The dramatic increase in cannabis use among teenagers over the past decades in western countries is now clear. It concerns both the prevalence of experimenters and regular users.
There is a sex-ratio boy / girl around 1.3. Currently in France one in three young people aged 15 to 19 and over half of 18 year olds have tried cannabis.
According to the same survey, 5.2% of girls and 14.4% of boys would have regular drinking.According to other studies, this use would have doubled during the last decade in our country. The Nezelof study included 386 subjects aged 15 to 24 years and 400 subjects aged 25 to 49 years. It shows that for 12.7% of 15-24 year-olds and 5.4% of 25-49 year-olds, there is occasional or regular use of cannabis. Regular consumption concerns 2.3% of 15-24 year olds and 0.25% of 25-49 year olds. It has a strong male predominance.
This increase in consumption concerns all European countries. The United Kingdom and Ireland, countries of high consumption, have prevalences of consumption among younger people who seem to have stabilized in the last few years around 35%. On the other hand, consumption prevalence is increasing in other countries: Finland (5-10% between 1995 and 1999), Denmark (17-24% in the same period) , and Belgium. This rate of experimentation puts France first in tie with the Czech Republic and the United Kingdom. Thus, about 16% of young people in the European Union aged 15-16 (born in 1983 and questioned in 1999) reportedly used cannabis at least once.
At the same time, the percentage of tetrahydroxycannabinol (THC) in cannabis is increasing. Finally, requests for specialized care in relation to cannabis increased from 12.7% to 15.5% of all initial consultations between 1997 and 1999.
These requests for care concern only the specialized centers and it is currently impossible to evaluate all the demands on the whole care system.
The plant and its derivatives:
Cultivation of cannabis:
Cannabis is the Latin name for hemp. There are two main types depending on the mode of cultivation: cannabis sativa sativa and cannabis sativa indica. The first, grown in wet soil, is rich in fiber. It is used in the manufacture of fabrics and ropes. The second, grown in warm, dry environments, will produce a resin to fight drought. It is this resin, present in abundance in the leaves and floral summits, which is used for the manufacture of products rich in psychoactive substance.
In order to further increase the THC concentration, some producers use the “sinsemilla” technique (in Spanish, “sinsemilla” means without seeds), which involves separating the female plants from the male plants before pollination.
Indeed, female plants produce more THC than male plants especially when they are unpollutated and seedless. Thus, it is possible to obtain products which, in the raw state, contain up to 15 or even 20% THC. It has been shown that consumers preferentially seek these products with a high concentration of THC, and thus a higher risk of addiction.
Three forms: raw plant, resin, oil
Marihuana leaves, as well as stems are crushed and rolled into cigarettes to form what consumers commonly call a “joint.” In France, raw cannabis is mainly smoked. By this route, an intensity and a duration of the optimal effects are obtained since half of the active principle is absorbed. The effects appear in a few minutes and last several hours. In other countries like India for example, it is also chewed or used in food or drinks. In this country, cannabis is divided according to its potency into several categories, each from a different part of the plant. The “bhang” corresponds to the stems and leaves that have the lowest potency. The “ganja” is made from the flowering tops, it is much more powerful.
The sticky resin, which contains the most THC, is collected and pressed into “barrette” or “soap”. This concentrated form is called hashish or more commonly “shit”. It is mixed with tobacco, rolled to make the “joint”, and smoke.Hashish is also smoked in special pipes called “bongs” or “hookahs”. As hashish is more concentrated, it is easier to smuggle it.
This hashish is rarely sold in its pure state, it is often cut with other substances like henna or paraffin.
It is also possible to extract hashish oil from the plant (using solvents). Most often, it is used to coat cigarette rolling paper. It is also possible to pour the dripping oil onto crushed cannabis leaves, in order to increase the psychoactive effects of the “seals”.
The hashish oil (“red oil”) may contain 20-30% THC. This oil is also consumed orally by being mixed with food for example in certain pastries called “space cake”. Due to the first hepatic passage and slow absorption, the effects are slower to appear and can last from 8 to 24 hours, they will also be much more intense.
A recent study has gathered the results of analyzes obtained since 1993 on products seized by the customs and the gendarmerie and analyzed by various toxicological laboratories. The results show that for the grass (5.5% to 8.7%) and the resin (7% to 10%), there is a great variability in the concentrations.
However, over the years there have been products with a high 9% strength for 31% resin, 22% for grass. Nowadays we can find on the market herbs called “skunk” (abbreviation of “skunk weed”) or “super-skunk” obtained from cultivation under glass, hydrotonic, with conditions of brightness and optimum temperature.
Pharmacokinetics:
The active principle of cannabis has long been identified, it is delta9-tetrahydroxycannabinol or D 9THC.
After inhalation, 15% to 50% of the D 9THC present in the smoke is absorbed and passes into the blood stream. This absorption is rapid and the maximum blood concentrations are obtained 7 to 10 minutes after the initiation of the inhalation.
Very lipophilic, THC is distributed in all tissues rich in lipids. They are found in large quantities in the brain. One study showed that after a joint had been consumed, the psychic effects persisted for a long time, while the blood concentrations decreased very rapidly. In fact, because of the lipophilic character and the large volume of distribution (4 to 14 l / kg), the psychic effects of cannabis extend well beyond the drop in blood concentration. The elimination of cannabinoids takes place by different routes, digestive, renal and sweat. About 15% to 30% of D 9THC is excreted in the urine as D 9 -THC-COOH while 30% to 65% is excreted in the stool as 11-OH- D 9 -THC and D 9 THC-COOH.Because of its high tissue binding, D 9THC is slowly eliminated in the urine. They are found 7 to 14 days after the last intake in occasional consumers and 7 to 21 days in regular consumers.
Dosage in biological media:
Blood is the biological fluid of choice in any medico-legal context, including road accidents. It aims to highlight or confirm recent use of cannabis. The blood analysis makes it possible to determine the different psychoactive or non-cannabis forms as well as to carry out a quantitative analysis whose results can give rise to an interpretation. It may also give an estimate of the time elapsed between the last consumption and the time of collection. However, although blood concentrations of THC are often accompanied by physical and psychological effects, it was not formally demonstrated that there was a close correlation between blood concentration and nature and intensity of behavioral disorders. This is probably due to the large inter-individual variations and the tolerance that is established among regular consumers.
