Kristen Quinlan, Ph.D. Linda Barovier, M.S. June 15, 2011

1. Understanding the Consequences, Associated Risk and Protective Factors and Available Strategies for Preventing Non-Medical Marijuana Use Kristen Quinlan, Ph.D. Linda Barovier, M.S. June 15, 2011

2. Welcome & Introductions ME VT NH NY MA CT RI PA NJ MD DE

3. Learning Objectives Training participants will be able to identify: • Short- and long-term consequences of non-medical marijuana use • Risk and protective factors most strongly associated with non-medical use of marijuana and progression onto consequences • Effective strategies available to reduce non-medical marijuana use and its consequences and how to locate them

4. Background • Kristen Quinlan, Ph.D. (CAPT NE Regional Evaluator), Renee Boothroyd, Ph.D., and Karen Friend, Ph.D. reviewed a body of literature containing over 200 articles, including numerous meta-analyses and summarized relevant findings. • Regional Epidemiologist May Yamate reviewed numerous data sources concerning consequences and consumption patterns associated with marijuana. • CAPT staff collaborated with National Institute on Drug Abuse epidemiologists to identify current data or research gaps.

5. Who Cares and Why? • Six States within the Northeast Region (mostly in New England) are among the top ten nationally for marijuana use. • These same States rank among the lowest in perception of risk of harm for marijuana use. • States throughout the region report erosion of norms at the societal, community, and family levels that seriously impede their efforts to prevent onset or reduce use.

6. Past-Month Marijuana Use Among Persons Aged 12 to 20 WA ME MT ND MN VT OR NH WI ID NY SD MA CT MI WY PA IA NE NE NJ NV IN IN OH IL UT WV CO CA VA KS MO KY NC TN TN AZ OK OK SC NM AR SC AR Percentages of Persons AL GA MS 7.82 – 10.86 TX LA TX AK 7.18 – 7.81 FL FL 6.30 – 7.17 5.72 – 6.29 4.47 – 5.71 Source: 2007 and 2008 SAMHSA National Surveys on Drug Use and Health (NSDUHs).

7. Perception of Great Risk Among Persons Aged 12 to 17 Highlights Adolescents who perceived great risk from smoking marijuana once a month were much less likely to have used marijuana in the past month than those who perceived moderate to no risk. Adults who first used marijuana before age 12 were twice as likely as adults who first used marijuana at age 18 or older to be classified as having significant mental illness in the past year ME VT NH NY MA CT RI PA NJ MD DE Percentages of Persons 38.70 - 44.50 29.61 – 32.58 36.05 – 38.69 24.08 – 29.60 32.59 – 36.04 Source: 2007 and 2008 SAMHSA National Surveys on Drug Use and Health (NSDUHs).

8. Consequences of Non-Medical Marijuana Use

9. Myths About Harm from Marijuana

10. Marijuana Consequences • There are both short- and long-term effects of use, including: • Acute psychiatric symptoms or mental health effects • Cognitive impairment • Risk of injury or harm • Dependence • More research is needed because existing research is mixed and often includes other variables that confound the findings.

11. Short-Term Consequences of Marijuana Use

12. Short-Term Consequences • Acute psychiatric reactions (especially in new users) • Driving impairment and potential for injury • Risk of other injury

13. Acute Psychiatric Reactions • Anxiety and psychotic symptoms—most commonly in new users (Hall & Degenhart, 2009) • 22% of new users reported acute anxiety or panic attacks immediately following use • Acute marijuana intoxication may also be associated with impaired judgment and risky behavior (Jacobus, Bava, Cohen-Zion, Mahmood & Tappert, 2009) • Examples: Unprotected sexual intercourse, driving while impaired or intoxicated

14. Driving Impairment and Risk of Injury • Use impacts many of the processes required for safe driving, including tracking, reaction time, and attention (as cited in MacDonald, 2003; Kalant, 2004) • Marijuana’s effect on driving skills seems to indicate that THC concentrations of 7-10ng/ml may produce similar impairment to blood alcohol concentrations of .05% (Groternhermen et al., 2007). • Reports on drugged driving and various federal or state efforts (Per Se laws) to reduce this consequence are available from your state liaison.

