Chapter II.

Theoretical framework

Background to the investigation

The possibility that cannabis use in adolescence may hide unadated intra-
family dynamics, sometimes characterized by abuse and violence, justify the
research that attempts to uncover these serious situations by identifying young
users regardless of the pattern of consumption.

International

In a study conducted in Mexico City (Martínez-Mota, Jiménez-Rubio et al.,

2018) through a systematic review and meta-analysis, the main objective was to
relate exposure to various types of violence in childhood with cannabis abuse or
dependence in adolescence, in addition to determining the main risk factors. The
following types of violence were analyzed: sexual abuse, physical abuse, and
witnessing violence. Witnessing violence by exposure to violence directed against
another family member or any person, and in any environment (home or
community) was defined. Cannabis use (or abuse) included all forms of use,
encompassing one-time use, inequent or intermittent use, and chronic use.
The study showed that all three types of violence contributed to an
increased risk for cannabis use, or the development of cannabis dependence in
adolescence, although this association varied according to the type of abuse.
Sexual abuse was the strongest predictor for cannabis abuse or dependence in
adolescents of either sex while witnessing violence weakly impacted the main
results of the research.
It is worth mentioning that, in this study, because of the three types of
violence, not only the development of cannabis dependence was considered, but
any type of consumption was included, up to the use on a single occasion.
Therefore, and regarding punctual consumption, it is quite daring to associate it
with some type of violence, this pattern of consumption being very common in the
adolescent population.
 Clinical experience tells us that a wider range of less severe conflictive
family situations can act as a trigger for cannabis use and therefore further studies
are required to confirm these relationships.
The study provides to the present research the premise of knowledge about
the cannabinoids that contribute to the final psychoactivity of cannabis and that
precedes the adequate understanding of the phenomenon of its consumption in the
adolescent population.
Casajuana Kögel, López-Pelayo et al. (2018) carried out a systematic
review of different scientific articles published before March 2016 following the
PRISMA guidelines. The study sought to analyze the contribution of other
cannabinoids naturally present to psychoactive effects in humans considering their
concentrations and pharmacodynamics, the authors emphasize that cannabis use
has always been accompanied by controversy due to its psychotropic effects,
defined by the WHO as "ability to change an individual's consciousness, emotional
state or thought processes" (WHO, 2004).
The literature review carried out showed that despite the increase in
knowledge about its therapeutic potential, the use of cannabis is part of a great
controversy, especially due to the difficulties of separating the psychotropic effects
from the therapeutic ones, having an impact on the evaluation of consumption and
on the screening of problematic users focused on the frequency of consumption or
on the criteria of the CAST, being practically unexplored the amount of
cannabinoids consume Gives.

The results of the research were broken down into three aspects:

1) Naturally present cannabinoids that affect the psychoactivity of cannabis: In

the first part, dose-dependent psychoactive effects of Delta-9-trans-
Tetrahydrocannabinol (9-THC) were observed in different routes of administration
(intravenous, oral and inhaled). Delta-8-Tetrahydrocannabinol (8-THC) and
Cannabinol (CBN) produce psychoactive effects in humans, but with less intensity
than 9-THC. Especially CBN has a potency ratio of 1:10 (CBN: 9-THC), but no
psychoactive effects were presented after oral administration. Another cannabinoid
that produced no psychoactive effects after oral administration was cannabidiol
(CBD). A finding of enormous interest was that CBD has a modulating effect on the
psychoactive activity of 9-THC whose intensity depends on different factors such
as the relationship between CBD:9-THC or the order of administration of
cannabinoids.
2) Pharmacodynamiceffects: In the second part the authors highlight the
pharmacodynamic effects both psychological and systemic of cannabinoids
naturally present in cannabis. Among the psychological effects, pure 9-THC and
cannabis derivatives produce dose-dependent effects and in particular sensations
of intoxication and stimulation have been described more frequently. Other effects
often observed were anxiety, sedation, deviations from psychomotor performance,
memory impairment, emotional changes, and decreased perceptual accuracy. The
studies included in the review focused mainly on CBD suggesting that this
substance has a potential influence on the ultimate effects of cannabis. CBD was
shown to antagonize and modulate memory impairment as well as having
projective effects on anxiety and psychotic symptomatology induced by 9-THC.
Among the systemic consequences of the cannabinoids naturally present in
cannabis were described dose-dependent cardiovascular effects (marked increase
in heart rate) in addition to feelings of hunger, decreased balance and increased
pupil size.