Dosing in the urine now appears to be the most appropriate sampling for the rapid detection of cannabis use.However, it detects only D 9THC-COOH which is the non-psychoactive form. Moreover, it does not make it possible to prejudge the time elapsed between the moment of consumption and that of the collection of the urine, the D9THCCOOH being able to be present there from several days to several weeks after the sampling. The recommended positivity threshold in urine is 50 ng D 9THC-COOH per milliliter of blood.
Dosage in saliva has been the subject of numerous studies.
It could be a good screening test because of the presence of D 9THC, ie the active form, in saliva. A non-invasive examination would then be available to demonstrate recent use. However, to date there is no rapid test adapted to this biological environment.
The analysis of the hair makes it possible to highlight a chronology of the consumption by the analysis of the segments.
The interest is mainly medico-legal.
Endocannabinoid system:
Cannabinoids act on the organism via the endogenous cannabinoid system, composed of neurochemical substances (endogenous ligands) and specific receptors.
Three types of endogenous cannabinoid ligands:
• Endogenous ligands represented by anandamide and 2-arachodonylglycerol. Their role is to modulate the release of neurotransmitters.
• Natural exogenous ligands, all of which are derived from the cannabis sativa plant. There are more than 60 but the main one remains the D 9THC.
• Synthetic ligands such as HU-210, CP-55940; WIN-55212-2 or SR141716A and SR144528 which are cannabinoid antagonists or inverse agonists.
Receivers:
Two types of cannabinoid receptors have been isolated: CB1 and CB2. These are seven-domain transmembrane proteins coupled to G-proteins. CB1s are widely distributed in the brain at the cerebral cortex, base ganglia, thalamus, cerebellum and especially at the hippocampus and striatum. CB2s are widely present throughout the immune system, especially in macrophages, spleen, and B and T lymphocytes. Because of this distribution, CB1 are rather involved in psychotropic effects and CB2 rather in immunomodulatory effects.
The distribution of CB1 receptors in the brain is remarkably well correlated with the behavioral effects of cannabinoids.Thus, the inhibitory effect of cannabinoids on psychomotor performance and coordination is related to the high concentration of CB1 at the nuclei of the base and the molecular layer of the cerebellum.
As for the deleterious effects of cannabis on short-term memory, they can be explained by the expression of CB1 receptors in layers I and IV of the cortex and in the hippocampus.
Thus, the cannabinoid system plays a regulating role in many functions: mood, motor control, perception including pain, appetite, sleep, memory, certain cognitive functions and the immune system.
Like many other addictive drugs, cannabis activates the mesopimbic dopaminergic system that is commonly referred to as the reward area.
9THC administration has been shown to activate dopaminergic neurons in the ventral tegmental area that project at the nucleus accumbens and cause an increase in dopamine. This effect is blocked by naloxone, an opiate antagonist.This suggests a common mechanism between opiates and 9THC. Other products have an enhancing effect on the reward system.
Neuropsychological effects of cannabis use:
The effects of cannabis generally appear 15 to 20 minutes after inhalation and between 4 to 6 hours if taken orally. For regular consumers, these effects appear more delayed.
Immediate Effects:
Because of its neuromodulatory effect, the effects felt after taking cannabis are very variable according to the individuals and depend closely on personal feelings before consumption.
Two types of phenomena:
Classically, the user will experience two types of phenomena.
A feeling of relaxation in which the user is slightly confused and psychologically separated from his environment.
There is also a detachment, a feeling of being elsewhere, drowsiness and difficulties of concentration.
A change in all sensations. The most potent varieties of cannabis can cause dizziness, excitement with increased liveliness, major distortions of perceptions of time, color and sounds. Very strong doses can even produce cenesthetic and visual sensations.
The loss of the sense of time is responsible for several effects felt with cannabis. The boring and uninteresting work seems to take place faster.
It should be noted that there has never been a report of cannabis overdose.
Unlike heroin, THC has no action on the brain stem which can lead to respiratory distress.
However, some people will feel anxiety, or even a real panic attack. Other reactions are rarer and some include a paranoid experience, dysphoria, depersonalization with derealization.
This being said, there has been no formal evidence, and confounding factors such as psychiatric comorbidities and concomitant use of other drugs often exist in the studies. These effects are spontaneously resolved without external intervention. In case of symptoms persisting beyond 24 hours after the end of the intoxication, another diagnosis is to be evoked, especially psychiatric.
Amnesia of recent events:
In the experimental studies, these showed mainly amnesiological effects in the short term (working memory).Cannabis use impairs the ability of subjects to remember words, images, stories, or sounds that are under the influence of the product, as soon as or several minutes after the presentation. These disorders may persist for several weeks after cessation of the poisoning.
However, these attacks of memory seem reversible to the cessation of intoxication even in case of high consumption.
The performance of the volunteers in tests other than those intended to evaluate the memory is little or not modified according to the studies.
Behavior disorders:
Studies of behavioral disorders under the influence of the product, including effects on driving, are contradictory. Some studies show that people under the influence of cannabis have less performance when tested with driving simulators.
These alterations in performance would be similar to those encountered in the event of alcohol consumption, they would last longer, would not be perceived by the subject despite the persistence of deficits during the tests.
However, a review of all the studies carried out highlights the inconsistencies of some of them, the methodological difficulties inherent in this type of research and points out that individual characteristics may be at the origin of observed differences .
According to all studies, cannabis use leads to impairment of psychomotor performance when performing complex tasks related to attention disorders, psychomotor coordination and lengthening of reaction time. In addition, 9THC potentiates the effects of alcohol, barbiturates, caffeine and amphetamines.
The association of cannabis and MDMA (ecstasy) would make driving almost impossible.
