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Relief-oriented use of marijuana by teens Bottorff, Joan L; Johnson, Joy L; Moffat, Barbara M; Mulvogue, Tamsin Apr 23, 2009

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ralSubstance Abuse Treatment, ssBioMed CentPrevention, and PolicyOpen AcceResearchRelief-oriented use of marijuana by teensJoan L Bottorff*†1,2, Joy L Johnson†2,3, Barbara M Moffat†2 and Tamsin Mulvogue†2Address: 1Centre for Healthy Living and Chronic Disease Prevention, University of British Columbia Okanagan, 3333 University Way, Kelowna, BC V1V 1V7, Canada, 2NEXUS Research Unit, University of British Columbia, 302-6190 Agronomy Road, Vancouver, BC V6T 1Z3, Canada and 3School of Nursing, University of British Columbia, 302-6190 Agronomy Road, Vancouver, BC V6T 1Z3, CanadaEmail: Joan L Bottorff* - joan.bottorff@ubc.ca; Joy L Johnson - joy.johnson@ubc.ca; Barbara M Moffat - barb.moffat@nursing.ubc.ca; Tamsin Mulvogue - tamsin.mulvogue@mail.mcgill.ca* Corresponding author    †Equal contributorsAbstractBackground: There are indications that marijuana is increasingly used to alleviate symptoms andfor the treatment of a variety of medical conditions both physical and psychological. The purposeof this study was to describe the health concerns and problems that prompt some adolescents touse marijuana for therapeutic reasons, and their beliefs about the risks and benefits of thetherapeutic use of marijuana.Methods: As part of a larger ethnographic study of 63 adolescents who were regular marijuanausers, we analyzed interviews conducted with 20 youth who self-identified as using marijuana torelieve or manage health problems.Results: Thematic analysis revealed that these teens differentiated themselves from recreationalusers and positioned their use of marijuana for relief by emphasizing their inability to find otherways to deal with their health problems, the sophisticated ways in which they titrated their intake,and the benefits that they experienced. These teens used marijuana to gain relief from difficultfeelings (including depression, anxiety and stress), sleep difficulties, problems with concentrationand physical pain. Most were not overly concerned about the risks associated with using marijuana,maintaining that their use of marijuana was not 'in excess' and that their use fit into the realm of'normal.'Conclusion: Marijuana is perceived by some teens to be the only available alternative for teensexperiencing difficult health problems when medical treatments have failed or when they lackaccess to appropriate health care.BackgroundThere is lively public debate surrounding the use of med-ical marijuana. While some remain sceptical about thetherapeutic value of marijuana, there is a growing body ofvariety of symptoms including pain, nausea, musclespasm, insomnia, anorexia and anxiety as well as the treat-ment of a variety of medical conditions that are bothphysical and psychological [1-5]. However, less is knownPublished: 23 April 2009Substance Abuse Treatment, Prevention, and Policy 2009, 4:7 doi:10.1186/1747-597X-4-7Received: 3 December 2008Accepted: 23 April 2009This article is available from: http://www.substanceabusepolicy.com/content/4/1/7© 2009 Bottorff et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.Page 1 of 10(page number not for citation purposes)research that emphasizes its salutary effects. The literaturepoints to the use of marijuana among adults to alleviate aabout adolescents' use of marijuana for therapeutic pur-poses.Substance Abuse Treatment, Prevention, and Policy 2009, 4:7 http://www.substanceabusepolicy.com/content/4/1/7Background LiteratureFor individuals who set out to "feel better" through theuse of marijuana, use has also been referred to as "self-medication," a hypothesis which posits that people donot misuse substances solely for the experience of being"high;" rather, they do so as a means of gaining relief frompsychological and emotional pain [6]. In contrast to theadult literature on marijuana use where therapeutic use islinked to treatment of specific symptoms and illnesses, inthe adolescent literature there is less clarity about how todefine non-recreational uses of marijuana.A motivationally-driven approach is one way thatresearchers have attempted to understand marijuana useamong adolescents [7]. It is proposed that different rea-sons for using marijuana may shape patterns and contextsof use, which in turn may be associated with differentproblems related to use. Social motives for marijuana use,for example, have been associated with patterns of recrea-tional use (e.g., sensation seeking). Coping motives havebeen used to classify adolescents using marijuana for non-recreation purposes. Differences have been observedamong youth using marijuana for social and coping rea-sons that support the motives framework. In contrast toyouth aged 16–24 years using marijuana for social rea-sons, users of the same age reporting coping motives havebeen observed to have lower mental health, higher psy-chopathology, more psychosocial distress and morestressful life events than non-cannabis-using youth [8].Although there is a large body of literature related to rec-reational use of marijuana among adolescents [9,10] lessis known about other motivations for the use of mari-juana in this population. Several hypotheses haveemerged related to non-recreational uses of marijuanaamong adolescents. The "self-medication hypothesis"[11-14] is most closely associated with the therapeutic useof marijuana. Instrumental use is another term applied totaking drugs for specific pharmacological effects of thesubstance