15. Risk of Other Injury • Examinations of the relationship between marijuana use and unintentional, non-traffic-related injury have generated mixed results, likely because of the many confounding variables associated with use. • In one study of 60,000 patients, marijuana users were more likely to be admitted to the hospital due to injury from all causes than non- or former users (Gerberich, Sidney, Braun, Tekawa, Tolan, Quesenberry, 2003)

16. Long-Term Consequences of Marijuana Use

17. Long-Term Consequences • Cognitive impairment • Psychosocial adjustment • Crime and violence • Mental health effects • Respiratory system effects • Birth defects • Dependence

18. Cognitive Impairment - Adults • Chronic users have shown impairments in visual search skills, which are necessary for everyday tasks like reading or safely driving a vehicle (Huestegge, Radach, & Kunert, 2009). • Experimental studies have shown that chronic adult users experience problems with attention, learning, and memory following brief periods of abstinence (as cited in Jacobus et al., 2009).

19. Cognitive Impairment - Adolescents Although more longitudinal studies are needed to elucidate the relationship between marijuana use and adolescent brain development, experimental studies have consistently shown that heavy adolescent users experience problems with attention, learning, memory, and processing speeds, and that these deficits continue beyond one month of abstinence (as cited in Jacobus et al., 2009).

20. Psychosocial Adjustment Heavy use of marijuana prior to age 21 may lead to psychosocial difficulties such as lower levels of income, lower levels of educational attainment, higher unemployment, lower levels of relationship satisfaction, and lower levels of life satisfaction at age 25 (Fergusson & Boden, 2008).

21. Psychosocial Adjustment Research has pointed to a dose-response relationship, which means that as marijuana use increases, so do problems in psychosocial adjustment (Fergusson & Boden, 2008).

22. Crime and Violence Generally, links between marijuana and violence are recognized, but studies attempting to make causal connections have met with mixed results (MacDonald, 2003; Macdonald et al, 2008; Pedersen & Skardhamar, 2009).  

23. Mental Health Effects - Schizophrenia Longitudinal studies have clearly demonstrated that marijuana use increases the likelihood that schizophrenia will develop in at-risk individuals, with more frequent use linked to increased risk of diagnosis (as cited in Degenhardt & Hall, 2006).

24. Mental Health Effects – Depression & Suicide • There are links between depression and marijuana use, but the evidence is not as strong as that seen between marijuana use and psychosis (as cited in Moore et al., 2007). • A link between suicide and marijuana use exists as well, but causation remains unclear (as cited in Moore et al., 2007).

25. Mental Health Effects – Panic Disorder Research has also suggested links between marijuana and panic disorder. In a large community survey, lifetime marijuana use was found to be associated with a panic disorder history, even after controlling for confounds like alcohol or nicotine dependence (Zvolensky, Johnson, Cougle, & Bonn-Miller, 2010).

26. Effects on the Respiratory System - Bronchitis • Regular, heavy smokers of marijuana report chronic cough, throat irritation, and other symptoms of chronic bronchitis (as cited in Kalant, 2004). • Damages to the respiratory system may occur after only a short period of heavy cannabis use (Kalant, 2004; Taylor, Poulton, Moffitt, Ramankutty, & Sears, 2000).

27. Effects on the Respiratory System – Cancer Related • Marijuana smoke and tobacco smoke contain many of the same carcinogens (Tetrault, Crothers, Moore, Mehra, Concato,& Fiellin, 2007). • Most researchers agree that chronic, heavy use of marijuana increases cancer risk (as cited in Kalant, 2004).

28. Birth Defects • Use of marijuana during pregnancy has been associated with low birth weight, mild developmental abnormalities, and future hyperactivity and impulsivity (as cited in Hall & Degenhardt, 2009). • Epidemiological studies have been unable to find evidence that marijuana causes birth defects, largely because those using marijuana during pregnancy are also more likely to use alcohol, tobacco, and other illicit drugs and are less likely to seek or receive appropriate prenatal care (as cited in Hall & Degenhardt, 2009).

29. Dependence • It is estimated that 8.5% of the U.S. population will experience a marijuana-use disorder during their lifetime (Stinson, Ruan, Pickering, & Grant, 2006). • Longitudinal studies have indicated that initiating use during adolescence leads to an increased risk of future dependence—it is estimated that of those who initiate use during adolescence, one in six will go on to become marijuana dependent.

30. Dependence • Daily or weekly use also strongly predicts future dependence (as cited in Hall & Degenhardt, 2009; Kalant, 2004). • Withdrawal symptoms can include anxiety, restlessness, insomnia, appetite disruptions, stomach pain, and mood disturbance. Withdrawal symptoms can appear after only two weeks of daily use (as cited in Ashton, 2001).

