think about them in relation to one another. So, if the likelihood of it happening for someone who just does not use any cannabis is 1, you’re going to get for the casual cannabis users, it’s 200% to 300% greater the likelihood that they would have these outcomes, the depression, the suicidal thoughts, the academic problems, the cognitive effects, which is a lot higher. And kind of in between that and those that have—meet criteria for that full addiction diagnosis.

Joe: So, a key predictor. Again, we’re going to stay away from causation, but what you’re saying is the earlier one begins using cannabis, the more likely they are to be in that heavy user group later on.

Ryan: Absolutely.

Joe: Okay. You mentioned you sliced and diced the data and broke it down both by age and by sex. We hear a lot about post pandemic and the dawn of social media dominating our lives that there’s female populations seem to be more vulnerable to those kinds of distractions and the negative effects of those. Was there a similar breakdown? Who fared worse or better within a female versus male adolescents?

Ryan: So, what we found is pretty consistent what’s been seen before, which is that it’s either pretty even or that boys are a little more likely to be using cannabis.

Joe: Okay. All right. Now, again, we’re not going to say causation, but is there a chemical mechanism by which you think the THC on adolescents has this direct impact on reduced brain function or suicidal ideation or underperformance in school? What is the actual mechanism that affects, is likely? Again, we’re not going to say causation, but what is it? What is the data infer for that?

Ryan: I think it’s helpful to think about a little bit differently on that. So, one of the things that I’ve observed since this study has come out and getting it reviewed and seeing questions that people have had is that people tend to fall into two different groups. One group looks at the science and says, “See, this proves what I already knew, which is that this cannabis stuff is creating these mental health conditions, that it is a cause of it.” And then the other thing that people say is, “Oh, no, no, no, no, no, you’re completely wrong. These people, they’re already depressed. They’re already having these problems. You know why they’re using the cannabis? Because their life sucks and they’re self-medicating.” And so, a common question I’ve got is, which direction are we going in? And I actually think that that’s not the right way to think about it. In some ways, it’s the wrong question because it’s more like a feedback loop that’s happening. So, let’s take a kid that’s a teenager and depression is caused by a predisposition, but more importantly, it’s an acute event that happens to you that sets you off. So, your parents are getting divorced, maybe you had a breakup, you’re struggling academically, you’re having some negative feelings. You might be on the verge of having a depressive episode and look, you vape with your friends, you get high, and you probably feel better actually for a period of time. You probably find that the negative emotions that you’re having are being diminished, that you’re less anxious, you’re less stressed. And so, it does actually kind of acutely improve the symptoms. The issue is that you keep repeating that and that becomes a regular coping strategy for you, for your depression, for your anxiety, for any of these issues that you’re having, that now it’s very easy to see how the cannabis is actually putting you on a track to worsen your depression. Because if you’re getting high with more and more frequency to manage things that you’re having trouble with, your motivation is going to be going down, your sleep is going to be disrupted, you’re going to be less active, your cognition and memory are going to be affected. And all these things are actually criteria for a depressive episode. And you’re going to get further and further behind in your life, which is only going to be now another kind of psychosocial risk factor that’s going to push someone further into depression. So, I think the way to think about how this is kind of happening and how they’re actually interconnected is that it’s a feedback loop that’s kind of building on one another.

Joe: Again, I think our listeners might be more familiar with the obvious effects, say, something like alcohol, where someone may have a drink after a long day, but then the act of drinking has its own cause, the problem you make it DWI or in a fight or something like this, making you like that much more depressing, which causes you to drink more. So, it’s as you say, a feedback loop. I think listeners probably are familiar with at least that— cannabis, not surprising, may follow a similar pattern. So, I want to play devil’s advocate because I’m anticipating listeners hearing this and saying, look, kids are depressed, that’s what they do, they smoke. And a listener might say, yeah, I got high as a teenager and I’m just fine. How can we explain why it is that some people can, and I think this is probably true with alcohol as well, how can some people just be able to casually use and have no apparent effects and others seem to be inclined towards abuse? Is there some markers that we may know?