Long-term effects:
An extremely frequent consequence of the regular use of cannabis on the population studied, cognitive impairments and their impact on schooling (drop in results, absenteeism) with a risk of more or less global disinvestment.
Cognitive disorders:
The disturbances mainly concern short-term memory, the other functions being conserved.
Nevertheless, most authors believe that this alteration of cognitive functions is reversible.
Recent studies have shown the harmful influence of consumption during the critical period of adolescence when the brain is still in a maturation phase.
This would be particularly true for high cannabis use before 15 years. The aggravation of certain cognitive disorders in connection with an established mental pathology (schizophrenia, major depression) by a cannabis intoxication can precipitate the patient in the school failure.
Effect on motivation:
Regular use of cannabis would have an influence on academic performance, sports and out-of-school activities, and on the ability to maintain interpersonal relationships. This use would be correlated with a higher frequency of risk behaviors such as unprotected ratios, pipes under the influence of toxic substances. However, some authors point out that disorders precede consumption and that these consumers previously exhibited emotional and behavioral disorders.
Some authors mention the diagnosis of amotivational syndrome, according to the French denomination. This syndrome would involve significant apragmatism, with loss of interest, an anhedonia, an intolerance to frustration and a psychological slowdown. It would specifically concern some adolescent chronic consumers. Nevertheless, the responsibility for cannabis is difficult to prove because this semiology is often found in teenagers depressed, even depressed even among non-consumers, as the dimension of defensive passivity can appear in the foreground in subjects whose narcissistic foundations are fragile . Moreover, for other authors, this amotivational syndrome is common to all chronic intoxication to psychotropic drugs.
Impairment of interpersonal relationships:
Another type of complication that arises from cannabis use in adolescents requiring psychological care is alterations in relationships with those around them, particularly parents. This complication appears very little in the literature.However, it invades systematically and sometimes massively therapeutic work with parents (or their legal substitutes).This relational degradation can follow a more or less long period of denial on the part of the relatives or, conversely, of a persecutory suspicion compromising in both cases the attempts for the young person to be able to talk about the reality of its consumption. Certain attitudes of the entourage towards this consumption will have an influence on the risk of perpetuation of the driving. We then encounter several cases of figures that range from the parents who are suppliers to their children to those who even threaten to drive their teenagers from their homes if they continue to use them. These parental counter-attitudes, not to mention unconscious instinctual motions, are increased in their effects by the incoherence of positions and attitudes between parents on the issue of cannabis. Judicial complications when they arise (arrest of a young person for detention or trafficking) can reinforce parents’ sense of helplessness to be respected as guarantors of authority and respect for the laws in force. However, they are in some cases a necessary limit to integrate by the whole family.
Finally, the consequences on the treatment of mental disorders are the most worrying. First there is the risk of making psychotropic treatments less effective, especially neuroleptics. In schizophrenia, cannabis aggravates the dissociative process, short-term and long-term relapses are more frequent, resocialization is less and adherence is lower. The risk of delayed access to care is also noted. The “autotherapeutic” use of cannabis is probably favored by the feeling of having reached a pseudo-insight by the disinhibition operated by the product, at least for some patients. Equally worrying are the risks of breakdown of care for adolescents hospitalized when their consumption goes beyond the limits of tolerance of the institution.
Here again, the quality of the links between the parents and the institution and the position of the parents towards the transgressions of the therapeutic framework can greatly influence the evolution of the care.
Evolution towards other consumption:
While some authors have pointed out that the majority of teenagers who consume toxic drugs do not necessarily evolve into abuse or dependence, others point to longitudinal risk regular consumption, and even dependence, and the gradual shift from the consumption of legal substances (alcohol, tobacco) to cannabis, and then to other drugs (gateway theory).
Dependence and weaning syndrome:
Regular use of cannabis can be regarded as addictive behavior. There is indeed a real dependency syndrome with loss of control of consumption.
The frequency of the catch is a good predictive factor in the evolution towards addictive behavior. Adolescents are more likely to develop cannabis dependence than adults. According to the same study, about one third of adolescents who consume cannabis daily develop a dependency syndrome. Other studies have shown that a tolerance phenomenon is established after a daily intake for 3 weeks.
Cannabis withdrawal syndrome is fairly well defined. Symptoms begin approximately 24 hours after discontinuation, are at their maximum after 72 hours and then resolve in 7 to 10 days. The main manifestations are irritability, anxiety, severe physical tension as well as a decrease in mood and appetite.
Other signs accompany the picture: impatience, trembling, sweating, insomnia and restless sleep. For these authors, the signs of withdrawal would resemble the weaning of opiates. However, they would be less violent because of the large quantities of cannabis contained in the fats and not active immediately with the possibility of spreading out over time.
Comorbidities:
Many studies have reported a frequent association between psychiatric pathology and cannabis use.
Among the abusers or addicts to cannabis, there is a great frequency of psychiatric pathologies. Similarly, in patients with mood disorders or psychotic disorders, there is a greater frequency of abuse or dependence on cannabis.Comorbidity studies demonstrate this and show the frequency of associations between cannabis use and eating disorders (mainly bulimic and mixed forms), alcohol abuse, depressive symptoms, anxiety disorders, or suicidal behavior and conduct disorders. Some patients with depression, anxiety or negative signs of schizophrenia reported that cannabis attenuated their symptoms. Similarly, adolescents admitted to smoking hashish to calm their anger, to fill their boredom. It remains very difficult to discern the part of responsibility for hashish in the appearance and maintenance of a given psychic disorder. The international literature attests to this difficulty.
The authors remain very divided on the existence of schizophrenic diseases induced by cannabis and the notion of cannabis psychosis is not unanimous.
Four recent studies have been conducted to investigate the fate of adolescent cannabis users. The aim was to investigate whether adolescent cannabis use was a factor in the poor prognosis for the onset of schizophrenia in adulthood. The Swedish study consisted of a cohort of 50,000 conscripts followed prospectively over 27 years. It shows that there is a correlation between cannabis use before the age of 18 and the onset of schizophrenia in adulthood. Moreover, the importance of consumption seems to be an aggravating factor. The New Zealand study stresses the risks of early consumption before 15 years. Follow-up studies of British and Dutch cohorts, eliminating as many confounding variables as possible (social group, ethnic group, parental background, etc.), support the hypothesis that there is a correlation between cannabis use in adolescence and development from schizophrenia to adulthood.
