Going to Pot … Appropriately Addressing Cannabis Use with College S tudents

1. Going to Pot…Appropriately Addressing Cannabis Use with College Students Katie Dunker, M.S. Director of Health Promotion University of Denver

2. Today • Background, Medical Marijuana, & Current Trends • Relevant Research • Early-Intervention Program for College Students • Lessons Learned @ DU

3. Learning Objectives • Understand the history & current state of Marijuana in the U.S. and in college, including information on medical marijuana. • Develop familiarity with cannabis research and evidence-based best practices regarding early and brief interventions. • Learn at least three ways to better appropriately address cannabis use on campus with college students.

4. Bit o History • Began to appear for recreational use in the early 1900s • Marijuana use linked to crime and social problems • 29 states prohibited marijuana by 1931 for non-medical use • Marijuana Tax Act of 1937 • 1942 removed from U.S. Pharmacopoeia • Late 1960s and early 70s – sharp increase • Controlled Substances Act – 1970 • 5 schedules of drugs Institute of Medicine. (2001). Marijuana and medicine: Assessing the science base. National Academy Press: Washington, D.C.

5. Drug Classification • Schedule I Narcotic = “High potential for abuse & no accepted medical uses” For a list of all “Schedules” go to http://www.usdoj.gov/dea/pubs/scheduling.html . How are drugs scheduled? Go to http://www.usdoj.gov/dea/pubs/abuse/1-csa.htm

6. Federal Laws • Illegal to... • possess it, • sell it, • smoke it, • eat it, • traffic it, • grow it. U.S. Drug Enforcement Administration. http://www.usdoj.gov/dea/pubs/abuse/1-csa.htm#Penalties

7. Why Worry • Criminal record, illegal activity • Memory, attention, & learning • Poorer school performance • “Amotivational syndrome” (inconclusive) • Lower relationship & life satisfaction • Increased risk of mental health issues • Impaired emotional development, increased likelihood of depression, psychosis, dependence & addiction • Increased risk of physical health issues • Asthma, chronic bronchitis and URI, stay sicker longer, risk of lung cancer (esp. if tobacco user), irregular menstrual cycles, decrease semen National Cannabis Prevention & Information Centre (AU) Fact Sheet #17 Fergusson, D. & Boden, J. (2008). Cannabis and later life outcomes. Addiction 103, 969-976.

8. Medical Marijuana • Legal in 13 states: AK, CA, CO, HI, ME, MD, MT, NV, NM, OR, RI, VT, & WA • Clinics in OR, WA, HI, CO, & CA

9. Medical Marijuana • “Recommended” NOT prescribed by state physician, only when exhausted all other options • “Terminal or debilitating medical condition” • Marinol ONLY for Wasting AIDS syndrome & chemo-nausea • Application w/ state registry system, Yearly Fee, ID card • No (little) reciprocity among states CO Information: http://www.cdphe.state.co.us/hs/Medicalmarijuana/marijuanafactsheet.html

10. Medical Marijuana • No more than 2 ounces or 6 plants (3 mature) • Still illegal! (Supreme Court upheld in 2001) • Alternate options may be available such as “vaporization” • Marinol – synthetic THC in pill form • Researching new “inhaler” for cancer patients in the U.K.

11. Denver City Ordinance • Sec. 38-175. Possession or consumption of marihuana. • (a)   It shall be unlawful for any person under the age of twenty-one (21) to possess one (1) ounce or less of marihuana. If such person is under the age of eighteen (18) years of age at the time of the offense, no jail sentence shall be imposed and any fine imposed may be supplanted by treatment as required by the court. • (b)   It shall be unlawful for any person to openly and publicly display or consume one (1) ounce or less of marihuana. If such person is under the age of eighteen (18) years of age at the time of the offense, no jail sentence shall be imposed and the fine may be supplanted by treatment as required by the court.

12. Why Use ? • Good things? • Not-so-good things? • What do you do when you use? • What do you NOT do when you use?

13. Research

14. Evidence Based Practices • ACHA Standards of Practice in Health Promotion • Integration With the Learning Mission of Higher Education • Collaborative Practice • Cultural Competence • Theory-Based Practice • Evidence-Based Practice • Professional Development and Service American College Health Association. Health Promotion Section http://www.acha.org/info_resources/SPHPHE.cfm

15. Why a Marijuana Group • Know students are using • Need to address use & abuse • Need to address legality and policy • Know we can do something, evidence- and/or theory-based

16. Marijuana Use • ___% of High Schoolers (Monitoring the Future) lifetime use • ___% of College Students lifetime use* • ___% within the last 30 days (1.2 all 30 days) (NCHA & Core) *Johnston, L. D., O'Malley, P. M., Bachman, J. G., & Schulenberg, J. E. (2007). Monitoring the Future national survey results on drug use, 1975–2006: Volume II, college students and adults ages 19–45 (NIH Publication No. 07-6206). Bethesda, MD: National Institute on Drug Abuse.

