Cannabis use is a rapidly growing public health concern in the United States. According to the most recent data from the National Survey on Drug Use and Health (NSDUH) in 2024, 73.6 million individuals aged 12 and older reported using illicit drugs in the past year, and of those, 64.2 million used marijuana—far surpassing all other drugs.¹ Use was particularly high among young adults aged 18 to 25, 35% of whom used cannabis in the past year. Despite rising use, perceived risk remains low: only 25% of respondents viewed weekly marijuana use as carrying great risk, compared with 68.5% for both alcohol and tobacco, 83.2% for cocaine, and 91.9% for heroin.² Additionally, there has been a dramatic rise delta-9 tetrahydrocannabinol (THC) potency. In 1995, cannabis seized by the Drug Enforcement Administration averaged around 4% delta-9 THC, whereas today’s products—particularly concentrates—can contain delta-9 THC levels as high as 90%.³ THC concentrates are often consumed via vaping—a trend of particular concern given recent NSDUH data showing that 71% of adolescent and 52% of young adult cannabis users report vaping as their primary mode of use.¹

Oklahoma’s medical marijuana law is among the least restrictive in the nation. In 2018, the passing of State Question 788 (SQ 788) established the Oklahoma Medical Marijuana Authority (OMMA) and created a medical cannabis program without a list of qualifying conditions. Instead, any licensed physician can recommend cannabis for any condition they deem appropriate, a policy that is rare among other state medical marijuana programs. Notably, minors are also eligible to obtain a medical marijuana license with the consent of their legal guardian and recommendation from two physicians, further broadening youth access relative to most other states. Additionally, Oklahoma has minimal marijuana marketing regulations. A recent study showed 74.5 % of Oklahomans had been exposed to cannabis marketing in the past 30 days, and this was positively correlated with cannabis use, positive attitudes about cannabis, lower cannabis harm perceptions, and greater interest in obtaining a medical cannabis license.⁴

The Oklahoma legislature passed Senate Bill 1033 in 2021, further increasing access to intoxicating cannabis products. This bill amended the state’s definition of marijuana to exclude delta-8 and delta-10 THC, which legalized the sale of these forms of cannabis outside of the medical cannabis structure and without requiring a medical license. This decision was based on the classification of delta-8 and delta-10 THC as hemp-derived compounds, falling under the federal 2018 Farm Bill’s definition of hemp as cannabis containing no more than 0.3% delta-9 THC by dry weight—distinguishing these forms from marijuana, which exceeds this threshold. As a result, highly concentrated delta-8 and delta-10 THC vape products have become widely available in gas stations, vape shops, and online retailers, often with minimal age restrictions and youth-targeted marketing.^5,6 Studies have shown that these products contain THC concentrations ranging from 60 to 95% THC by weight, comparable to delta-9 THC distillates found in regulated cannabis markets.⁷ Despite delta-8 THC’s lower intrinsic potency at the cannabinoid-1 receptor (CB1), its high concentration in commercial vapes and puffing behaviors from vaping produce psychoactive effects subjectively similar to those of delta-9 THC.^8,9 Furthermore, product labeling can be inaccurate, with many delta-8 and delta-10 THC products containing inconsistent THC concentrations, residual byproducts from chemical synthesis, and unlabeled additives including delta-9 THC.¹⁰ These dynamics—combined with rising rates of adolescent cannabis use—are particularly concerning in permissive policy environments such as Oklahoma, especially with a 2023 study showing 11.4% of 12th graders reported past-year use of delta-8 THC, with frequent use patterns (defined as 10 or more times in the past month) common among users.¹¹ On November 2025, federal law reversed this regulatory gap by redefining hemp to impose a strict limit of 0.4 mg of total THC per container, and by prohibiting synthetically derived cannabinoids, rendering most delta-8, delta-10, and similar products federally illegal; this provision takes effect November 2026.¹²

A recently published Oklahoma High Intensity Drug Trafficking Area (HIDTA) report further illustrates difficulties in regulating cannabis use and protecting public health.¹³ Since the passage of SQ 788, Oklahoma has experienced a 73% increase in adolescent cannabis use, with youth in the state now reporting 44% higher use than the national average. Oklahoma ranks third nationally in adolescent past-month marijuana use, up from 43rd just a few years prior. Compounding these trends is the issue of massive oversupply. Licensed growers are producing cannabis at levels estimated to be 64 times greater than medical license holder’s local demand, contributing to widespread diversion into illicit markets. HIDTA also highlights an increase in criminal violations, illegal grow operations, and links to organized crime, which point to significant gaps in regulatory oversight. These trends suggest that Oklahoma’s current medical cannabis framework has inadvertently created conditions that enable illicit cannabis activity to flourish.