rather than for pleasure or recreational pur-poses. For example, Glassner [15] examined the notion ofinstrumental drug use in a qualitative study of young drugusers, and found that marijuana was used for its calmingeffects, to relieve tension, and to gain self-confidence. Fur-ther, support for a typology of drug related beliefs thatincluded relief-oriented beliefs [16] was demonstrated ina study of cannabis use in a sample of 285 French highschool students [17]. In this study, four 'positive' relief-oriented beliefs were identified related to how the sub-stance creates relaxation and calms anxiety, reduces suffer-ing, relieves boredom, and makes one feel better. Thepresence of relief-oriented beliefs was the only predictorof cannabis dependence.explanations, including whether marijuana use may rein-force psychiatric symptoms or increase the risk of devel-oping a psychiatric illness later in life [18-21]. A fullunderstanding of marijuana use and its potential adverseeffects, however, will require further research.The trend toward the use of marijuana for therapeutic pur-poses among adults raises questions regarding how this mayinfluence young people's use of marijuana for similar rea-sons. Recent studies suggest that adolescents are aware thatmarijuana is sometimes used to gain relief from physical andpsychological pain [22-24]. Furthermore, there is evidencesuggesting that adolescents may be using marijuana for rea-sons that are analogous to adults who use marijuana for ther-apeutic reasons. For example, young marijuana users withcoping motives report more stressful life events (e.g., deathof a family member or friend), personal injury and illnessthan socially motivated marijuana users and non-users [8].There is also indirect evidence that adolescents with mentalhealth conditions might be seeking relief through marijuanause. In a sample of 992 adolescents in drug treatment pro-grams in four U.S. cities, more than half had at least one co-morbid mental disorder. In total, 72.5% of these youth weredependent on marijuana [25]. Among youth entering outpa-tient treatment programs for cannabis use disorders, 76%were reported to have concurrent mental health conditions[26]. Finally, in a sample of homeless young people in theUK who used a variety of drugs including marijuana, partic-ipants were found to be self-medicating to deal with thestress and problems they encountered including depression,loneliness, and physical problems such as aches and pains[13].As part of a larger study to understand the culture of fre-quent marijuana use among young people, we were struckby the extent to which some participants spontaneouslydescribed using marijuana to gain relief from symptoms.In order to develop these emergent findings, we con-ducted a focused ethnography in which we examined theways in which youth use marijuana to seek relief.MethodsThis study was designed to understand and describe ado-lescents' experiences in using marijuana for therapeuticreasons, and explore how their constructions of theseexperiences are influenced by social norms. Compared toother types of ethnographic studies, focused ethnogra-phies occur on a smaller scale and seek to examine a spe-cific problem or phenomenon [27]. Typically, focusedethnographies are time-limited, involve a limited numberof participants drawn from a specific population whohave experience and understanding directly related to thearea of inquiry, and are conducted through selected epi-Page 2 of 10(page number not for citation purposes)Associations between marijuana and psychological prob-lems have also lead researchers to consider other possiblesodes of participant observation and/or interview [28]. Inthis focused ethnography, both in-depth interviews andparticipant observation were employed.Substance Abuse Treatment, Prevention, and Policy 2009, 4:7 http://www.substanceabusepolicy.com/content/4/1/7We drew data from a larger ethnographic study of fre-quent marijuana use among adolescents conducted in tworural and one urban location in British Columbia (BC),Canada. In the study communities, as is the case in muchof BC, marijuana is readily accessible to youth despite thefact that it is illegal to grow, sell or possess. The use of mar-ijuana for medical reasons is legally supported in Canadain limited circumstances; individuals meeting the criteriaare provided with cannabis or given a license to grow alimited quantity for personal use.Ethical approval for this study was obtained from the Uni-versity Behavioral Research Ethics Board. Given the sensi-tivity of the topic and because we successfully argued thatteens were able to provide consent for research participa-tion, we did not require parental consent. As a courtesy,we provided the youth with a parent/guardian informa-tion letter which outlined the study's focus as pertainingto attitudes about marijuana use in general. Participantswere told that they could take the letter home if they sochose. Prior to the interviews, written consent wasobtained from the participants. Confidentiality wasensured at the outset and participants were informed thatall identifying information would be removed from thedata.SampleIn the larger study, participants were recruited by means ofinformation fliers posted at high schools which invitedyouth to share their "views on marijuana use and teens."Youth who expressed interest in participating werescreened for eligibility by the research team. Eligibility cri-teria included being 13–18 years of age and reporting hav-ing smoked marijuana at least once in the previous week.In total, 63 young people participated in the study.Although