Ryan: Yeah, so there’s probably at least two aspects to this question. First of all, the cannabis of today is not the cannabis of the past. It is a fundamentally different product. So, your experience 20 years ago with cannabis is not representative of what’s currently going on. The cannabis industry has intentionally, and they market this, increased the potency of cannabis anywhere from 30 to 90 times higher than what it was like a few decades ago. That is, I mean, that makes my head explode. That is a completely different compound. And to give an analogy, because everyone’s been thinking a lot about the opioid epidemic, let’s take morphine, which is, you know, like if a unit, that unit is 1, and you were to compare it to say fentanyl, fentanyl is 100 times more potent than morphine is. And so, cannabis of today is similar in many ways to that, where it’s actually a very different substance than the one that we previously studied. And one of the things that in the scientific community that we’re very anxious about is that we already don’t have enough information on cannabis. And the information we have is obsolete because it’s really not based on the cannabis of the last five to 10 years. It’s based on information we have for a product that was probably closer to a natural plant that was growing, a natural plant that humans had been smoking for thousands of years that had a fairly low potency and its effects that were much, much, much milder than they are today. One of the things that we see a lot now, and is this thing called hyperemesis syndrome associated with cannabis, this is something that if you wouldn’t look in the scientific literature, it would, anytime that you got it would have been a case report, which means that it is such a big deal that the scientific community says you were allowed to write up one specific case on it and people care about it, which is very, but means it’s very rare. Now it’s becoming very common. I personally have multiple people in my practice that have had this. I have friends that have had this, and I’ve seen multiple papers on it recently. And it’s this idea that the cannabis, it’s so potent. And when you think about what cannabis is original medical indication for, the one that it’s tightest for is around decreasing nausea. It was used for HIV patients that were very skinny. It was used for cancer patients. It would reduce their nausea and increase their appetite. And so that system, when you’re using cannabis, gets, gets dysregulated. And so, if you change where you’re getting your cannabis, if you abruptly change your dose, people go into this cycle where they’re vomiting over and over and over again until they’re eventually vomiting bile, which is like, means you’ve cleared out your entire gastrointestinal tract. To get back to your question about like, what’s the predisposition? Why do some people go on to have troubles and other people don’t? That’s a hard question, one that we’ve been struggling with a lot in science. You want to think about it in a couple of ways. So, one way that you want to think about it is that for whatever reason, we all have a circuit in our brain that is a reward circuit. It’s that same circuit that when you were a hunter-gatherer running around thousands of years ago and you saw a bunch of berries, you wanted to eat those berries and they tasted so good and you should eat those berries, you were rewarded for that. So, it increased the likelihood that you had food and increased the likelihood that, that you would mate and pursue other pleasurable activities. That system was fine-tuned over many years to help us with that. When you use a substance that is potentially addictive, particularly like the higher potency cannabis, that system gets hijacked. Some of us have a version of that system that is just more susceptible to it getting hijacked than others. So, people with another mental health condition are much more likely to have that issue and that could be anything from depression, anxiety, ADHD is definitely a very high risk one for substance use. So, people’s pre-existing situations, the psychosocial events that are happening, what’s going on with their life, if they had a recent divorce, do they feel like they’re in a stable situation? Things that would create stress for them in combination with another mental health condition can be many of the factors that determine who is able to use it casually once a month and never increase their use and who is able to, who is not able to do that and the use escalates.

Joe: And if I’m going to try to combine your two answers into one sort of follow-up question, given that it’s not your parents’ marijuana or cannabis use—it’s many more times potent—and that the effects are likely to be to increase or for some people the effects, the negative effects of use, more potent marijuana or cannabis use increases the likelihood of bad events, meaning the data that we have in the past about what percentage and what the effects of heavy use are useless because currently a more potent cannabis means whatever was going on before is accelerated and magnified to a greater degree. Is that fair to say?

Ryan: Yeah, the effects of the cannabis are much stronger, the effects that people like are much stronger and the downsides are going to be stronger too.

Joe: I want to go further into like confounding issues. Now your analysis makes clear that these are self-reported users and that they may represent a different group than people who actually use. As they say, nobody cheats on their taxes when asked. Are you concerned that perhaps only people who are having severe problems admit to using cannabis?

Ryan: You know, there’s a very long history in science that people underrepresent and under-report their substance use. Ask anyone who’s in the medical field that asks about these things, they’ll tell you people always under-report it. And they’re not lying. It’s that we have this little thing that we do in our mind where we sort of adjust these things. We don’t want to believe that it’s as frequent as it actually is. In fact, when I work with people that were asking questions together about whether they’re having trouble with managing their use, one of the things I do is I just send them home and I’m like, you just use however much you have been using, just write it down. Just write it down. Let’s take a look at it and let’s actually see what’s actually happening. In terms of my analysis, I think that it doesn’t change the findings. What it might change is that the prevalence, meaning how common it is, is probably under-represented.

Joe: Indeed. So, we’re talking a lot about the negative effects on adolescents and all of them seem to logically affect the rest of their lives. If they’re depressed or they’re underperforming in school or have some cognitive deficit, it’s going to affect the rest of their lives. You haven’t studied this effect, but would you guess that, going forward, these effects that we see in adolescents are going to essentially determine or damage their future both in mental health, but also in every other way?

