Marihuana.pdf

ADOLESCENT MEDICINE

Menstrual Disorders

PIR QUIZ

9. Joy is a 15-year-old girl who

complains about recurrent heavy

vaginal bleeding since menarche.

She feels healthy otherwise and

says she is not sexually active. In

arriving at a diagnosis, it would

be essential to test for:

A. Blood dyscrasia.

B. Fibroid tumors.

C. Malignancy.

D. Pelvic inflammatory disease.

E. Systemic lupus erythemato-

sus.

10. Diane is a 16-year-old girl who

complains of persistent irregular

menses since menarche at age 14.

She does not complain of dis-

comfort with her periods and

does not believe she has unusu-

ally heavy bleeding. She feels

healthy and is on the gymnastic

team, although she has com-

plained about persistent acne and

increasing amounts of facial hair.

She says she is not sexually

active. The most likely cause of

her irregularity is:

A. Athletics.

B. Eating disorder.

C. Polycystic ovary syndrome.

D. Sexually transmitted disease.

E. Thyroid disorder.

11. Ann is a 15 1 ⁄ 2 -year-old girl who

has complaints of prolonged

bleeding with her periods. She

says her periods last 8 or 9 days

but does not believe bleeding is

excessive. She feels well other-

wise, and her appetite is normal.

She says she is not sexually

active. Her hemoglobin is 9 g/dL.

The best treatment for her disor-

der is:

A. Dilatation and curettage.

B. Exploratory surgery.

C. Intravenous conjugated

estrogens.

D. Long-acting injectable

progestin.

E. Oral contraceptives.

12. Andrea is a 17-year-old girl who

complains of cramping lower

abdominal and pelvic pain asso-

ciated with her menstrual periods.

The pain radiates to her back.

The discomfort began about 1

year after menarche and varies

somewhat from period to period.

She says that she is not sexually

active. The first line of treatment

for her discomfort is:

A. Acetylsalicylic acid with bed

rest.

B. Acetaminophen.

C. Ibuprofen.

D. Irradiation.

E. Oral contraceptives.

13. Patricia is a 15 1 ⁄ 2 -year-old girl

who has not had a menstrual

period since menarche at age 13 1 ⁄ 2

years. Breast development was

noted at about 12 years of age.

She says that she feels well but

thinks she is overweight and pays

very strict attention to her diet.

She feels this is necessary to help

her maintain her place on the

gymnastics team. Her weight is

about 5 pounds less than normal

for her height. With this history,

you should direct specific atten-

tion to:

A. Anorexia nervosa.

B. Autoimmune oophoritis.

C. Polycystic ovary syndrome.

D. Thyroid disorder.

E. Turner syndrome.

IN BRIEF

Marijuana

Adolescent Tobacco, Alcohol, and

Drug Abuse: Prevention Strategies,

Empirical Findings, and Assessment

Issues. Botvin G, Botvin EM. J Dev

Behav Pediatr. 1992;13:290–301

National Survey Results On Drug Use.

Johnston LD, O’Malley PM, Bachman

JG. In: The Monitoring The Future

Study, 1975–1994 . Rockville, Md.:

National Institute on Drug Abuse; NIH

Publication No. 95-4026, 1995

Urine Drug Screening. Neal W,

Alderman EA. Pediatrics In Review .

1996;17:51–52

American Academy of Pediatrics and

the Center for Advanced Health

Studies: Specific Drugs. In: Schon-

berg SK, ed. Substance Abuse: A

Guide for Health Professionals . Elk

Grove Village, Ill.: American Academy

of Pediatrics; 1988:115–176

Illicit Drugs of Abuse. Brown R,

Coupey SM. AMSTARs. 1993;4:

321–340

enced a dramatic increase in popu-

larity among teenagers over the next

2 decades. At its peak, approxi-

mately 60% of high school seniors

reported some lifetime use of mari-

juana. Although use declined during

the 1980s, the past few years have

witnessed a resurgence in popularity

among adolescents in the United

States. Currently, approximately

40% of high school seniors report

some lifetime use of marijuana, with

35% reporting use during the past

year, and nearly 5% using on a daily

basis. Approximately 20% of 8th

graders has had some lifetime expe-

rience with marijuana, with 75% of

these young students reporting use

during the past year.

Marijuana is derived from the

hemp plant (cannabis sativa). The

psychoactive compound within mari-

juana, delta-9-tetrahydrocannabinol

(THC), is found in differing concen-

trations within the plant and, in par-

ticular, the leaves and flowering

shoots. Hashish, containing a much

higher concentration of THC, is

derived from a resinous exudate

found on the tops of female plants.