However, some points remain under discussion.
Given the difficulty of identifying the prodromes of schizophrenia, it is unclear whether some young cannabis users are not actually prepsychotic personalities who would use cannabis as an “autotherapeutic”. In addition, while there is an increasing number of cannabis users among adolescents, there has been no increase in the incidence of schizophrenia.
Recent work has even found a gradual decline in the incidence of schizophrenia since the 1950s. However, massive use among young people under the age of 16 is a recent phenomenon. It may be too early to say whether this will affect the prevalence of schizophrenia.
In summary, it appears that on the one hand, experimentally, everyone, starting from a certain dose of THC administered, presents acute psychotic disorders of “schizophrenic type” resolving and that on the other hand the risk of developing schizophrenia in adulthood when an adolescent consumes cannabis exists even if this risk remains low.All in all, it is now possible to suppose that chronic hashish poisoning in adolescence, on fragile ground, can be at the origin of true psychotic states.
We must insist on the greatest vulnerability linked to the youth of the consumer. Comorbidity studies also revealed some important data: twice the risk of cannabis dependence in adolescence, far more consumers in subjects with suicidal behavior than in the general population, and the exponential evolution is known of the incidence of attempted suicide in adolescence over several decades. This vulnerability seems to be a factor favoring the risks of greater dependency than in adulthood. In addition to the many psychosocial factors involved, it is necessary to recall here the biological factors that could actively interact with the product. For Stahl, spectacular synaptic rearrangements occurring at the age of 6 and throughout adolescence may explain the large increase in the incidence of thymic disorders and the exacerbation of disorders prior to this period of life. From our point of view, this neurophysiological specificity linked to age is probably not sufficiently taken into account in the evaluation of psychiatric risks induced by cannabis. The generalization of cannabis use is expected to be accompanied by a lower average age of onset, currently around 14 years. However, it is precocity of the first experiments that represents a reliable indicator of prognosis: earlier in life is the consumption of psychoactive substances, the greater the risk of abuse and / or dependence, poly-consumption and passage to other illicit drugs with high health costs in adulthood. These data have been extensively verified for cannabis by Golub and Perkonigg.
Consumption conditions and classifications:
From natural history …
The population of cannabis users is not homogeneous as to how to consume the product. We distinguish occasional, often festive, use autotherapeutically and finally the “fights” with anti-thinking aim.
The first puffs of cannabis are often taken in groups by “turning the joint”. The adolescent then discovers the first effects: laughter, removal of inhibitions and improved friendliness between friends. Neurobiologists talk about the neuromodulatory effect of the endogenous cannabinoid system on which tetrahydroxycannabinol will act. Thus, cannabis would have a modulating role on mood, motor control, perceptions, appetite and sleep. Smokers often describe an exacerbation of sensory perceptions and an impression of feeling the world around them with greater acuity. One will feel better music, the other will have a better communication with his entourage.
For some, the use of cannabis will remain festive and associated with the conviviality. For others, generally the most fragile, the relaxing and hypnotic effects experienced during the first intake will be used to treat sleep disorders and other tensions of everyday life: it is the stage of consumption ” self-therapy “.
Gradually, cannabis will become indispensable for the benefits it brings, without there being dependence in the proper meaning of the term. However, it is not uncommon to observe signs of withdrawal at this stage during periods of abstinence.
These manifest in the form of anxiety with irritability, disturbances of sleep and appetite, and above all an almost irresistible desire to take products.
Finally, there is the “busting” that erases all painful thoughts at once. Generally, this requires large catches in the form of “bongs”: water pipes that allow to absorb a large quantity of product in a minimum of time. Cannabis can then be aimed at distancing the underlying psychological problems. Stopping consumption becomes synonymous with a return to reality. One understands the difficulty to stop.
… to classifications: use, abuse and dependence
It is classical to differentiate three main modes of substance use: use, abuse and dependence.
Only the latter two are recognized as morbid entities, listed as “substance use disorders” in international classifications (APA 1994, DSM-I and ICD-1). To these categories, the DSM-IV, by individualizing 11 groups of substances (licit and illicit), adds the category “substance-induced disorders”, some of which include intoxication, amnestic disorder, psychotic disorders single take.
These nosographic aggregations intersect, often imperfectly, with the individualized categories of consumption in the epidemiological studies that distinguish non-consumers, experimenters, occasional consumers and regular consumers. This descriptive epidemiological approach based on the frequency of consumption is not always easy to put into perspective with the morbid entities that can result from it. As Reynaud points out, the question is “too much?“, By” too much is when? and too much is how? “.
Use:
The use is characterized by the consumption of substances causing neither complication nor damage. This controversial definition implies that there may be socially regulated, risk-free consumption, the place of which is linked to the acceptance or even valorisation of a substance by a given society at a given time given, for personal pleasure or user-friendliness. The limitations of this definition are, however, vague. It is not always easy to define the boundaries between simple use and certain risky uses such as consumption in certain situations (driving, pregnancy, etc.), certain festive consumptions that are socially integrated but abusive (festivals, rave-party, etc.), or certain consumptions (tobacco, alcohol, etc.) whose thresholds of quantity and duration eventually increase the risk of somatic mortality and morbidity, even if they do not fulfill the criteria of ” abuse or addiction.
Abuse:
“Substance abuse” within the meaning of the DSM-IV classification (which is consistent with the “harmful use” of ICD-1) is characterized both by repetition of consumption and by finding damage in somatic or judicial social fields. The criteria of its definition relate more to a dysfunction in the social sphere than to a specific suffering of the subject.However, its individualization has an interest in psychopathology since it is often a case of damage that may be related to certain psychological characteristics (impulsivity, sensation seeking, transgression, etc.) that would favor both the taking of toxic substances and the risk taking.