Ryan: I mean, I don’t need to study it. That’s a well-established thing in our field. If you have a mental health condition when you are a teenager, the likelihood that you have it as an adult has gone up exponentially. The likelihood that you have other mental health conditions has also gone up. To me, it’s concerning. One of the things that I get really frustrated with is you were saying, oh, my listeners are going to say, no, no, no, they’re just smoking. Sometimes it’s okay. They’re just helping with their own symptoms. OK, that might be true. I don’t deny that, but we actually have a laundry list of things that are highly effective treatments for depression or suicidal thoughts. And cannabis is not one of them. It absolutely is not one of them. We have a variety of psychotherapies. We know that protective factors like having closer relationships, being in nature, physical activity, are all associated with improvements in depression. And certainly, we have a variety of medications that are really effective with that. Cannabis is not one of them. When I see that and I see kids that have bad grades, kids that are not going to school, kids that are more likely to be depressed or suicidal, and the answer is, “Well, they’re just using the cannabis to manage this bad thing that’s happening to them,” I think that’s a public health problem because we’re actually dropping the ball as adults because we should be helping them in a way that we know will actually improve the likelihood that they recover from this and decrease the likelihood that they have these kinds of issues as an adult. If you don’t do anything, it’s almost always worse as an adult.

Joe: So, self-medicating is not indeed self-medicating. It’s imagining you’re doing self-medication and in fact, harming yourself in the long term. You’ve done a lot of important work. This is a great study and I hope our listeners will let you give a reference to it at the end of the show, but you have made this research for the benefit of your fellow psychiatrist and the medical community at large. What do you hope the medical world will do with this information? How do you think this will help or change or ultimately reduce the benefit of users’ ordinary people?

Ryan: I think that from a clinical point of view, so talking to other psychiatrists, mental health professionals, pediatricians, primary care docs, and even educators, I think anyone who’s interacting directly with youth, if you have a youth that is using cannabis, regardless of what you think the effect of the cannabis is on them, it is unequivocal that it is what we would call in public health a risk marker, meaning that anyone who’s using cannabis is twice as likely to three times as likely to have a bunch of things going on with them that we would be concerned about with teens, like not going to school, like having a low GPA, like having a depressive episode or suicidal thoughts. And that it will hopefully help people think about what interventions can I do to support and help this youth to put them on a better track. Rather than when I think has historically happened, which is it’s easy to dismiss it as a developmentally common and appropriate stage. And look, I’m 39, maybe in the ‘60s and ‘70s, that might have been more true, but as we’ve said several times, the stuff that people are using now, that teens are using now, is actually not the same thing that people were using in the past.

Joe: So, given what we’ve talked about when we’re getting close to the end of our show, I’d like to ask this of many of my guests, the king for a day question. If you were a policy advisor or perhaps the surgeon general and you’re acutely aware of the findings of your study, what would you want either as a policy prescription or what would you want everyone to understand, to boil it down to a bumper sticker about the impact of your study?

Ryan: Yeah, I think that I would want people to understand and have the study influence policy at a level where, from a federal point of view, that there’s a federal regulation overhead around states, because at the moment states are just doing whatever they want to do. I don’t really feel what they’re doing is particularly influenced by the science that we have on it. I think at a federal level, there should be stronger regulation around this with a higher age. The 21 age that is being used by most states is just an extension of alcohol and really isn’t backed by the science. I would want us to think about a higher age and I’d want us to think about how perhaps money through taxing of cannabis could be used to educate youth, particularly teens, that cannabis is not benign for them in that age group and that if they want to use cannabis, that’s fine, but maybe let’s wait till you’re in your mid-20s when the associated risks, not just from my study, but from other studies like on schizophrenia, have been really reduced substantially.

Joe: So, I’m sure we’ve at least piqued the interest of many of our listeners who are adolescents or have adolescents at home. Where can our listeners find your study? I think I stumbled across it in JAMA as I mentioned, but where can our listeners do a deep dive into your data?

Ryan: Yeah, if you want to read the study, I’m very excited. We’ve been moving towards open-source journals and so this is an open-source journal, meaning you don’t need to get behind a paywall or have an access through a university. If you just Google JAMA and put non-disorder cannabis, so you could put my last name JAMA-Sultan, it should come up as one of the top three things on your search engine.

Joe: And once again, a plug for your practice. You are practicing down in the city, where if our listeners are near that area may want to consult you about mental health disorder or some psychiatry, where would they find you?

Ryan: I’m right in the office right now. Our office is on the border between Chelsea Meatpacking and the West Village. We do both remote work and in person.

Joe: Wonderful, that’s great. Well, that’s all the time we have to get today together. Thank you very much for joining me today on Hubwonk, Dr. Sultan.

Ryan: Thank you.

Joe: This has been another episode of Hubwonk. If you enjoyed today’s show, there are several ways to support Hubwonk and Pioneer Institute. It would be easier for you and better for us if you subscribe to Hubwonk on your iTunes podcatcher. It would make it easier for others to find Hubwonk if you offer a five star rating or a favorable review. If you have suggestions or ideas or comments for me about ideas for future episode topics, you’re welcome to email me at Please join me next week for a new episode of Hubwonk.

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