Although products containing

THC may be ingested or injected,

adolescent use primarily is limited

to smoking marijuana cigarettes or

“joints”. When smoked, marijuana’s

euphoric effects may be appreciated

within seconds of inhalation because

cannabinoids are transported rapidly

from the lungs to the brain. Peak

effects are achieved within minutes,

with blood levels falling rapidly

over the ensuing half hour.

Because cannabinoids are distrib-

uted widely to tissues throughout the

body, subtle impairments of function

may persist for long periods after

smoking, and laboratory testing may

confirm the use of marijuana for

days and even weeks after use. In

general, urine testing remains posi-

Uncommonly used by adolescents

prior to the 1960s, marijuana experi-

Pediatrics in Review

Vol. 18 No. 1 January 1997

tive for up to 3 days after a single

use and for 3 or more weeks subse-

quent to heavy use.

The major concerns regarding

marijuana use by adolescents relate

to behavioral consequences; how-

ever, the drug is not without physio-

logic effects. Use is accompanied

by a transient increase in both heart

rate and blood pressure, which are

of no clinical importance in the oth-

erwise healthy adolescent. Acutely,

marijuana causes bronchodilation,

but with continued inhalation the

user experiences bronchoconstric-

tion. The chronic user is subject to

consequences similar to those

encountered with tobacco smoking,

including bronchitis, obstructive air-

way disease, pharyngitis, and sinusi-

tis. Also similar to tobacco is the

presence of carcinogens in mari-

juana smoke, raising the potential

for malignancy if use is continued

over many years.

Studies of heavy users have

demonstrated a decrease in both

sperm count and sperm motility,

which return to normal after discon-

tinued use. In addition, animal stud-

ies have suggested interference with

ovulation and a decrease in circulat-

ing gonadotropins. However, the use

of marijuana has not been associated

with infertility in humans.

If the physiologic consequences

of marijuana use can be regarded as

minor or of little clinical signifi-

cance, no such statement can be

made about the behavioral effects.

Acutely, marijuana causes euphoria,

disinhibition, and intoxication. Motor

and sensory abilities are impaired.

There is an adverse effect on motor

coordination, the ability to track a

moving object, and the sense of time

and speed. All of these impairments

interfere with the safe operation of a

motor vehicle or any other poten-

tially dangerous equipment. It must

be noted that motor vehicle colli-

sions secondary to driving while

under the influence of drugs is a

major cause of adolescent morbidity

and mortality. An additional concern

is other risk-taking behavior, includ-

ing engaging in sexual or delinquent

acts while intoxicated.

With large acute doses, the user

may experience dysphoria rather

than euphoria. Such unpleasant

episodes may include distortion in

body image, depersonalization, para-

noia, and panic attacks. Occasionally

delirium and hallucinations are

reported, which may be secondary to

the marijuana, but should raise the

suspicion of adulteration with a hal-

lucinogen, particularly phencyclidine.

Marijuana use has an adverse

impact on short-term memory. The

abilities to learn and to solve prob-

lems are impaired, raising serious

concerns about use in a scholastic

setting. Chronic use has been associ-

ated with an amotivational syndrome,

in which the individual evidences a

lack of goal-directed activity.

Tolerance to the effects of mari-

juana emerges with chronic use, and

abstinence symptoms are reported

by heavy users who discontinue the

drug abruptly. This withdrawal syn-

drome is characterized by irritability,

agitation, insomnia, and document-

able changes in the electroenceph-

alogram. The withdrawal syndrome

lasts for only a few days and

requires no specific therapy.

THC crosses the placenta and,

when given in high doses to labora-

tory animals, is associated with fetal

growth retardation and congenital

anomalies. Studies of the effects of

marijuana on human fetuses have

been difficult to interpret because

they are confounded by use of mul-

tiple drugs, including alcohol and

tobacco. To date, evidence of a ter-

atogenic effect in humans remains

inconclusive.

The use of intoxicants, either

alcohol or marijuana, by adolescents

in the United States is so common as

to warrant the routine incorporation

of drug-related anticipatory guidance

into the health care of all teenagers.

It is the rare young person who has

not been exposed to the risks of

intoxication, either through personal

use or the use by close friends. Ques-

tioning not only should address what

drugs are being used and how often,

but also at what risk and with what

consequences. In particular, the

clinician should focus on issues of

driving while intoxicated, being a

passenger in a car where the driver is

intoxicated, and the potential impact

of marijuana use on scholastic

achievement. For the majority of

teenagers, whose use of marijuana is

confined to occasional intoxication in

social circumstances, conversation

regarding risk reduction is all that is

indicated. For that minority of

teenagers whose use of marijuana is

frequent, out of control, or associated

with repetitive episodes of danger,

further evaluation and referral for

drug abuse treatment is well advised.

S. Kenneth Schonberg, MD

Director, Division of Adolescent

Medicine

Montefiore Medical Center

Bronx, NY

Pediatrics in Review

Vol. 18 No. 1 January 1997

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