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Considering the Context:
Overlapping and Co-Occurring Health Issues in Our Communities
Jason R. Kilmer, Ph.D.University of WashingtonAssociate Professor
Psychiatry & Behavioral SciencesAssistant Director of Health & Wellness for Alcohol & Other Drug Education
Division of Student Life
Overview of this presentation
• Huge thanks to Al Fredrickson
• Examples of ways in which substance use can exacerbate or even cause co-occurring issues
• Implications for prevention, with a focus on positive community norms
EXPECT
Alcohol No Alcohol
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The potential role of
expectancieswith
marijuana
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EXPECT
Marijuana Placebo
Jane Metrik’s research at Brown
Some examples of areas in which substance use could exacerbate or cause unwanted effects
Substances and sleep
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Absorption and Oxidation of Alcohol
• Factors affecting absorption
– What one is drinking
– Rate of consumption
– Effervescence
– Food in stomach
• Factors affecting oxidation
– Time!
– We oxidize .016% off of our blood alcohol content per hour
Time to get back to .000%
• .08%?– 5 hours
(.080%....064%....048%....032%....016%....000%)
• .16%?– 10 hours
(.160%....144%....128%....112%....096%....080%... .064%....048%....032%....016%....000%)
• .24%?– 15 hours
(.240%....224%....208%....192%....176%....160%... .144%....128%....112%....096%....080%....064%... .048%....032%....016%....000%)
http://pubs.niaaa.nih.gov/publications/arh25-2/101-109.pdf
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REM
Stage 1
Stage 2
Stage 3
Stage 4
REM
Stage 1
Stage 2
Stage 3
Stage 4
REM
Stage 1
Stage 2
Stage 3
Stage 4
Next day, increase in:•Daytime sleepiness•Anxiety•Irritability•Jumpiness
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REM
Stage 1
Stage 2
Stage 3
Stage 4
Next day, increase in:•Daytime sleepiness•Anxiety•Irritability•JumpinessNext day, feel:•Fatigue
REM
Stage 1
Stage 2
Stage 3
Stage 4
With marijuana, two things happen…Extension of Stage 4 or “deep” sleep and REM deprivation
Sleep impairment documented as persistent effect of marijuana use NIDA (2012)
REM
Stage 1
Stage 2
Stage 3
Stage 4
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REM
Stage 1
Stage 2
Stage 3
Stage 4
Next day, just like with alcohol, increase in:•Daytime sleepiness•Anxiety (note that there is a Cannabis Induced Anxiety Disorder)•Irritability•Jumpiness
REM
Stage 1
Stage 2
Stage 3
Stage 4
Next day, just like with alcohol, increase in:•Daytime sleepiness•Anxiety (note that there is a Cannabis Induced Anxiety Disorder)•Irritability•Jumpiness
Next day, feel:•Fatigue
Alcohol and decision making
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.02% Relaxed
.04% Relaxation continues, Buzz develops
.06% Cognitive judgment is impaired
Blood Alcohol Level
“Alcohol Myopia”
?
Impelling Cues Inhibiting CuesAlcohol impairs
information processing,
narrowing attentionto only the most
salient internal and environmental
cues.
Marijuana and mental health
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Cannabis Use Associated with Risk of Psychiatric Disorders
(Hall & Degenhardt, 2009; Hall, 2009; Hall 2013)
• Schizophrenia
– Those who had used cannabis 10+ times by age 18 were 2.3 times more likely to be diagnosed with schizophrenia
– “13% of schizophrenia cases could be averted if cannabis use was prevented (Hall & Degenhardt, 2009, p. 1388)”
• Depression and suicide
– “Requires attention in cannabis dependent” (Hall, 2013)
• Screening suggestions
– Revised CUDIT-r– http://www.otago.ac.nz/nationaladdictioncentre/pdfs/cudit-r.pdf
Separating out underlying issues from management of withdrawal symptoms
• Research team utilized qualitative open-ended responses for using marijuana among incoming first year college students to identify which motivations were most salient to this population
Lee, Neighbors, & Woods (2007)
Motivations for Use
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Lee, Neighbors & Woods (2007)
Enjoyment/fun
Social enhancement
Boredom
Altered perception
Activity enhancement
Celebration
Image enhancement
Motivations for Use
Lee, Neighbors & Woods (2007)
Relaxation (to relax, helps me
sleep)
Coping (depressed,
relieve stress)
Anxiety reduction
Medical use (physical pain,
have headache)
Habit
Food motives
Motivations for Use
Withdrawal: Cannabis
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Where might we see that targeting one behavior impacts another?