3) The reported potencies of naturally present psychoactiveconstituents: With

respect to the reported potencies of naturally present psychoactive constituents, 9-
THC is almost always the cannabinoid present in greater proportion (39.85% in
Dutch hashish). On the other hand, the highest percentage of 9-THC (25.5%) in
herbal cannabis was found in New Zealand indicating in general clearly lower
concentrations compared to hashish.
One of the limits of this systematic review was that the use of synthetic
cannabinoids, usually very potent in terms of the search for increasingly strong
products for recreational use, was not considered. In conclusion, the study
considered that, when evaluating the effects of cannabis, 9-THC should be
considered as the main contributor to the psychoactivity of cannabis because it is
the most potent psychoactive cannabinoid and the one that is most present in the
derivatives, likewise, the authors affirm that it is more important to identify the
problematic consumption pattern not only by frequency criteria, units
consumed/day or qualitative, but it would be necessary to introduce as a criterion
also the concentration of the different cannabinoids naturally present in cannabis.
The use of Psychoactive Substances in Colombia has always been
considered a major public health and safety issue. A 2018 study that was carried
out for a population of 234 students between 12 and 18 years old through a cross-
sectional cut evidenced the increase in consumption in Barrancabermeja,
especially highlighting the early age of onset of this (Jiménez Meriño and Rojas
Fernández, 2018).
As the study points out, the consumption of psychoactive substances,
through its "facilitating" function in the face of different aversive situations, is
increasingly taking on a central role in the lives of adolescents. The objective of the
study was to describe the behavior of consumption of psychoactive substances in
students of Barrancabermeja identifying the different variables that are associated
with an increased risk of consumption.
The period of adolescence is decisive for the development of the human
being and also the time of greatest tendency to experiment. Among these
experiences is the consumption of psychoactive substances. Depending on the
vulnerability of each one, an alarming number of adolescents may meet the criteria
for substance use disorder, and family and social aspects may act both as
protective and risk factors.
The study confirmed a high level of perception of accessibility to marijuana
by noting that 53.85% of young people would take a time range of 0 to 30 minutes
to get the substance. Only 3% of the study population admitted to using marijuana
today (slightly more men than women) with a percentage that rises to 9.4% if you
consider using it at some time in life.
Regarding the accessibility to marijuana in the school context, 39% of
students considered it easy or very easy to get it. 61.5% acknowledged living in a
family context that is a user of legal substances (alcohol, tobacco, anxiolytic). This
percentage is reduced to 20% when we talk about illegal substances. If we look
only at the use of marijuana or creepy 26.5% admitted that members of their family
used these substances at some time. The data also confirmed the tendency to
associate marijuana use with legal psychoactive substances (alcohol and tobacco)
emphasizing the importance of preventing or delaying as much as possible the
onset of consumption of any type of psychoactive substance.
The study concluded that early experimentation with one type of substance
facilitates further experimentation with other substances. The predisposing factors
towards consumption related to the personal, family, and social sphere of the
adolescent were confirmed crucial factors to take into account in order to an
adequate and effective intervention.