31. Summary • Use of marijuana does have significant consequences. • Areas where more research is needed include: • The extent to which marijuana use actually causes … • Crime and violence • Levels of depression elevated enough to lead to suicide • Actual risk of birth defects for children born to women who otherwise had prenatal care but used marijuana

32. Risk and Protective Factors for Non-Medical Marijuana Use and Progression onto Consequences

33. Discussion – Experiences

34. Conceptual Framework DOMAINS - The information contained in this webinar is divided into the following prevention domains: • Community/environment • School • Family • Peer • Individual

35. Conceptual Framework STRENGTH OF ASSOCIATION as demonstrated in the literature was divided into the following categories: • Strong – consistent evidence of relationships in longitudinal or meta-analyses • Moderate – show smaller effect size and/or sometimes drop out when accounting for other variables • Insufficient Evidence* - inadequately studied (i.e., fewer than 1-2 peer reviewed published studies, no longitudinal analyses) • Weak* *Note: information on risk or protective factors with insufficient evidence or weak associations are described in the literature review but are not described here.

36. How Findings Might Be Used Direct limited resources to target those risk/protective factors with the strongest association with non-medical use (defined as those with strong or moderate associations with use) • Inform the selection of priority risk/protective factors • Identify related strategies with strongest impact and best fit

37. Strong Associations These factors have a clear, strong to moderate relationship to use/intention to use.  • This relationship consistently persists even after accounting for a host of other variables that have been shown to relate to use.  • The relationship has been supported by meta-analytic work and/or by several longitudinal and cross-sectional studies.

38. Risk & Protective Factors with Strongest Association with Use

39. Risk & Protective Factors with Strongest Association with Use

40. Community Domain Availability/opportunities to use • For adolescents, perceptions of availability influence both lifetime and past-month use (Fagan et al., 2007). • Receiving marijuana offers consistently puts adolescents of any age at risk of initiating use (Tang & Orwin, 2009). • For adolescents, marijuana use increases more rapidly in urban areas or larger cities than in rural communities (Martino, Ellickson and McCafffrey 2008).

41. Young Adult Access • 2002 – 2009 regional data on18-25 year olds requested from Center for Behavioral Health Statistics and Quality • Method and source of obtaining marijuana for NE Region • Bought it:  38% - 47% • Friend:  74% - 86% • Got it for free or shared it:  52% - 62% • Friend:  88% - 92% •  Results by individual state are too small to report • Where (location) young adults obtained marijuana—numbers too small to report

42. School Domain Academic failure/academic achievement • There is a clear connection between marijuana use and academic performance. • Below average school performance is associated with the development of a marijuana use disorder nearly a decade later (Hayatbakhsh et al., 2009). • Causation is difficult to determine, as marijuana use and academic performance are engaged in a “complex positive feedback loop” (Ryan, 2010).

43. Family Domain Family marijuana use/family history of marijuana use • Parental use plays a critical role in initiation of use for younger adolescents (Tang & Orwin, 2009). • When parental use is elevated (i.e., dependence), it continues to play an important role in offspring use well past adolescence (Merikangas, 2008).

44. Family Domain Parental monitoring/clear standards • Longitudinal studies suggest that parental monitoring may be most important for adolescents younger than 14 (Tang & Orwin, 2009). • Parental monitoring may continue to protect against use through the transition from high school to college – perhaps because early parental monitoring heightens opportunities for prosocial involvement (White et al., 2006).

45. Peer Domain Peer norms & peer use • Normative beliefs about peer use have a robust effect on substance use in general (Connell et al., 2009) and on marijuana use specifically (Stephens et al., 2009). • Perceived peer use was a stronger predictor of use than parental attitudes or perception of risk in a population of 13-18 year old students(Chabrol et al., 2006)

46. Individual Domain • Intention to use • Longitudinal research has demonstrated a clear and strong connection between intention to use and future use (Perez, 2010; Stephens et al., 2009). • Attitudes toward use • Attitudes toward use have a clear and direct relationship with use (Stephens et al., 2009). • Attitudes toward use (including perceived risk) may be some of the strongest predictors of current and future marijuana use.

47. Individual Domain • Prior use of alcohol/tobacco • Historically, the link between prior use of alcohol and tobacco and current and future marijuana use has been well documented (Graves et al., 2005; Gorman & Derzon, 2002; Derzon, 2010). This has also been confirmed in longitudinal studies (Tang & Orwin, 2009).

48. Individual Domain • Antisocial behavior • Antisocial behavior (including fighting, truancy, and stealing) is associated with initiation of marijuana use (Guxens et al., 2007) and with the future development of a marijuana use disorder (Hayatbakshs et al., 2009). • Early age of initiation • Early age of onset is clearly and consistently linked to future marijuana use and marijuana use disorders (Creemers et al., 2009, and many others).

49. Moderate Associations These factors may show smaller effect sizes, and/or the relationship of these factors to use may drop out after accounting for other factors in some studies, but appear significant in others.

50. Risk & Protective Factors Moderately Associated with Use