Against this permissive policy backdrop, increasing adolescent cannabis use poses significant risks. Neurodevelopmental consequences of adolescent cannabis use include disruption of cortical maturation, particularly in the prefrontal cortex, leading to impairments in executive functioning, attention regulation, and impulse control.¹⁴ Cannabis use during adolescence has also been associated with a moderately increased risk of major depressive disorder (odds ratio (OR) ~2.5), anxiety, and suicidality—including suicidal ideation and attempts—that may persist into young adulthood, with elevated risk in early-onset and frequent users.¹⁵Notably, cannabis use is robustly linked to the development of psychosis, particularly in those using high-potency products or engaging in daily use.¹⁶ Academic functioning is similarly impacted: adolescent cannabis use is associated with lower academic performance, increased absenteeism, higher dropout rates, and reduced high school completion, especially among early or heavy users.¹⁷Risk of cannabis use disorder rises steeply with frequency of use (relative risk ≈ 2.0 yearly, 4.1 monthly, 8.4 weekly, 17.0 daily; absolute risk increase ≈ +3.5, +8.0, +16.8, +36).¹⁸ Recent cannabis use is associated with a higher risk of motor vehicle collision; a systematic review and meta-analysis estimated nearly a 2-fold increase (pooled OR 1.92, 95% CI 1.35–2.73), with stronger associations for fatal crashes.¹⁹

Intervention starts with physicians routinely screening adolescents for cannabis and other substance use. A positive screen or clinical red flags for cannabis use (unexplained functional decline, worsening mood or anxiety, conjunctival injection, stained fingertips, cannabis odor, increased appetite) should prompt a more formal assessment for cannabis use disorder (CUD) and co-morbid psychiatric conditions. Management (and prevention) starts with treatment of co-morbid psychiatric conditions if present and brief, patient-centered motivational interviewing (1 to 2 visits, 15 to 30 minutes) which would optimally occur across several settings including schools and in primary care settings. Family therapy, cognitive behavioral therapy (CBT) and motivational enhancement therapy are first line psychological treatments for CUD. There can be additional benefit from contingency management (CM) using vouchers and contingency contracting if response is inadequate, however the benefits have not been sustained after cessation of CM. Digital delivery can extend access for mild CUD.²⁰ Consider using the APA App Advisor to screen digital interventions prior to implementation.

While there are no FDA approved medications to treat cannabis use disorder, there are several small, controlled trials suggesting that agents such as N-acetylcysteine, topiramate, gabapentin, and varenicline may reduce cannabis use. Ongoing research continues to explore pharmacologic options, including agents targeting cannabinoid receptor signaling pathways, which show early promise but remain investigational.²¹

Oklahoma psychiatrists are gravely concerned about the public health risks of expanding cannabis use in our state, especially in youth. In 2024, the American Academy of Child and Adolescent Psychiatry awarded a grant to the Oklahoma Psychiatric Physicians Association (OPPA) to produce a video aimed at educating teens about the risks of marijuana use. It has since been published on various social media platforms and shared with state and national organizations. It is their hope that this resource will allow physicians and parents to have crucial conversations with teens about the dangers of cannabis product use. SAMHSA’s “Talk. They Hear You” app is an additional reliable reference for parents or caregivers. Further online video resources can be found here on YouTube and Instagram.

Rising prevalence of cannabis use, increasing THC potency, permissive regulatory frameworks, and persistent oversupply collectively represent a growing public health challenge in Oklahoma. Adolescents are particularly at risk, both because of their neurodevelopmental vulnerability and because risk perception remains strikingly low. Narrowing this gap requires coordinated, evidence-based messaging across clinical, educational, community, and policy settings. We hope that our video provides an early, accessible tool to promote awareness and encourage discussions with youth and families while broader regulatory and legislative solutions continue to evolve.

Dr Thetford-Harvey is a Child and Adolescent Psychiatry Fellow at the University of Oklahoma School of Community Medicine where she also completed psychiatry residency. She received her medical degree from the University of Oklahoma College of Medicine.

Dr Manning is an associate professor at the University of Oklahoma School of Community Medicine where she serves as the Associate Residency program director and the medical director of Consultation-Liaison Psychiatry. She is a former president of the Oklahoma Psychiatric Physicians Association. She received her medical degree and completed Psychiatry residency at the University of Texas Southwestern Medical School in Dallas. She is board certified in Psychiatry by the American Board of Psychiatry and Neurology and in Addiction Medicine by the American Board of Preventative Medicine.