17. Who uses? • Male sex • Relative youth, average age 28 • Cigarette smokers • Heavy drinkers • Alcohol problems • Cocaine users Ogborne, A., Smart, R., & Adlaf, E. (2000). Self-reported medical use of marijuana: A survey of the general population. Canadian Medical Association Journal 162 (12).

18. Evidence BasedCognitive Behavioral Therapy • Cognitive Behavioral Therapy (CBT): talk therapy based on theory that psychological symptoms are related to thoughts, behaviors, and emotions. • 6 session CBT • Single session CBT • Delayed Treatment Control (DTC) • Individuals in the treatment groups (1 or 6) showed decrease in use, increase in abstinence, fewer cannabis-related problems Copeland J, Swift W, Roffman R, Stephens R. (2001). A randomized controlled trial of brief cognitive-behvarioral interventions for cannabis use disorder. Journal of Substance Abuse Treatment, 21, 55-64.

19. Evidence BasedMotivational Interviewing • 14 session CBT group intervention • Brief 2 session MI, individualized assessments • 4 month delayed treatment control group • Both the CBT & MI treatments showed substantially greater improvement than the control group at 1, 4, 7, 13, 16 month follow ups Stephens, R.S., Roffman, R.A., & Curtin, L. (2000) Comparison of extended versus brief treatments for marijuana use. Journal of Consulting and Clinical Psychology, 68, 5, 898-908.

20. Evidence BasedSingle Session • Study in the U.K with 200 college students. • Peer recruited & paid to participate • Single-session Motivational Interviewing • Compared w/no intervention control • 12 week follow up, most significant reduction in marijuana use (dec. in alcohol & tobacco) • Greatest effect among heaviest users McCambridge J, Strang J. (2004). The efficacy of single-session motivational interviewing in reducing drug consumption and perceptions of drug-related risk and harm among young people: results from a multi-site cluster randomized trial. Addiction, 99, 39-52.

21. Evidence Based Group MI • Uncharted territory. • Proven effects of individual MI, group is more complicated. • GMI maybe more cost-effective or not. • Should be combined with other efforts, such as an individual session &/or personalized feedback. Resource: Miller, W. & Rollnick, S. (2002). Motivational interviewing: Second edition.

22. Evidence Based Group MI • Students self-selected from First Year Seminar classes. • MI trained therapist conducted group psychoeducational alcohol intervention. • 75-100 minutes in length (50 min. twice or 75 mins once) • 30-45 day follow up: 4.5 fewer drinks & 1.5 fewer intoxicated episodes compared to control. Michael, K., Curtin, L., Kirkley, D., Jones, D., & Harris, R. (2006). Group-based motivational interviewing for alcohol use among college students: An exploratory study. Professional Psychology: Research and Practice, 37 (6), 629-634.

23. Assessments for Students • Cannabis Use Disorders Identification Test (CUDIT) • Cannabis Use Problems Identification Test (CUPIT) • Cannabis Abuse Screening Test (CAST) • Severity of Dependence Scale: Cannabis (SDS) • Adolescent Cannabis Problems Questionnaire (CPQ-A) • Electronic THC Online Knowledge Experience (E-TOKE) • Costs $750/year & includes personalized feedback Betsy Foy, MHS, CHES. Assistant Director Student Health Services at Washington University Dissertation research on the topic of cannabis assessment tools for college health professionals.

24. Research Summary • Cognitive Behavioral Therapy (CBT) • Motivational Interviewing (MI) • Individualized & group interventions • Assessments w/personalized feedback reports • Brief interventions are worthwhile! Copeland, J. (2004). Developments in the treatment of cannabis use disorder. Current Opinion in Psychiatry, 17(3), 161-168.