Addiction:
Substance dependence is defined as a psychopathological and behavioral entity that breaks with the usual functioning of the subject. To the usual signs of drug dependence, which are tolerance (need to increase the doses to obtain the same effects) and withdrawal (physical syndrome occurring in case of deprivation of the product), are associated, to define the dependence, compulsive search for the product (“craving”), and the impossibility of stopping consumption despite its somatic and social consequences.
Addiction is not an addiction to a product, but an inadequate mode of consumption that centers the life of the subject, and causes it to persist in its consumption in spite of the consequences that it suffers from the toxic.
More than product, it is an experience that certain subjects become dependent. However, this experience varies from product to product. Each subject finds a specific action in its product. According to that it seeks euphoria, stimulation, sedation.
Psychopathological aspects:
Multiple origins in connection with other disorders:
The factors involved in the genesis of addictive behaviors in adolescence, especially hashish, are multiple, complex, closely entangled, cumulative and interactive. Hence the need for a multidisciplinary approach. Indeed, it allows the construction of hypotheses based on a true public health phenomenon, which is not limited only to the field of proven pathology, far from it (notion of a continuum from normal to pathological and d a gradient of gravity), and which appears to be particularly variable in its nature and intensity. This variability is not only individual with a dependence on genetic and biopathological factors, but also collective in relation to socio-cultural factors.
In order to understand the psychopathological nature of addictive behaviors, we must place them, it seems, in the more general context of behavioral disorders of adolescents, of which they can be both causes and consequences.
Thus, from the epidemiological and clinical point of view, the use of toxicants and deviant conduits are conventionally associated.
They reinforce each other in the same way as they share common determinisms. Conduct disorders usually precede drug use. Tarr and Kandel observed that minor delinquency was the most important predictor of switching to “hard” drugs. For Leblanc, the higher the delinquency, the greater the increase in consumption, and the statistically significant relationship between having crimes in common and being a drug user.
Socio-cultural factors and the influence of the family:
Adolescent behavior in adolescents is indeed part of this type of behavioral disorder, which has seen its frequency increase significantly over the past thirty years: fugues, impulsivity and violence, criminal activities, attempted suicide.This increase concerns western and westernizing countries. For example, in Europe, three countries with strong growth rates between 1983 and 1992, Spain, Italy and France, are the most affected: 65% of the cases reported in Europe. There is, therefore, a phenomenon that goes beyond individual psychopathology to fit into the lifestyle changes affecting these countries. According to Bergeret et al., “… the progression of drug addiction reflects a real disarray in the level of our civilization. This confusion results from a lack of mental, and in particular imaginary, satisfactions of men of our time. It is above all a lack of ideology that is truly commensurate with the real deep needs of dreams that create desire that can not be reduced to material or behavioral satisfactions. Thus, addiction, like many other behavioral disorders, would reflect a lack of ideality or, more subtly, the confrontation of the adolescent with a world where ideals are clearly defined but yet inaccessible. The way in which social changes and individual behaviors articulate involves a series of relays, of which the family is surely the essential hub. For example, changes in society will affect the development of the child through, for example, the elimination of the specific role of the father, overinvestment of child- child in response to a capture in the desire of the adult to the detriment of the satisfaction of his own needs and the development of his capacities of autonomous pleasure. But these same changes will also have a direct bearing on the actuality of adolescence by favoring the elimination of the intergenerational barrier, the escape of all conflicts which can only be indirectly expressed in behavioral disorders with the use of toxic in particular, or to emerge periodically in a dramatic fashion, in risk behaviors more or less obviously suicidal.
In other words, we are in a system of interrelationships between the development of adolescent functioning and the crisis of family development, where what appears to be predominant is the resonance between the problem of the adolescent and the undeveloped conflicts of adolescence. the adolescence of parents. And the question of permissiveness in relation to the hashish of the generations from the 1960s is to be highlighted.
Cannabis use reveals vulnerability rather than pathology:
These behaviors occur on different personalities in terms of psychopathological characteristics. It is the entire psychiatric nosographic field, ranging from neurosis to psychosis through the perversion that may be associated with them. These behaviors thus testify to the transnosographic, that is to say trans-structural, aspect of the concept of addiction which essentially assesses mechanisms and behaviors. It is thus necessary to see these behaviors rather as the expression of a vulnerability of certain subjects, than a response to a hypothetical psychic addiction.
This biopsychological vulnerability in a given sociocultural context may lead them to adopt these addictive behaviors with pathogenic effects because they reinforce and reorganize the personality around it. One can only speak of true pathology when these subjects are enclosed in the repetition of these behaviors. As Bergeret says, “there is no deep and stable psychic structure specific to addiction. Any mental structure can lead to addiction behaviors (visible or latent) under certain affective and relational conditions “. This author sees the addiction “as an attempt to defend and regulate against the deficiencies or occasional faults of the deep structure in question”.
This relative diversity of the structural terrain reflects the clinical variety of these behaviors as differences in prognosis and responses to therapeutics, which depend to a great extent on the conditions of family support and early management.
It should also be considered that the important comorbidity observed in these behaviors is not synonymous with co-occurrence, and that some observed symptoms are closely related to the underlying psychological structuring. There is therefore a necessary discrimination to be made between primary psychiatric disorders favoring addiction and the numerous psychiatric disorders secondary to the effects of addiction (anxiety, depressive, psychotic and psychosomatic disorders).
There is a convergence of studies from various clinical and theoretical perspectives, leading to the notion of addiction, conceived not only as deviant behavior, but as a process of regulating the equilibrium of the subject pleasure-displeasure facing the issue of emotions), and a way to escape internal discomfort. In other words, a means of ensuring a certain balance of the psychic apparatus which can not be obtained by the usual means, in particular the regulation of the experienced and the emotions by the internal resources of the subject.
These studies highlight the existence of psychological dimensions stemming from biological factors (temperament), the child’s eventual history of the subject, in particular the quality of the child’s early interactions with his environment and the quality of the construction of his psychic apparatus.
It is striking to note that addictive behavior takes place essentially after puberty and most often during adolescence or in its immediate aftermath, that is to say at the moment when the subject has to become autonomous and can no longer benefit from the same protections on the part of his parents.