many youth described "feeling better" after theysmoked marijuana, a subset [n = 20] explicitly describedexperiences of using marijuana on a regular basis specifi-cally to manage, reduce or eliminate unpleasant anduncomfortable feelings or other health problems. Theyconstructed marijuana as a treatment for health problems,often suggesting it had significantly greater benefit thanother medical treatments they had been offered. None ofthese students were legally provided with cannabis formedical treatment or given a licence to grow marijuana formedicinal use. Characteristics of this sub-set of partici-pants are presented in Table 1. The majority of youthusing marijuana for relief were male, and the average ageof initiation of marijuana was 13 years of age. Youth inthis subset were of diverse ethnic backgrounds. Most [n =12] indicated that they were "Canadian" or "Caucasian; "More specifically, 2 participants identified as FirstNations, 6 individuals were part First Nations, 3 of UKused marijuana for the purpose of relief, those recruited tothis study who smoked marijuana for recreational pur-poses (n = 43) smoked marijuana less frequently (averageof 11 days in the last 30 days) and used marijuana moreoften with others.Data CollectionThe primary source of data was in-depth, semi-structuredinterviews with youth to glean accounts of their experi-ences with marijuana. We used a short questionnaire priorto beginning the qualitative interview to collect demo-graphic data and to assess history of marijuana use andcurrent use. The questionnaire included items related tomarijuana use including age of initiation, use in the lastmonth, frequency and quit attempts. We also collecteddata on the time of day that individuals usually used mar-ijuana.The interviews were conducted using an interview guide.Broad discussion categories included: history and patternof use, the reasons for their use, what they knew aboutmarijuana, the sources of that information as well as con-textual factors related to their use. Open-ended questionswere posed in relation to each of these topics, as requiredduring the interviews. Many of these youth were at easewhen talking about their use of marijuana and needed lit-tle prompting. When youth described the use of mari-juana to help them feel better, participants were asked toelaborate further on their experiences.The tape-recorded interviews took place in privacy withinthe school setting and lasted from 1 to 2 hours. Partici-Table 1: Description of participants who smoke marijuana for relief (n = 20)GenderFemale 7 (35%)Male 13 (65%)Age (years) X = 16 yrs (range 14–18 yrs)Age of initiation (years) X = 13 yrs (range = 10–16 yrs)Frequency of use (days) X = 2 days/mo (range = 2–31 days/mo)Number of times/day 1 – > 5 times/dayTime of day of first useMorning 4 (20%)Afternoon 11 (55%)Evening 5 (55%)Marijuana use when alone yes = 16 (80%)Reasons for use*Depression 6Stress/anxiety 12Sleep problems 9Focus/concentration 3Physical pain 5* some participants used marijuana for more than one reasonPage 3 of 10(page number not for citation purposes)descent and 3 were of European background includingItalian, Croatian, and Ukrainian. Compared to those whopants were offered a $20 honorarium. Field notes wereused to record impressions of responses to the interviewSubstance Abuse Treatment, Prevention, and Policy 2009, 4:7 http://www.substanceabusepolicy.com/content/4/1/7and the interviewer's assessment of the quality of theinterview. In addition, field notes were maintained torecord pertinent observations within the school and in thelarger community (e.g., noting school policies regardingmarijuana use at school and the presence of graffiti relatedto marijuana in close proximity of the school; visitingfavourite outdoor settings where some indicated that theypreferred to smoke marijuana along with hemp shopswhere they purchased pipes and bongs and other para-phernalia).Data AnalysisAll data including transcribed interviews and field noteswere reviewed several times by the research team payingclose attention to young people's descriptions of experi-ences with the use of marijuana to address uncomfortablefeelings or health problems, and the circumstances thatsurrounded this use. Close readings of the interviews bythe investigative team involved highlighting potentiallyimportant comments, raising questions about the data,and identifying prominent dimensions of participants'experiences. During team meetings, interview data werediscussed and emergent categories were identified to cap-ture experiences related to marijuana use. These categorieswere organized into a coding framework and used to codethe data. All coding was completed by one of the authorswho completed a majority of the interviews (BMM). Tocode the data, we used [29] the NVivo software programdesigned for qualitative analysis of textual data. The pro-gram was also used to retrieve data coded under each cat-egory for a more nuanced analysis by the investigativeteam. Through reflective questioning of these data anddetailed comparisons, themes were identified and dis-cussed in team meetings.ResultsThe Context of Using Marijuana for ReliefThe teens situated their use of marijuana for relief ofhealth problems in the context of difficult life events andillness experiences marked by a lack of supportive familynetworks, unexpected and sometimes traumatic losses ofclose friends or family members, and difficulties atschool. Many indicated that they had few people to turnto help them; for some their parents were having difficultycoping with their own situations of unemployment, sub-stance use, and marriage