Special attention requires the consumption of psychoactive substances in
the school context. A study conducted in 2020 described the evolution of
trafficking and consumption of drugs or psychoactive substances in school
contexts in the department of Nariño (Benavides Mora and Casallas Murillo, 2020).
In the context of an increasingly confirmed trend at the beginning of
consumption at an early age, the study shows how micro trafficking facilitates
those children and adolescents in school have access to psychoactive substances.
Studies carried out by the United Nations Office on Drugs and Crime (UNODC)
and the Colombian Drug Observatory (ODC) indicated that the most vulnerable
stage for consumption is the passage from early adolescence, between 12 and 14
years, to late adolescence, between 15 and 17 years.
As evidenced by the National Study of Consumption of Psychoactive
Substances in the School Population in Colombia, the situation of consumption in
this context is especially worrying. The data of this study showed that 11.7% of
adolescents had used marijuana at least once in their lives, with the consumption
of this substance occupying the first place among Colombian students. In addition
to those already widely confirmed and numerous individuals, family and social risk
factors, the authors emphasize the role played by the planting of illicit crops, drug
trafficking and especially microtrafficking in order to increase accessibility to
substances.
 On the other hand, drug trafficking and microtrafficking offer the tempting
opportunity for young people to increase their economic income. The policy of
"wars on drugs" introduced by the United States since 1969 instead of solving the
problem has produced significant collateral damage such as violence, in addition to
harming vulnerable population sectors (peasants and indigenous people involved
in production). Obviously, poverty and social inequality increase the likelihood of
participating in this type of illegal business.
Another important aspect is the very close relationship between the planting
of illicit crops and the presence of organized armed groups that guarantee
territorial control for production that has made the drug business finance these
groups. Obviously, with the increase in drug cultivation and trafficking in Nariño,
violence also increased. This does not allow the region to progress socially and
develop projects of another nature for the economic development of its inhabitants.
For example, there are no greater employment possibilities in Tumaco, it is logical
that young people participate in these illegal activities, accepting drug trafficking as
a source of sustenance and becoming key pieces of microtrafficking.
Using children and adolescents in school contexts shows that micro-
trafficking organizations consider minors as a very profitable potential market. In
addition, involving young people in microtrafficking, on the one hand, reduces the
risk of losing goods, given that the authorities do not control this population so
exhaustively, and on the other hand, the expansion of drug markets is promoted
from the generation of addictions (giving away doses to children and adolescents).
The increasingly easy access to psychoactive substances in Nariño has generated
an alarming decrease in the age of onset of consumption between 9 and 10 years.
The authors, based on the report of the Inter-American Commission for the Control
of Drug Abuse, highlight that, according to the perception of schooled adolescents
of the Colombian population, for the year 2018, the most easily accessible drug
was marijuana.
Therefore, it is crucial to implement efforts to prevent the linking of
adolescents at risk to criminal structures for the commercialization of drugs, with a
clear association between the commercialization of psychoactive substances and
the generation of consumption.