This set-up appears to be related to earlier psychological factors that would represent a vulnerability to dependence and conjunctural eventual, familial and social factors. These factors sometimes appear to be decisive and the history of the risk factors that make the response to adolescence difficult to avoid can be summarized. In other cases, it is only a vulnerability and a potentiality that will not necessarily give rise to a response through addictive behavior. These early risk factors, which can be expressed in adolescence, are to be sought especially in the failure of the processes of attachment in childhood described by Bowlby.
Break of the bond of continuity with other people, compost of the dependence:
The interest of these models from theories of child development is that they illustrate the dialectical relationship between the individual’s capacity for autonomy and the quality of his internal resources and that of his initial object relations.
Thus, the quality of the interactions and investment that the child has been the object is reflected in the modalities of the investment of his own body. Its pleasure to function, to use its skills and its physiological and then psychic resources is the translation of the quality of internalized links.
The indispensable bond of continuity with others is ensured in part by this pleasure to be, to experience and to function of the child. In this case, there is no conflict between the need for the link, the desire to receive, the dependence on the object and the necessary empowerment. One feeds on the other.
Conversely, anything that introduces a too brutal break, too early in this continuity of the bond, and this reciprocal adequacy of interactions, makes the child aware of his impotence and dependence on the external world. The conditions of an antagonism between autonomy and dependence, between him and others are created, which will create the breeding ground for the development of a dependency behavior.
Instead of the more or less interrupted link, the child invests and then becomes dependent on a neutral element of the surrounding environment or part of his or her own body. But the nature of this investment also depends on the quality of the broken link as well as the way in which the bond is re-established or what remains of that bond. The more the relational dimension is lost, the more the supplementary investment of the frame and / or the body takes place in a mechanical and disaffected mode. The violence of this investment and its destructive nature are proportional to the loss of the relational quality of the link and what might be called its dehumanization.
Addiction: Fight against threatening emotional dependence
It is also conceivable that the essential stages of the subject’s autonomy throughout his or her life represent periods favorable to the emergence of addictive behavior. This is particularly the case of adolescence and its immediate consequences with the effect of bodily and psychic transformations on the regulation of emotions, that is to say, of what binds affect to external objects. But everything that confronts the subject with separation and the feeling of internal vulnerability can encourage its emergence throughout life.
A whole clinic of addiction is likely to develop then as a defense against an emotional dependence perceived as a threat to the identity of the subject and an alienation to its objects of attachment. It is a clinic where the subject tries to substitute links of mastery and control for his relational affective bonds, experienced as all the more threatening as they are more necessary. It is a matter of introducing between the subject and his possible attachments substitutive objects which he thinks to master, an external object that has its own effects on the body and distances the human objects on which it depends, the drug in particular.
We thus see clearly the function of controlling the relational distance by this behavior. It allows the subject to maintain apparently satisfying relations and a relatively diversified social life, but at the cost of a cleavage of the ego.
But addictive behavior tends to gradually drain the subject’s investments and what remains in him of objectal appetite.They become a “common final route of discharge of all excitations”, as Brusset has rightly called it, in an increasingly undifferentiated way. We find in this increasingly totalitarian character of conduct with all the possible connotations of this qualifier a common parameter to addictive behaviors, towards the massiveness of the dependence on objects and that of narcissistic engagement in the relation to them. The “behavior-symptom” thus has a double narcissistic and objective value which confers its undifferentiated character. A primitive object, “archaic”, asexual, always available to the subject in a mutual reciprocal relationship, and at the same time, a protective envelope that protects the subject from internal and external excitations. It quickly acquires a stabilizing function which represents an outcome to the instability of the mental organization of these subjects.
The behavioral response takes on a compromise value, not as a neurotic symptom, the fruit of the internal conflict between desire and a prohibition or between conflicting desires, but as a behavior intended by an action on the external environment to be assured both of the reality of a relational contact, uncertain at the internal level, and of its maintenance outside the limits of the subject. The central problem is no longer of the order of conflict, even if it is still active, but of the preservation of identity. The practice of this behavioral behavior allows him to rediscover a link that is not unrelated to that which he previously maintained with his privileged objects of attachment, that is to say a dependency link that reveals in a mirror the one that connected it to its internal objects and their external representatives. Thus, the relational modalities of the subject with the drug object are a reflection of its possibilities and impossibilities of object trade.
But as an essential economic function, the subject can easily ignore the nature of this link and develop, on the contrary, the fantasy of a mastery of this neo-object that is behavior, when in fact it has become an object of dependence addictive.
This pre-eminence given to the object as the need to maintain it in a status of exteriority contribute to the instability of the addictive solution. One can imagine that the depressive problem is omnipresent and made up of an alternation of experience of loss of the object as of self-esteem and momentary reunion, reminiscent of manic-depressive oscillations.
But they remain as flattened, without depth, and neither manic elation nor melancholy self-accusation can be found.
In fact, there is no complete denial of otherness or incorporation. One remains in close combat with the object, made up of an objective quest that talks about its refusal to receive in an indefinite bond of which the sadomasochistic component is undeniable although often suffering from a secondary eroticization that remains poor and disappears in favor of an activity of self-stimulation more mechanical than instinctual.
Associated destructurant depression:
In all the addictive behaviors, we can observe, underlying the behavioral disorder, this depressive tone, which emerges clearly at the time of weaning. The nature of this depression is narcissistic in close connection with a failure in the introjection of stable identifying images and an inability to elaborate loss in the context of a mourning work. Addictive behavior can be understood as a struggle, and the repeated incorporation of the addictive object to fill an unbearable sense of emptiness. Since addictive behavior has a tendency to self-reinforce and self-maintain, any possibility of psychic elaboration diminishing as a result of the systematic use of addictive behavior, the patient substitutes a dependence on another, avoiding any elaboration depressive (some clinically objectivable depressive decompensations are observed during evolution). In any case, in addictive behavior, depression as it is constituted rarely structuring, and most often increases the affective dependence.