breakdowns and offered littlesupport. Those living in households with a parent andstep-parent had difficulty coping with unresolved feelingstowards their estranged biological parent. Finally, severalteens who made frequent moves with their families expe-rienced social isolation at school and were subject tobeing bullied and teased.tations; their problems were either not taken seriously orthe solutions offered were not helpful. For example, youthwho reported they had been prescribed drugs such as Rita-lin, Prozac or sleeping pills, stopped using them becausethey did not like how these drugs made them feel or foundthem ineffective. Despite visits to doctors, prescribedtreatments and, for a few, hospitalizations, many of theseteens perceived that they did not receive the help theyneeded from doctors.A final contextual feature to these teens' lives were theirobservations of others' use of marijuana to deal with dif-ficult circumstances or symptoms, including, in a fewcases, parents and other significant adults in their life. Forexample, one young man reported that his mother wasusing marijuana while receiving cancer treatment. As heobserved, "It helped her sleep and calmed her down."Others described how they were given advice from otherteens about how marijuana could "help." Together thesecircumstances created a context where teens routinelyturned to marijuana to manage physical and psychologi-cal problems in their lives. Marijuana was readily availa-ble, used by others in their network, and was perceived toprovide an effective solution not offered to them from themedical system.Regular Relief:Patterns of Using Marijuana for Persistent ProblemsMost of the participants who consistently used marijuanafor relief, smoked it when alone, often several times a day.For some, their day began and ended with using mari-juana; they smoked before leaving home for school andprior to going to bed. Some indicated that they needed tosmoke marijuana during the school day to manage symp-toms, and when this occurred it was often in the companyof friends. A few participants smoked marijuana for reliefin adult company that included relatives and "older"friends who supported their need to use marijuana tomanage symptoms.There were two patterns of marijuana use for relief: inter-mittent and chronic. With intermittent use, youth rou-tinely relied on marijuana to deal with short-termproblems such as stressful situations or limited periods ofphysical pain. One 14 year old male described non-dailyuse occurring whenever he had a "really bad day." In thecase of chronic use, daily marijuana was used for the reliefof identified conditions such as depression, ADHD and toroutinely settle at night or manage sleeplessness. Youngpeople's descriptions of marijuana use for relief wereimbued with language common to using pharmaceuti-cals. A number of these youth indicated how they care-fully titrated their intake; others described their use asPage 4 of 10(page number not for citation purposes)Experiences with the medical system to address theirhealth problems consistently fell short of the teens' expec-"moderate," involving a "few puffs," or just a "certainamount." Through experience, they had learned to honeSubstance Abuse Treatment, Prevention, and Policy 2009, 4:7 http://www.substanceabusepolicy.com/content/4/1/7ways of using the right amount of marijuana to achieve astate of relief. As one male elaborated, he regulated hisintake by mixing his marijuana with tobacco so as to get"just enough" marijuana to relieve regular states of agita-tion and high levels of stress. Along with skills at monitor-ing their intake of marijuana, these youth confidentlyshared in-depth knowledge of the strength and associatedeffects of different strains of marijuana.Explaining the Need to Use Marijuana for ReliefThe young people in the sub-sample were particularlyarticulate in describing their "need" to use marijuana.They were adamant and confident that marijuana pro-vided relief from their health problems. The decision tosmoke marijuana was stated in a straight forward fashion(e.g., "I started it to make myself feel better") and justifiedbecause they had a "reason for it." Participants alsoframed their marijuana use in a positive manner; in sodoing, gave credence to the claim that this was the rightcourse of action. As one girl elaborated on her daily use,"Pot helps me be me." Several described unpleasant phys-ical sensations such as feeling "jittery" associated with theabsence of marijuana. For these youth, regular marijuanause allowed them relief from these unpleasant symptomsso that they were able to feel "normal." One 18-year oldmale who used marijuana everyday indicated, "If any-thing, it makes you more normal." Of note, he had firststarted to use marijuana at the age of 13, and smoked itregularly for 5 years typically 4 times a day.For these youth, the purpose of smoking marijuana wasnot specifically about getting high or stoned, nor was mar-ijuana used for "pleasure." In fact, participants tended todifferentiate their own use from peers who were recrea-tional users who smoked marijuana when they were "par-tying" or "socializing." As one 16-year old male describedhis use, "I don't get a strong sense of euphoria, I just calmdown a bit, that's just how it is for me." However, therewere a few instances when female participants did smoke"to get high" for the purpose of "escaping reality," a strat-egy used to remove themselves temporarily from the chal-lenging circumstances that accompanied their daily lives.The participants also distinguished themselves from the"stoner" stereotype, whose preferred