National

A relevant study is the one entitled "Qualitative Sociological Study on the

consumption of alcohol and cannabis among adolescents and young people"
(Socidrogalcohol, 2017), which showed the different motivations of Spanish
adolescents and young adults residing in different autonomies to consume
cannabis. According to the study, in principle, the main cause to start consumption
has to do with the need to belong to a group coupled with the desire for
transgression and the experimentation or exploration of the forbidden.
Subsequently, with the continuity of consumption, other causes of greater
relevance emerged, such as: relaxing effects, escaping from reality, the regulation
of emotions and as a strategy to face daily frustrations. This national study, which
refers to children under 25 years of age, highlighted the importance of analyzing
these motivations for consumption especially at an early age and studying their
relationship with problematic consumption. The environment in which the young
person lives, and in particular the family context, was considered a decisive
component in the face of consumption.
The study showed that there are parents who dismiss the adolescent stage
and their vulnerabilities, focusing their upbringing usually towards academic
performance, among the conclusions the need for family involvement was
emphasized in order to promote families more competent in problem solving and
assertive communication skills.
It is considered that despite the conclusions presented in the study carried
out by Socidrogalcohol, clinical practice with regard to my personal experience
suggests to me that studies should be intensified with respect to these first causes
of consumption and there is a risk of trivializing the responsibility for relevant
factors such as conflicting family relationships, previous psychopathology or
possible trauma.
 In another very recent research published in the journal Addictions by
Casajuana Kögel, López-Pelayo et al. (2021), the relationship between motivations
to consume and problematic cannabis use in people over 18 years of age is
emphasized. The study indicated raised the motivations that lead to consumption
as a fundamental fact from a perspective of comprehensive care centered on the
person.
The main objective of this research was to highlight the importance of
analyzing the motivations of consumption, which is why the authors point out the
importance of motivational attention focused on the person as an indispensable
tool especially among cannabis users who use it to face discomfort, since this type
of consumer must be deepened and guide a more detailed evaluation of their
consumption pattern and in turn it is essential explore the role that cannabis plays
in relieving discomfort and that can degenerate into problematic use.
It was concluded that the use of cannabis as a coping strategy poses a
greater risk to health and greater social vulnerability. The authors consider that
policies should be formulated that limit accessibility to the substance or that
diversify the possibilities of leisure in young people, the study suggested that such
strategies are less effective in users with a problematic consumption pattern whose
main motivation for consumption is to face discomfort.
Therefore, the authors recommended intensifying for these patients an
approach that included education in emotion management even as a preventive
strategy. Based on these premises, research could be proposed on the
effectiveness of education in emotional management, in those sporadic users who
use the substance to relieve discomfort, to prevent the negative evolution of
consumption and prevent it from becoming a problematic consumption.
The importance of identifying the profile of the consumer is taken as a
significant contribution of this research, in order to be able to propose an adequate
intervention plan.
Another important study corresponds to the one developed by Arias-de la
Torre, Eiroa-Orosa et al (2021) who carried out a cross-sectional design based on
data from the 2015/2016 edition of the Household Survey on Alcohol and Drugs
(AGES). The inclusion criteria were the age of the participants between 15 and 35
years, having used cannabis at least once during the last year and having taken
the Cannabis Abuse Screening Test (CAST). Setting as cut-off point for
problematic cannabis use at 4 or more. The study aimed to describe the patterns of
cannabis use (problematic or non-problematic) in the young Spanish population
and to investigate how problematic consumption is related to perceived risk, and
the ecological factors that imply access to the substance and exposure to
situations of consumption, of a sociodemographic type that include gender, age,
level of education and employment situation.
It was evidenced in the study that problematic cannabis use was more
frequent in men (38.9%) than in women (23.2%). The availability of the substance,
exposure to consumption situations and the level of education were significantly
related to problematic use among men, highlighting an increased risk especially
among those of a primary or illiterate level of education. With regard to women,
there was a higher incidence of problematic cannabis use among those who did
not perceive "any problem" related to its use and among the unemployed.
These results, according to what the authors propose, interventions in this
area will have to adapt to the person, their way of perceiving the risk, the search for
emotional stability through the substance either due to some disorder prior to the