25. Marijuana Research Resources • “Motivational Interviewing” (Miller & Rollnick) • “Buzzed” (Kuhn, et al.) • “Marijuana & Medicine: Assessing the Science-Base” (Institute of Medicine) • “Marijuana & Driving – Going to Pot on the Highway” (Jim Porter) • “Grazing in the Grass: Understanding Marijuana as a Drug of Dependence” • Article by Jim Porter, MA, NCACII, LAC, SAP • www.ushighwaysafety.com/drughound

26. Underground Research • Marijuana Pro-Sites • Check out Federal Gov’t sites • Movie: Half-Baked (language) • Documentary: Grass (history) • TALK to students • TALK to smokers • TALK to ex-smokers • TALK to counselors who specialize in this area

27. The Stages of Change • Precontemplation • Contemplation • Preparation/Determination • Action • Maintenance Resource: Prochaska & DiClemente, (1982, 1984, 1985, 1986)

28. Motivational Interviewing • Client (student)-centered, Directive • Strength-based • Way of being with people • For enhancing intrinsic motivation to change by exploring and resolving ambivalence Resource: Miller, W. & Rollnick, S. (2002)

29. Spirit of MI • Collaboration – partnership, honor student’s perspective & expertise. • Evocation – intrinsic motivation for change can be enhanced by drawing on student’s own goals & values. • Autonomy – student has the capacity for facilitating change in their own life. • Listen for “Change Talk” Resource: Miller, W. & Rollnick, S. (2002)

30. Marijuana Group at DU • Two 90 minute sessions, back-to-back weeks • Facilitated by health educator and staff psychologist • Psychoeducational Group • Approach is more important than knowledge • Empathetic, non-judgmental, open, directive • Motivational Interviewing style

31. First Group • Pre-Group Survey & Assessment • Introductions • Group Norms/Expectations • Confidentiality Piece • Exploration of “Why am I here?” “What’s on your mind?” • Popular topics: Policy, Medical Marijuana, Good & Not-so-Good discussion. • Homework • Record times you smoke (feelings, activities noted)

32. Results from DU Pre Assessment

33. Second Group • Re-cap first session (students summarize) • Discuss homework • Discussion Points • Who did the homework? • What did you think of it? • What did you notice? • What did you learn about your use? • “NORML Principles of Responsible Cannabis Use”

34. Harm Reduction • Having a Designated Driver or using alternate transportation. • Setting limits on where, when, & how much to use. • Not using where smoking is prohibited. (Halls) • Avoiding other drugs & alcohol when using. • Avoid using around people who don’t smoke or don’t like it. • Recognizing “red-flags” for yourself and others.

35. Further Discussion • What do you like about using marijuana? • What are some not so good things about using? • What do you DO when you use? • What don’t you do (or neglect when you use)? • How do you see marijuana in your life after college? • How do you see your marijuana use changing in the future?

36. Further Discussion • How would you know when your marijuana use was getting out of control? • How would you cut down if you wanted to or thought you needed to? • What are some ways you could achieve a “natural” high without the use of pot or other drugs? • Are there good substitutes for the role marijuana plays in your life?

37. Results from DU Post Assessment

38. Why it appears to be useful • Total drug violations: • 2007-2008: 66 • 2006-2007: 87 • 2005-2006: 90 • 2004-2005: 42 (?) • 2003-2004: 104 • More than one: • 2007-2008: 2 • 2006-2007: 4 • 2005-2006: 8 • 2004-2005: 1 (?) • 2003-2004: 17

39. Why it appears to be useful • Drug-related probations: • 2007-2008: 59 • 2006-2007: 74 • 2005-2006: 67 • 2004-2005: 34 (?) • 2003-2004: 75 • Drug-related suspensions: • 2007-2008: 1 • 2006-2007: 4 • 2005-2006: 8 • 2004-2005: 1 (?) • 2003-2004: 12

40. Looking Ahead • Further assessment @ 3, 6, 9, 12 months • Research w/ group, individual, & control • Personalized feedback reports • Cannabis Use Disorder Identification Test (CUDIT) • Peer co-facilitator?

41. QUESTIONS

42. Great Resources • NCPIC – National Cannabis Prevention & Information Centre www.ncpic.org.au • NDARC – National Drug & Alcohol Research Centre www.ndarc.med.unsw.edu.au • EROWID - www.erowid.net

43. PRO Sites to Check out • www.norml.com • www.erowid.org • www.lycaeum.org • www.thc-foundation.org • www.sensiblecolorado.org

44. thank you Katie Dunker Katie.Dunker@hcc.du.edu 303-871-3763 University of Denver Health & Counseling Center