activities were watch-ing movies or listening to heavy metal music while smok-ing marijuana.Some explanations of using of marijuana to feel betterwere further bolstered with a focus on use for described"health" reasons. As one 16-year old female indicated, herdaily use of marijuana was "more of a health thing, thanto get high." She reflected on her history of "mild depres-sion" and her difficulties with antidepressants that hadmarijuana, thereby providing solid rationale for her con-tinued use of marijuana. One male situated his marijuanause within a perspective that medications are used to helpdeal with problems.I bet you if I had never been put on Ritalin at a youngerage, I might not have had the same opinion of drugsgrowing up, you know, because I was taught growingup that you take drugs to help you out with your prob-lems, you know. [18 years, non-daily use]Often, marijuana was compared to other substances in away that suggested marijuana was the best option, furthersupporting ongoing use of marijuana for relief purposes.Some constructed marijuana as a "natural" substance thatwas preferable and considered "safer" than many pharma-ceutical alternatives. One 14-year old female discoveredthat marijuana was a better option than dealing with theside effects of pharmaceuticals stating, "Well, my body, Ihave to be careful what pills I take. I have bad reactions tosome medications. My body rejects it and I get really sick."Interestingly, one 18-year old who smoked twice a day on21 days during the last month, went as far to describehimself as a "healthy marijuana user" adding, "It's notgood for you, but then again, neither is MacDonald's anda lot of other things." The health claims in these descrip-tions served to explain the ongoing use of marijuana forrelief.Painful Lives: Types of Symptoms and Distress Requiring ReliefIn the interviews the teens directly linked their use of mar-ijuana with the management of difficult feelings (includ-ing depression, anxiety and stress), sleep problems,problems with concentration and physical pain. Each ofthese will be described in the following sections.Difficult FeelingsAlthough some teens described using marijuana to dealwith instances of being angry, experiencing a significantdisappointment (e.g., with exam results), being afraid, orto forget the past, the most frequent uses were associatedwith dealing with depression, and managing stress andanxiety.DepressionSix participants indicated they were using marijuana spe-cifically to deal with depression and several othersreported knowing teens that were doing the same. Dealingwith difficult personal circumstances was a commontheme for this group of teens and was linked to the loss ofsignificant people in their lives, a family history of depres-sion, financial worries at home, "fights" with parents,Page 5 of 10(page number not for citation purposes)resulted in insomnia and a loss of appetite. She suggestedthat these health issues would re-surface in the absence ofabuse, and too much "shit" in their lives. Several reportedreceiving treatment for depression in the form of antide-Substance Abuse Treatment, Prevention, and Policy 2009, 4:7 http://www.substanceabusepolicy.com/content/4/1/7pressants and counseling, sometimes over extended peri-ods, yet with little relief. For others, these options werenot available in part because "nobody wanted to listen" tothem. As a last resort, these teens had opted to try smokingmarijuana. In a relatively short time, marijuana helpedthem to feel better about themselves, happier and morelike the person they "wanted to be" as well as alleviateother problems associated with depression (poor appe-tite, difficulty concentrating, poor sleep).Not all participants agreed about the use of marijuana fordepression. One 16-year old male used marijuana to dealwith his unhappiness surrounding the conflict betweenhis mother and father, and worried that he might be usingpot too frequently. He reasoned that being happy all ofthe time was not natural, and that there was nothingwrong with being sad and confused sometimes. As aresult, he tried to limit using marijuana to weekends withfriends. Others believed that marijuana should only beused for certain types of depression because of the possi-bility of becoming more depressed by smoking pot:I think it depends on the level of depression that youhave. If it's like depressed because you are sick, thenpot is helping you. It's making you happier. But ifyou're depressed about killing yourself, I don't thinkthat it's a good idea to smoke pot just because it couldbring you down more. It's hard to say, though, it's dif-ferent for every person, right? That just how it makesme feel. [Female, 17 years, daily use]Stress and anxietyThe use of marijuana to manage stress and anxiety wasdescribed by 12 teens in our sample. Dealing with bully-ing at school, heavy demands of school work, taxing shiftsat work, and just "giving as much as you can" along sidedifficult relationships with parents or guardians, andreceiving threats from neighbors all took its toll on theseyouth. For some, these experiences contributed to highlevels of stress and anxiety, and for others uncomfortablelevels of anger – both were difficult to manage. Althoughsome had friends they could turn to, marijuana providedan additional source of stress relief that was ready at hand.Lots of people know me, know I do pot and they thinkthat I'm a pot head but really the thing they don't real-ize is that I have a reason for it. It's for my stress andan antidepressant. I get really upset. It [pot] helps mefeel better about myself, because you know peopledon't