The Journal of Clinical InvestigationV I E W P O I N T3 9 4 7jci.org Volume 130Number 8August 2020Cannabis and the developing brainchallenge risk perceptionYasmin L. Hurd1,21Department of Psychiatry and Department of Neuroscience, Icahn School of Medicine, New York, New York, USA.2Addiction Institute of Mount Sinai, Behavioral Health System, MountThepastdecadehasseenareductioninsociety’sperceptionofcannabisbeingof any risk or harm. However, we are in atransformationaltimeinwhichcannabis’health implicationsrelated to neurode-velopment, particularly forvulnerablepopulations,mustchallengesuchpercep-tions of harmlessness.The combinationof multiple interrelated factors — societal,political, and business — have created the“perfect cannabis storm” of unintendedneurodevelopmentalconsequences withan unmatched exposure to cannabis com-paredwithexposurelevelsneverexperi-enced before in human history. Increasedexposure is driven by the drug’s increasedavailability across all levels of society. Thisisduetothelegalizationofcannabisinmost states, coupled with the recent explo-sionofhighlymodifiedcannabisstrainsand extracted pureΔ9-tetrahydrocanab-inol (THC), the prominent psychoactivecannabinoidfromtheplant.Thisexplo-sion has led to diverse products consumedbynumerousroutesandwithextremelyhigh THC potencies. Thus, cannabis todayis dramatically different from cannabiseven ten years ago, with exponentiallyincreasedTHCconcentrations(1).Atthesametime,levelsofothercannabinoidssuchascannabidiol(CBD)thatappeartohave some protective properties are lowerin the plant, leading to THC/CBD ratios of104in2017versus23in2008(1).Whilesome turn to dispensaries for “safer” can-nabinoids, these products can containfargreaterTHCcontent(~70%)thanthecannabis plant (~17%).The wide expo-suretopotentcannabisandcannabinoidextractsacrossthepopulationparticular-lyheightensthehealthriskofvulnerablegroups associated with sensitive windowsof brain development,namelypregnantwomen, children, adolescents, and emerg-ing adults. Each group carries certain risksrelevant to mental health outcomes basedon specific features of their stage of brainontogeny, but cannabis exposure can alsoenhance vulnerabilityfor all, extendinginto later stages in life (Figure 1).Prenatal development,the first cannabis hitThe aggressive and broad educational pro-gramsregardingtobaccoandalcoholuseduring pregnancy have not yet been adapt-edforcannabis.Instead,pregnantwom-en are even targetedin advertisementsand social media about the benefits ofso-called medical cannabis to relieve nau-sea,vomiting,andweightlossassociatedwith morning sickness, as well as to allevi-ate anxiety and pain. Today, cannabis usebypregnantwomenintheUnitedStateshasincreasedsignificantly,withapreva-lenceofmorethan7%overalland12.1%duringthefirsttrimester(2).Shockingly,approximately16.2%ofpregnantwomenaged18to44yearsusecannabisnearly
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