The Dependency network has well individualized depression as a major risk factor in all addictive behaviors. The study by Ryan et al. of 92 major depressions of the adolescent showed that 18% used soft drugs at least occasionally and another 14% had at least tried hard drugs during the current episode. Thus, depressive symptoms often appear to precede the use of toxicants.
Depression is all the more to be feared that it risks reactivating a problematic identity and the chronicization of drug addiction is in itself a depressogenic factor due to secondary biological disorders and the psychosocial consequences of marginalization.
Most works link suicide, depression and drug abuse. Toxic abuse can aggravate depression and facilitate suicidal behavior. The medical severity of suicide attempts is related to drug abuse behavior.
All studies in adolescence abound in this sense. “The choice” of cannabis rather than another drug or other addictive behavior seems to depend on several factors: massiveness of supply and relatively moderate cost, favorable sociocultural environment, vulnerability to pre-addiction dependence, a product likely to be less than for future “addicted” to “hard drugs” or other behaviors because of the lower physical and psychic dependence with cannabis, nature, search for the effect of the product (disinhibition, confusion …). But let us repeat that the effect of reinforcement of the addiction to hashish and its impact in terms of social morbidity can in the long run, in some, favor the chronicization of the conduct and the development of comorbidity.
Therapeutic approaches:
General information:
Necessity of a location:
One in two adolescents has been in contact with cannabis. Of these, most are occasional consumers and only a part of them have problematic consumption. In addition, unlike other heroin products, cannabis use affects all adolescents.It is likely that the most fragile young people in this group will be the most affected. Identification is necessary in order to be able to treat those who can be and to orient those who need it.
Multidimensional support:
The consequences of cannabis use are not only medical, they are also social, educational and environmental.Management will of course have to take account of all these factors
Due to the frequency of psychiatric disorders among adolescents with difficulties in relation to cannabis, management taking into account both the addictive behavior and the underlying psychopathology seems necessary.
Indeed, patients taking cannabis for “psychiatric” reasons have a higher rate of relapse into addictive behavior than others. They are paradoxically more motivated to wean themselves than people whose origin of consumption is rather “social”. It is all the interest of a bifocal therapy that proposes to associate a therapy centered on the product and a more psychoanalytical approach face-to-face developed that will uncover a certain number of underlying conflicts remained hitherto unconscious.
It is essential to offer sufficient support to be able to tackle problems that will call into question a precarious equilibrium that the subject had forged.
Expression and depressive experience (if well tolerated enough to allow patient reinvestment in the inner world) should eventually abolish the need for addictive behavior.
Location:
Clinical tool:
It includes a rigorous assessment of consumption and its consequences. For some authors, in order to evaluate risky use it is necessary to take into account the conditions of consumption as well as the existence of individual and social risk factors. For them, the risk-taking modalities are: the precocity of consumption, the use in association with other psychotropic drugs, the search for cannabic intoxication, regular use for an autotherapeutic purpose, repetitiveness of consumption.
Individual risk factors are generally linked either to neurobiological factors that are still poorly defined or to factors of psychological vulnerability. These may include pathological personality traits such as sensation or psychopathy, or even psychiatric comorbidities.
Environmental risk factors are related to the family (family working habits, failing educational framework, etc.), the social environment (peer’s role, precariousness, etc.).
Standardized questionnaires:
There are two. The CAGE (an acronym for questions such as “Cut down your drinking, Annoyed by criticism, Guilty about drinking and Eye opener in the morning”) validated in the United States which focuses on the notion of dependency and ALAC (“Alcohol Advisory Council” ) (1996) (of New Zealand origin) is a self-assessment questionnaire that focuses on the harmfulness of alcohol. These questionnaires, initially intended for alcohol, have been adapted for cannabis. The advantage of these questionnaires is that they are reproducible and offer non-clinicians simple means of identifying risky uses. The field teams encounter all sorts of behavioral disorders in adolescents. The difficulty is whether these disorders are directly attributable to the consumption of the product.
Specific approach to cannabis addiction:
Specific aspects of the management of adolescents with disorders related to the use of cannabis have been largely developed by the North American teams.
They have been grouped under the CYT (Cannabis Youth Treatment) program and have been evaluated at the national level.
Two approaches seem to be particularly interesting: a family and multidimensional approach and an approach centered on motivational interviews coupled with cognitive behavioral therapies.
Motivational interviewing coupled with cognitive-behavioral therapies:
Motivational interviewing is a technique that aims to help the patient change his or her behavior. It is based on the idea that a person will only make changes if the motivation comes from the person himself. Motivational interviews use the five stages of change described by Prochaska et al.
According to these authors, patients will have to go through several stages to go from consumption to weaning.
• Precontemplation is characterized by the lack of awareness of the disorders at this stage, it is often the entourage who realizes the difficulties of the patient.
• Contemplation where there is awareness of addictive behavior and its consequences.
• Decision-making where the patient will begin to think about the steps to be taken to deal with the problem.
• The action where what has been reflected will be put into action.
• It follows, if the measures have been effective, a period of maintenance. This phase of maintenance will be marked by relapses which are a normal evolution of all the addictive behaviors. These relapses must be tolerated by the patient, his family and the doctor.
The motivational interviews propose to accompany and, if possible, to evolve the patients in all these phases. This consists of brief interventions. They are based on a number of basic principles that American authors have grouped under the acronymic name of Frames and which has been translated by Canadians as Flames, ie: Feedback, Free Referees and Notices , Options Menu, Empathy and Self-Efficiency.
The therapist will use empathy to create a climate of trust and avoid confrontation. Cannabis is often a subject of polemic between adult and adolescent with often the only result is a feeling of incomprehension on both sides. The attitude of knowing the products while adopting a position of listening (so-called low position) seems to be the most suitable to create a therapeutic alliance. This alliance will allow, without confrontation, to point out the contradictions between the benefits felt under-products and the inevitable consequences on his personal life, relational, school, family … The objective is not to convince but to restore a balance as faithful as possible the situation in order to raise awareness.