do that [help me], like my friend [name] can, butnobody else can. [Female, 14 years, non-daily use]There was general agreement among the teens that mari-recognized, however, that despite the fact that marijuanacould be a very effective stress reliever, it might not workfor everyone:Well as far as pot goes, the good thing is that it's defi-nitely a stress reliever, hands down. I know lots of peo-ple who would be just a complete wreck if they weren'tsmoking pot but then there's also people who are acomplete wreck because they do smoke pot, so it'skind of a hard thing. [Male, 16 years, non-daily use]Sleep problemsNine teens in our sample described using marijuana tohelp them sleep. The "trouble" they had with sleeping wasa constant problem that many had experienced for years.One 16-year old, who also experienced mild depression,indicated that she "stopped sleeping for two years." Notonly did the problem affect their school performance, butit was deeply disturbing to them. As another femaledescribed,I have a really hard time sleeping. I can lay there forabout four to five hours, just laying there. And I justfinally had it, and I just feel like screaming I don't wantto wake anyone up. So I go downstairs and ask mygran or my brother [for some marijuana] or I have aroach or two sitting around. [16 years, non-daily use]Although one teen indicated that she had spoken to hermother about her problems sleeping, others indicatedthat the adults in their lives did not offer any support.I have trouble going to sleep and waking up...My mumwanted to get the doctor to put me on sleeping pillsbut he said at such a young age it would cause like anaddiction to them...I've had these problems since ele-mentary school...I just, I can't go to sleep at night andthen I like to sleep during the day. [Female, 14 years,non-daily use]Many teens turned to pot and found almost immediatebenefits in helping them sleep. Likened to a "magic sleep-ing pill" by one young male, the teens found it calmedtheir "busy minds," helped them relax and fall asleepquickly.Focus/concentrationThree teens reported using marijuana to improve theirconcentration. They explained that they had difficultyfocusing at school and that this affected their school per-formance. As one male explained:Personally, I'm a very fast paced guy and my mind isPage 6 of 10(page number not for citation purposes)juana calmed them down, and helped them feel "not sonervous" and "not so uptight about everything." One teenalways rushing, hard to gather my thoughts. I think alot faster than I can speak. I get distracted very easily.Substance Abuse Treatment, Prevention, and Policy 2009, 4:7 http://www.substanceabusepolicy.com/content/4/1/7In social studies last year, I would talk and wouldn'tdo any work. But if I had just a little bit of pot, I couldreally focus my work. I could sit there and I'd work allday and finish everything and have no homework andbe done by the end of class. [16 years, non-daily use]These young people believed they could "think better"when they used marijuana because it allowed them tofocus their thinking, and, slow it down in a way that waspreferable. All suggested that these cognitive changes werelinked to improved school performance. One teen, whoself-identified as a having "attention deficit, hyperactivedisorder" shared the difficulties he experienced on Ritalin.He began smoking pot when he was 12 years of age andstill on Ritalin.Usually my mind is in over gear, right? I'm usuallygoing about a mile a minute and my hands are movingway too fast, and I'm really fidgety. But if I have a puffof marijuana in a moderate use, by moderate I meanone to three to four puffs, depending on the qual-ity....being toned down a bit I find really helps me....If Itry to do homework at home without smoking pot, Ijust can't focus. I'll be looking at my schoolwork and forme with my ADHD this is how it's always been for me.Like school was just a constant story of this scenariobefore I smoked marijuana. [17 years, non-daily use]Physical PainFive teens indicated they used marijuana to obtain painrelief, and several others shared similar stories about otheryouth. One male used marijuana to deal with pain associ-ated with rehabilitation after a muscle injury, anotherused marijuana following an accident where he sustained3rd degree burns and yet another because of plates in hisback due to a car injury. Others suggested that marijuanareduced muscle pain after a hard day of skiing and helpedwith headaches, and that girls used marijuana for men-strual cramps. One 17-year old male used it daily andexplained that marijuana "numbs your systems or senses[and] relaxes your muscles."Considering the Risks of Using Marijuana for ReliefIn spite of experiencing personal benefits from using mar-ijuana for relief, some participants wrestled with their useof marijuana. One girl noted her own problematic use ofmarijuana that had quickly evolved into relying on it todeal with the regular stress in her life. As she pondered,she commented knowingly that it would be preferable touse it only when her stress level was "really" high.I mean I started it, and I'm doing it for the wrong rea-sons...I think if I cut back and only did it when I wasAlthough knowing that it was "harmful" to her body, sheadded that she found it difficult to quit using marijuana.Most youth were aware of the health consequences associ-ated with marijuana use in general and their own use inparticular. They noticed physical symptoms such asdecreased stamina and shortness of breath with physicalactivities, while others worried about weakened immunesystems and how it affected