References

1. Substance Abuse and Mental Health Services Administration. Key Substance Use and Mental Health Indicators in the United States: Results From the 2024 National Survey on Drug Use and Health. 2025. Accessed August 10, 2025. https://www.samhsa.gov/data/data-we-collect/nsduh-national-survey-drug-use-and-health/national-releases

2. Substance Abuse and Mental Health Services Administration. Key Substance Use and Mental Health Indicators in the United States: Results From the 2023 National Survey on Drug Use and Health. 2024. Accessed August 10, 2025. https://www.samhsa.gov/data/report/2023-nsduh-annual-national-report

3. Cannabis (marijuana) research report: what is the potency of cannabis?National Institute on Drug Abuse. 2023. Accessed July 6, 2025. https://nida.nih.gov/research/research-data-measures-resources/cannabis-potency-data

4. Cohn AM, Alexander AC, Ehlke SJ, et al. Seeing is believing: how cannabis marketing exposure is associated with cannabis use attitudes and behavior in a permissive medical cannabis policy environment. Am J Addict .2023;32(4):333–342.

5. Rossheim ME, LoParco CR, Tillett KK, et al. Intoxicating cannabis products in vape shops: United States, 2023. Am J Prev Med. 2024;67(5):776–784.

6. LoParco CR, Rossheim ME, Walters ST, et al. Delta-8 tetrahydrocannabinol: a scoping review and commentary. Addiction. 2023;118(6):1011–1028.

7. Zhang S, Alam MM, Chandler BD, et al. Potency analysis of semi-synthetic cannabinoids in vaping oils using liquid chromatography diode array detector with electrospray ionization time-of-flight mass spectrometry for confirmation of analyte identity.Molecules. 2025;30(12):2597.

8. Spindle TR, Zamarripa CA, Schriefer D, et al. A within-subject cross-over trial comparing the acute effects of vaporized delta-8-tetrahydrocannabinol and delta-9-tetrahydrocannabinol in healthy adults.Drug Alcohol Depend .2025;272:112684.

9. Tagen M, Klumpers LE. Review of delta-8-tetrahydrocannabinol (Δ8-THC): comparative pharmacology with Δ9-THC.Br J Pharmacol. 2022;179(15):3915–3931.

10. Meehan-Atrash J, Rahman I. Novel Δ8-tetrahydrocannabinol vaporizers contain unlabeled adulterants, unintended byproducts of chemical synthesis, and heavy metals. Chem Res Toxicol. 2022;35(1):73–76.

11. Harlow AF, Miech RA, Leventhal AM. Adolescent Δ8-THC and marijuana use in the US. JAMA. 2024;331(10):861–865.

12. “New Federal Restrictions on Hemp and Hemp-Derived Products: Top Points | DLA Piper.” Dlapiper.com, 2025, www.dlapiper.com/en-us/insights/publications/2025/11/new-federal-restrictions-on-hemp-and-hemp-derived-products. Accessed 26 Nov. 2025.

13. Texoma High Intensity Drug Trafficking Area (HIDTA). Oklahoma Marijuana Report: Impacts of Legalization and Oversupply on Public Health and Safety. Texoma HIDTA; 2025. Accessed July 6, 2025.

14. Albaugh MD, Ottino-Gonzalez J, Sidwell A, et al. Association of cannabis use during adolescence with neurodevelopment.JAMA Psychiatry. 2021;78(9):1-11.

15. Gobbi G, Atkin T, Zytynski T, et al. Association of cannabis use in adolescence and risk of depression, anxiety, and suicidality in young adulthood: a systematic review and meta-analysis.JAMA Psychiatry. 2019;76(4):426–434.

16. Marconi A, Di Forti M, Lewis CM, et al. Meta-analysis of the association between the level of cannabis use and risk of psychosis. Schizophr Bull. 2016;42(5):1262-1269.

17. Chan O, Daudi A, Ji D, et al. Cannabis use during adolescence and young adulthood and academic achievement: a systematic review and meta-analysis.JAMA Pediatr. 2024;178(12):1280–1289.

18. Robinson T, Ali MU, Easterbrook B, et al. Identifying risk-thresholds for the association between frequency of cannabis use and development of cannabis use disorder: a systematic review and meta-analysis.Drug Alcohol Depend. 2022;238:109582.

19. Asbridge M, Hayden JA, Cartwright JL. Acute cannabis consumption and motor vehicle collision risk: systematic review of observational studies and meta-analysis. BMJ. 2012;344:e536.

20. Dulcan MK, ed. Dulcan’s Textbook of Child and Adolescent Psychiatry. 3rd ed. American Psychiatric Association Publishing; 2022.

21. Haney M, Vallée M, Fabre S, et al. Signaling-specific inhibition of the CB₁ receptor for cannabis use disorder: phase 1 and phase 2a randomized trials. Nat Med. 2023;29:1487–1499.