Finally, the therapist will emphasize the feeling of personal effectiveness. Often, consumption is experienced as inevitable and without any possibility of influence. It is the questioning of this dogma that will evolve the patient.
Alternative strategies will then be proposed so that the patient can face the situations of consumption.
They depend on the stage of motivation. Several techniques are used ranging from simple counseling for patients who are in the pre-contemplation stage to more elaborate strategies for those already in decision-making and action.
They are inspired by cognitive-behavioral methods and consist in the recognition of risk situations that could lead to consumption. The psychotherapeutic action is then focused on the acquisition of skills that will enable the adolescent to cope with these situations at risk.
The acquisition of skills is based on learning in individual or group interviews of several techniques that can be:
• stress management through relaxation;
• developing a list of attitudes to live without products (personal, professional, friendly);
• the acquisition of social skills through role-playing that emphasizes assertiveness. The adolescent will be able to identify different attitudes (usually passive or aggressive) that he may have when he is in conflict with a third party. The assumption is that his behavior is harmful and that they can lead to cannabis. The interest is that it can acquire a more efficient and less costly position: the affirmed position.
Multidimensional Family Approaches:
They have been developed with respect to cannabis use as part of a multidimensional family therapy (MDFT) approach, Liddle et al.). These are individual therapies but with an approach that includes family and friends.
The MDFT approach is a protocol of care based on a number of principles. In particular, the hypothesis that drug taking in adolescents is a multidimensional phenomenon. It includes a number of variables such as the personality of the adolescent, the family, the environment and the interaction between them. The literature has shown that there are favorable factors as protective factors for the consumption of products. In addition, advances in developmental psychology and psychopathology provide a conceptual and practical framework for a number of interventions.
This therapy will focus on four components:
• the personal characteristics of the adolescent, in particular his positioning in relation to the products (perception of dangerousness, emotional experience, behavior with regard to the catch);
• parents (drug representation, action taken against consumption);
• family interactions;
• and other sources of influence such as the school environment, and possibly the judicial system.
The objective is to try to re-establish a normal process of development. The therapeutic action takes place at different levels: personal, family and extrafamilial. The adolescent must acquire a certain number of skills such as identifying or even avoiding everything that leads to consumption, developing activities outside the context of use, trying to manage his emotions. The objective of parents is to support them in their efforts to support their child.
It is also about getting a therapeutic alliance with the parents. In terms of intrafamily relations, care consists in identifying dysfunctional attitudes in order to address them and eventually treat them.
Bifocal therapy:
Bifocal therapy involves two therapists, each in a different time and place. It is usually after an assessment, made in the aftermath of an acute attack, of the importance of intoxication, of the personality register, of the nature and intensity of the conflicts that the referent psychiatrist proposes in conjunction with his follow-up , a psychotherapy of analytical or cognitive behavioral inspiration contained in the here and now, according to the motivations and the insight capacities of the patient.
Listening to one (the psychiatrist consultant) takes more particularly into account the “external reality” (medical, academic, social) of the patient on which he can authorize himself to intervene actively. Once the symptomatic depressive state or the dysphoria often underlying the addiction is corrected, corrected for somatic disorders and some family conflicts, the psychiatrist accompanies the adolescent in the construction of his school, professional and leisure projects .
A source of self-satisfaction and self-reinforcement, they help the adolescent to move his investments away from family life and regain a sense of fun.
The psychiatrist consultant is not in benevolent neutrality; he does not wait for the psychotherapeutic demand (in the analytical sense of the term); it is in his need for care, represented by the repetition of the agirs or the installation in the fold, that is the request of the patient. He asks for the awakening and the desire to understand, explains the expected benefits of psychotherapeutic treatment, leaves open the discussion on his pursuit and is accountable for the absences of the patient, the resollicity by his motivation, his desire for therapist, meaning confidence in his abilities and his aspiration for change and in the possibility of expressing a structuring conflictuality because tolerable since tolerated.
Listening to the other speaker, the psychotherapist will lend oneself to that of the patient’s “internal reality” through the transfer and its countertransference. This can be the most frequent case of a psychotherapy of analytical inspiration in face-to-face, but also an analysis, even a treatment by psychodrama.
The two professionals work more or less simultaneously while respecting the spaces of each one. They tie more or less discrete ties in order to think of the articulation of the external reality and the psychic reality of the patient in its expressions acting on the body, the thought, and the relational ties within a broader and more stable therapeutic framework container.
The combined analysis of the behavior of the patient with the two participants has a considerable advantage in the precise evaluation of the psychopathological register presented and in the measured appreciation of the evolutionary potentialities.
From a clinical point of view, bifocal therapy seems particularly appropriate when we are confronted with problems that find no resolution other than in action, in particular those involving frequent outsourcing behaviors in the context of conduct . These “symptom acts” (Mac Dougall) require that, in counterpoint to the act, a therapeutic act be established as a “point of incarnation”, as an anchor and a potential support for a process of psychic transformation. This is “an economic point of view” in the sense of a Freudian metapsychology. This act is clearly manifested by the referent psychiatrist who will be able to set limits, express requirements, contain drive processes (function of clinical excitation and / or chemical excitation).
From a metapsychological point of view, the bifocal framework, with its corollary of a therapeutic alliance, is useful in the narcissistic registers which underlie many addictions when mechanisms of cleavage of the ego and invasive objects, idealization, and projective identification are at work prevalently. The existence of a third diminishes these mechanisms or rather the unconscious distribution or induction of an object (in particular maternal persecutor) role to the therapist alternates or is supported by the idealization of the other therapist.
There is therefore a therapeutic use of the mechanisms of cleavage of the patient (idealized object, persecutory object).
Conclusion:
Cannabis use today appears to be a major problem. Products derived from the plant are widely available in both quantity and quality.
The catch is not only festive but daily, resulting in a number of somatic, psychic and behavioral complications.Adolescents with high levels of substance use have more psychological difficulties and tend to be more degraded in all areas. The significant consumption of hashish in adolescence is not an isolated behavior but is part of a more general problem. This highlights the need to propose a double take-over that is both focused on the product but also on the underlying issues.