their energy level. Some rec-ognized that they were addicted to marijuana. One malewho had been using marijuana for six years framed it assomething that he would address at a later date. "I'm try-ing to get through school and then worry about mydependency issue with marijuana."Others noted that their marijuana use was linked to diffi-culties that they were having at school. One male con-cluded, "I think it brings marks down in one way andsometimes you don't understand things maybe as easily."Others recognized how their use had affected their mem-ory. For a number of the participants, their knowledge ofthe risks of smoking marijuana was limited and, at times,incorrect. For example, as one 14-year old male who hadstarted smoking marijuana in the past year to relieve mus-cle pain noted, "It's bad for your lungs, just it's 400 timeslower than tobacco."In what appeared to be an effort to minimize their use inthe face of health risks, the teens emphasized that theywere not using marijuana "in excess." One 18-year oldsummed up six years of using marijuana by saying, "Idon't feel that I have a problem," adding that "it doesn'treally have that many side effects." Some suggested thatthe benefits of smoking marijuana outweighed the risks.As noted, for those with difficulties sleeping at night, notbeing able to function the following day when sleepdeprived was agonizing; marijuana use at night was pref-erable and provided a solution to that quandary. How-ever, one male pondered both sides of his use ofmarijuana in dealing with his depression and was lessoptimistic:Well, in some ways, it's helped me and some ways ithasn't. It's good when it's there, but when it's not, itkind of makes me sad. So it's hard like to try to keepup with staying happy all the time.[18 years, daily use]Several participants made reference to the contradictionsthat they saw in their world regarding other licit sub-stances and used that argument to make sense of andpraise the benefits of marijuana over the risks.And the thing is that if it's already used, they're alreadygrowing it for people that need it for medical help,Page 7 of 10(page number not for citation purposes)really stressed out or something, then, you know,really cut back, I think it would be okay. [14 years,non-daily use]then like why not.... Like no one has ever overdosedon marijuana, but people die everyday from alcohol,everyday from cigarettes and everyday from vastSubstance Abuse Treatment, Prevention, and Policy 2009, 4:7 http://www.substanceabusepolicy.com/content/4/1/7amounts of things that the government has legalized,but they just won't legalize marijuana for some reason.It's never killed anyone, never really hurt anyone, itsaves people's lives and they could make a goodamount of money from it and drop crime rates, whydon't they do it? [Male, 14 years, non-daily use]DiscussionThe findings of this study provide one of the first in-depthdescriptions of youths' use of marijuana for non-recrea-tional purposes, adding to the growing body of researchon the use of drugs to self-medicate among young people.Teens involved in regular and long-term use of marijuanafor relief constructed their use of marijuana as essential tofeeling better or "normal" in situations where they per-ceived there were few other options available to them.Unlike the spontaneity typically involved in recreationaluse, these youth were thoughtful and prescriptive withtheir marijuana use – carefully monitoring and titratingtheir use to optimize its therapeutic effect. The findingsalso point to important contextual factors that furthersupport youth's use of marijuana for relief that extendbeyond the availability of marijuana and dominant dis-courses that construct marijuana as a natural product withmedicinal properties.Of key importance in the findings are the unmet healthneeds of these youth. Health issues such as depression,insomnia, and anxiety were significant problems thatinterfered with these youths' ability to function at school,maintain relationships with family and friends, and feelthat they could live a normal life. The level of distressassociated with these health concerns, along with the lackof effective interventions by heath care providers and fam-ily members appeared to leave them with few alternatives.Researchers have reported that when adolescents in ruralcommunities experience barriers to seeking health care,they think they can take care of the problems themselves[30]. Similarly, our study participants believed that theirbest option was to assume responsibility for treating theirproblems by using marijuana. Unpleasant side effectswith prescribed medications and long, ineffective thera-pies resulted in little hope that the medical system couldbe counted on as beneficial. In contrast, marijuana pro-vided these youth with immediate relief for a variety ofhealth concerns. Nevertheless, the regular use of mari-juana put youth at risk. Cannabis use has been identifiedas a risk factor for mental illness such as psychosis, schiz-ophrenia [21,31,32] and psychiatric symptoms such aspanic attacks [33]. Teens who smoked marijuana at leastonce per month in the past year were found to be threetimes more likely to have suicidal thoughts than non-users [34], and there is evidence that exposure to cannabisstance use and school failure [36]. What is interesting isthat the findings of this study suggest that youth have littleawareness of some of these risks; rather, some are usingmarijuana to counteract these very problems (e.g., depres-sion, school failure). Teens' perceptions that their healthconcerns were not addressed suggest that more attentionis