beginning of consumption or the need to compensate for the daily frustrations of
life, it can hardly be seen as harmful on the part of the adolescent. Anyway, more
studies with the Spanish population are needed to reach a better understanding of
this relationship.
Another interesting background is referred to the most recent report of the
Survey Program on Alcohol and Other Drugs in Spain (EDADES) directed by the
Government Delegation for the National Plan on Drugs (DGPNSD), it was done in
collaboration with the autonomous communities and is carried out every two years,
it is a very useful tool to observe the evolution of drug consumption over time. In
addition, it provides other important data regarding consumption, such as
consumer profiles and the perception of risk in the face of specific consumption
behaviors.
 The main objective of these surveys was to obtain information in order to
generate preventive actions regarding substance use and its consequences. The
2019/2020 edition of the Household Survey on Alcohol and Drugs (Spanish
Observatory of Drugs and Addictions, 2021) emphasizes that the vast majority of
cannabis users are experimental or occasional users, due to this evidence it was
considered necessary to introduce a scale (CAST) that would allow to identify that
consumption and establish a temporal trend. Through this instrument, it was
possible to affirm that for the period 2019/2020 the prevalence of problematic
cannabis use in the population of 15 to 64 years was 1.9%, corresponding to
approximately 590,000 people. If individuals who used cannabis in the last 12
months and who responded to the CAST scale are considered, the study observed
a prevalence of problematic use of 22.5%.
The study indicates an increase for 2019/2020 compared to the 2015 trend
in terms of the prevalence of problematic cannabis use. The same trend is evident
in the case of the consumption of hypnosedant. Notably, regardless of the score,
almost all cannabis users have drunk alcohol and smoked tobacco in the past year.
If the type of use in the last 30 days is analyzed, based on the CAST score, no
significant differences were detected between the two user profiles except for a
slightly higher percentage of individuals who used both types of cannabis
(marijuana and hashish).
Another important evidence obtained is that compared to the 2017 data, a
high percentage (85.3%) of people were observed who consider that using
cannabis once a week or more would cause enough or many health problems.
With regard to accessibility to the substance, 59.4% believed that it would be easy
or very easy to obtain cannabis in 24 hours, appreciating since 2009 a slight but
progressive decrease in the perception of availability.
The conclusion of the study indicates that, if on the one hand the
consumption of cannabis is undoubtedly more socially accepted and remains very
high in Spain the perception of accessibility to the substance, on the other hand,
has also greatly increased the degree of information regarding its consequences
jump to health among the general population.
 Around the contribution of this study to the present research consisted of the
analysis of the problematic consumption of cannabis, detected through the CAST,
as an excellent indicator of cannabis dependence or predictor of the evolution of
consumption towards a pattern of dependence.
On the other hand, the report called: "Alcohol, tobacco and illegal drugs in
Spain. Report 2020" of the Spanish Observatory of Drugs and Addictions (OEDA)
provided a comprehensive vision of the evolution and characteristics of the
consumption of psychoactive substances in Spain and the associatedproblems.
This report presents relevant information regarding the consumption,
perceptions and opinions of the population of students from 14 to 18 years old
regarding drug use from 1994 to 2018. The source of information is the Survey on
Drug Use in Secondary Education in Spain (ESTUDES) which is carried out
biennially.
The authors revealed that by 2018 around 222,200 students from 14 to 18
years old began using cannabis being this as the illegal drug most consumed by
young people, of this population it was found that 33% had used cannabis at some
time in life, 27.5% in the last year and 19.3% in the last month. Likewise, an
increase of more than 2 points was observed in the percentage of students with
problematic consumption.
The study revealed that, despite all the information resources, young people
still have a low perception of the risk associated with cannabis use, being also
perceived as the most available psychoactive substance after alcohol and tobacco.
The general objective of the ESTUDES survey is to obtain information in
order to develop actions aimed at preventing substance use and its consequences.
The survey was conducted nationwide. The population area was composed of
students from 14 to 18 years old who were studying Secondary Education (3rd and
4th of ESO, 1st and 2nd of Baccalaureate, Basic Vocational Training Cycles and
Intermediate Vocational Training Cycles) in Spain.
Another aspect revealed is that since 2016 a growing trend in the
consumption of cannabis began to be observed. On the other hand, the age of
onset (before reaching the age of 15) was constant in the historical evolution of the
survey. Use was more widespread among boys, resulting in 15.8% of 14-year-old
students having ever used cannabis and significantly increasing this percentage to
51.2% in the 18-year-old group. The same trend was detected among girls with a
percentage of consumption among 14-year-old students of 14.2%, which increased
