Assessment and management of cannabis use disorders in primary care

Thank you for a most helpful guide to assessing and managing a wide
range of Cannabis Use Disorders.[1] This makes the important point that
the youngest users are at the greatest risk of harm, for example a
depressed, pregnant adolescent in local authority care. Long term anxiety
is common among young people who smoke this drug and clinicians are
sometimes surprised by the abrupt emergence of symptoms like panic or
paranoia. Some doctors struggle to engage with school age users and even
find it difficult to distinguish residual intoxication from bloody
mindedness.

The clinical review seems oriented to engagement within a general
practice surgery, and GPs may find excellent advice from the Royal College
of General Practitioners' Adolescent Primary Care Society. However, key
case identification ("the teachable moment" for a young person) is much
more likely to arise within school health services. The "You're Welcome"
skills to build trust between a doctor and a vulnerable teenager are
crucial for success, here.[2] In both England and Scotland [3]
unprecedented levels of emotional distress are now appearing by the age of
15, and so working at establishing trust and reassurance is more important
than ever - before one can even talk about illicit drug use.

Cannabis use crops up in many other community services, from walk-ins
for minor injuries when cycling to Connexions advice for teenagers
struggling with education. In police custody Forensic Medical Examiners
will see it, as will Safeguarding teams (just look for domestic fires or
drowning incidents and 'neglect'). The spectrum of "Youth Taskforce"
services targeting support at troubled, alienated young people all see
this use. But from all the above agencies, referrals for clinical
management are rare: shame on their local Primary Care Trust 'partners'!
So where can we start to improve primary care for young cannabis users?
Most adolescents live with families, and Family Intervention Projects and
Parenting Early Intervention Programmes are steadily spreading.[4]
Appropriate "whole family assessments" should include a clinical
assessment of the actual impact of smoking cannabis on children in the
family, including use by siblings and carers. For that most vulnerable,
pregnant teenager above, looked-after children are promised a Lead
Professional in the Children Act 2004. That local authority employee has a
duty to ensure she registers with a GP, and that GP needs to collaborate
with her Lead Professional - and with her.

[1] Winstock AR, Ford C, Witton J. Assessment and management of
cannabis use disorders in primary care. BMJ 2010; 340: 800-804.

[2] Churchill D. Making health services young people friendly.
British Journal of School Nursing 2010; 5 (2): 93-94.

[3] Caan W. Editorial. Journal of Public Mental Health 2009; 8 (4): 2
-3.

[4] Department for children, schools and families, Department of
Health, National Treatment Agency for Substance Use. Annex A in: Joint
Guidance on Development of Local Protocols between Drug and Alcohol
Treatment Services and Local Safeguarding and Family Services. London:
DCSF, 2009.

Competing interests:
None declared