needed to assess these issues and ensure that otheroptions are available to them. Parents and health care pro-viders need to make a concerted effort to not only under-stand the pressures and influences on youth [37], but alsogain a better understanding of the effect of youths' healthproblems on their ability to engage in healthy lifestylechoices.Underlying problems related to youth health concernsalso need to be addressed. In many situations, the partici-pants' symptoms appeared to be directly related to theirlife circumstances. Along with the challenges inherent inbeing an adolescent in today's complex world, some teenswere also trying to deal with significant losses (death of aclose friend or family member), extremely difficult familyrelationships, disappointments with friends, school andsports, and a fragile family and peer support network. Therisk of substance use increases substantially when youthare attempting to deal with these kinds of situations inisolation. Although marijuana provided the youth withtemporary relief, the underlying situation often wentunattended – leading the teens into a regular pattern ofuse. Appropriate guidance and targeted support fromcounselors and health care providers must be sensitive tomeeting the needs of youth as they work through such sit-uations and life altering events. In addition, adults work-ing with youth must find better ways to talk with youngpeople about how they are coping with their health issues,including their marijuana use. Based on the experiences ofyouth in this study, there is a wide range of support thatmay benefit youth including counseling, stress manage-ment, social skills training, anger management, studyskills, pain management, and sleep hygiene. The youth inthis study had minimal access to these types of resources.The influence of the policy environment in Canada related tomedical marijuana cannot be dismissed. The youth in thisstudy were familiar with medical marijuana and its sanc-tioned use among those with serious illnesses; some knewindividuals in their social network who were medical mari-juana users. In addition, we acknowledge that the availabilityof marijuana in the study settings provided teens with oppor-tunities to try marijuana to relieve symptoms. In localeswhere it is more difficult to access marijuana and penaltiesfor possession of marijuana are harsh, teens with similarsymptoms may use other approaches.Page 8 of 10(page number not for citation purposes)may worsen depression in youth [35]. Marijuana useamong youth has also been associated with other sub-Despite presenting themselves as being sophisticatedusers of marijuana, with a rich knowledge of marijuanaSubstance Abuse Treatment, Prevention, and Policy 2009, 4:7 http://www.substanceabusepolicy.com/content/4/1/7acquired through direct experience, conversations andobservations of others, the youth in our study did notappear to be well informed about the therapeutic use ofmarijuana. Targeted education for youth regarding therisks of marijuana and its appropriate use as a therapeuticagent is warranted, including the risks of legal sanctions.However, as Tupper [38] has suggested regarding drugeducation, fear-based approaches are unlikely to be effec-tive when the reality of youths' observations and experi-ences suggest that few serious consequences stand indirect contrast to the "facts" teachers often provide. Alter-native approaches are required that acknowledge the com-plexity of the issues that inform understandings ofmarijuana. Tupper suggests that drug education be framedusing the metaphor of "drugs as tools" to allow "morenuanced understandings of the benefits and harms ofdrugs, depending on who is using them, in what circum-stances, and for what purpose" (p. 235). This approachmay be useful in education focused on marijuana.This study was conducted in three locations in the prov-ince of British Columbia (BC) Canada and as such maynot be generalized to other contexts. The province of BC isknown for its illicit marijuana production [39]. And, ingeneral the BC public is tolerant of marijuana use andsupport decriminalizing recreational use. In other con-texts, teens might turn to other substances such as alcohol.The findings of this study provide a snapshot of theseteens' use of marijuana. Further research is required toexamine how this therapeutic use evolves over time.ConclusionIn summary, this study highlights youths' efforts toaddress their health problems and their experiences inusing marijuana for relief. Marijuana may be perceived bysome teens to be the only available alternative for thoseexperiencing difficult physical or emotional problemswhen medical treatments have failed or when they lackaccess to appropriate health care. As has been noted inother studies of substance use [40], understanding whyadolescents use particular substances is key in developingappropriate educational and intervention programs.Competing interestsThe authors declare that they have no competing interests.Authors' contributionsJLB lead the data analysis, and conceptualized and partic-ipated in writing the manuscript. JLJ designed the largerstudy, participated in data analysis and the writing of thepaper. BMM collected and analysed data, participated inwriting of the manuscript. TM assisted with data manage-ment and contributed to the writing of the manuscript.AcknowledgementsThis study was made possible by grant funding from the Canadian Institutes of Health Research (CIHR) [Funding reference: MOP-77813] and career support provided by the CIHR to Dr. Johnson.References1. 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