progressively reaching 47.2% in the 18-year-old group.
With respect to the amount consumed, the 16-year-old group turned out to
be the one that consumes on average the highest number of porros in a day (3.6
porros), not actually detecting significant differences with the other age groups. If
we consider the form of consumption, 43.8% of those who used cannabis in the
last month claimed to have smoked mainly marijuana. This trend was observed
especially among girls and younger consumers. In contrast, only 19.3% admitted to
having smoked mainly hashish (resin or chocolate).
It is interesting to note that among students who never tried cannabis,
15.4% would try it if it were a legal drug, registering a slight increase in that
percentage compared to the 2016 data. In relation to this finding, 38.5% of those
who say they would try cannabis if it were legal, used tobacco at least once in their
lives.
Overall, in the ESTUDES survey, problem users accounted for 3.4% of all
students between the ages of 14 and 18 in secondary education, showing an
upward trend.
The study concludes by asserting that the tendency to increase during the
last 2 years of problematic cannabis use in the adolescent population is a social
phenomenon that should be comprehensively addressed because it is taken as a
way to escape or temporarily mitigate emotional discomfort or frustration.
The study carried out by the Spanish Observatory of Drugs and Addictions
(2020), through different sources of information, carried out the monitoring of the
development of the COVID-19 pandemic. The general objective of the study was to
know the effects of the pandemic and the measures that were implemented for its
control with respect to the consumption of psychoactive substances and their
associated problems.
 It emerged that the pandemic had an important impact on the given
consumption evidencing the following in general lines those who responded to the
survey indicated as consumers of illegal psychoactive substances that decreased
the frequency or amount of consumption by 71.9%, on the other hand, in 16.3% of
them no changes were detected, while 11.9% of consumers increased
consumption well in terms of frequency and quantity during the period of
confinement by COVID-19. It is pertinent to point out that with respect to the other
psychoactive substances, cannabis presented an atypical tendency, observing a
higher percentage of people who did not vary the consumption or even who
increased it.
The authors justified this finding with the fact that, despite the inevitable
limitation of its availability and consumption during confinement, cannabis remains
the easiest illegal drug to obtain.
As for the reasons that were stated in the study, cannabis use was due to
boredom, anxiety or being able to endure the situation generated by the pandemic.
The authors highlight the crucial role played by intra-family dynamics, especially in
dysfunctional and conflictive homes or relationships due to their determinant
negative influence on cannabis use essentially with respect to those young people
who had the habit of staying away from home for a long time.
With regard to the decrease in consumption, the authors affirm that among
some young people, the state of alarm may have acted as a filter whose result was
to distinguish in this sense two profiles of users: a) young recreational users who
considered that the benefits obtained did not compensate for the efforts to obtain
the substance, and b) young cannabis users who, faced with the situation of
confinement, reduced or even voluntarily left the cons umo.
In 2020 Sánchez-Niubò, Sordo et al., (2020), published a study whose
objective was to carry out a retrospective analysis of the sequence of onset and
progression of consumption in a sample of the general Spanish population.
The authors highlighted how an early onset in cannabis use would increase
the onset of use of other illegal substances and would be related to later
dependency problems in addition to family, social and legal problems.
 The study highlights that those young people at higher risk of becoming drug
abusers may be least likely to follow the typical sequence of substance use onset.
In any case, the most significant variation was registered in the age of onset of
consumption, being considered an essential variable to define prevention efforts
and their relationship with future substance use. Especially relevant was the
decrease in the age of onset and the progressive diffusion among women of
consumption patterns traditionally considered typical of the male population.
Regarding the progression of consumption, a very interesting fact of the
study was the correlation between smoking tobacco (the most consumed drug
initially) and the subsequent increase in the consumption of other substances,
especially cannabis. Correlation reinforced, in the latter case, by the practice of
mixing the two substances.
With regard to the relationship between cocaine and cannabis, the latter was
raised as a risk factor for cocaine use not necessarily as a direct cause, but
especially as a mediator for factors such as accessibility to the substance, the
choice of drug-using friends and the reduction of risk perception.
The study authors concluded that the ages of onset of use vary depending
on the previous consumption, or not, of other substances. According to the study,
tobacco more than cannabis and both more than cocaine, turned out to have the
ability to affect the onset and progression of the use of other substances
highlighting the need to strive to prevent (or delay) the onset of the use of any
psychoactive substance.