Targeting alcohol (and binge drinking) can reduce suicidal behavior
Past month alcohol use and relation to suicide among adults over 18 years of age
Substance Abuse and Mental Health Services Administration, Suicidal thoughts and behavior among adults: Results from the 2014 National Survey on Drug Use and Health. Released September 10, 2015
Percentage endorsing
item
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Laurie Davidson, Suicide Prevention Resource Center
“Alcohol prevention is suicide prevention…”
Support peer communication to change students’ social norms about alcohol use
Changing norm perceptions can decrease suicidal behavior (Manza & Sher, 2008)
Changing Social Norms Could Impact Behavior Elsewhere
Let’s a take a moment to acknowledge Deer River, Minnesota and Heather Schjenken!
Potential for marijuana to be driving non-medical use of prescription stimulants
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• Amelia Arria’s model:
Marijuana use
Past 12 month non-medical use
• “In the past 12 months, on how many days have you used an ADHD prescription stimulant non-medically?”• 82.8% 0 times• 3.3% 1 time• 3.1% 2 times• 1.9% 3 times• 1.3% 4 times• 3.3% 5-10 times• 2.1% 11-20 times• 1.5% 21-40 times• 0.8% 41-300 times
This is a low frequency behavior: 55.4% of the students with any non-medical use in the past 12 months did it 1 to 4 times
Normative misperceptions
• Although most (82.8%) students have not used stimulants for non-medical reasons in the past year, the perception is that non-medical use is much higher
• Actual rate: 17.2%• Perceived rate: 30.0% (range is 0% to 98%)
• 21% of students think half or more of the undergrads on their campus use at least once per year
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Motives for use over past six months (among those with use over the past six months)• Percentage endorsing “sometimes/half the time,” “often/most of the
time,” or “always/almost always”• 54.0% To concentrate better while studying • 52.8% To be able to study longer • 35.0% To feel less restless while studying• 28.9% Because it helps increase my alertness • 18.7% To concentrate better in class • 13.9% To keep better track of assignments • 11.2% To feel less restless in class • 10.7% To feel better • 9.4% To prevent others from having an academic edge • 9.1% To get high • 8.6% To prolong the intoxicating effects of alcohol/substances• 8.6% Curiosity and experimentation• 6.4% Because it is safer than street drugs • 5.9% To lose weight • 5.1% Other• 4.3% To counteract the effects of other drugs • 2.1% Because I’m addicted
Marijuana Use
• Overall sample:• Past year marijuana use: 45.9%• Past 30-day marijuana use: 29.6%
• Among those with no past year non-medical use of prescription stimulants:• Past year marijuana use: 38.8%• Past 30-day marijuana use: 23.0%
• Among those with past year non-medical use of prescription stimulants:• Past year marijuana use: 86.0%• Past 30-day marijuana use: 66.2%
Skipping Class
• Among those with no past year non-medical use of prescription stimulants:• % skipping at least one class: 34.9%• Of those with at least 1 skipped class, % reporting they skipped
because of use of alcohol/other substances: 8.9%
• Among those with past year non-medical use of prescription stimulants:• % skipping at least one class: 54.1%• Of those with at least 1 skipped class, % reporting they skipped
because of use of alcohol/other substances: 39.6%
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Substance use and academics
http://www.cls.umd.edu/docs/AmerDropoutCrisis.pdf
• “Of all the problems that contribute to dropping out, substance use is one of the easiest to identify and one of the most easily stopped by interventions including treatment.”
• “Research evidence shows that when adolescents stop substance abuse, academic performance improves.”
• Substance using students are at increased risk for academic failure, including drop out
• Marijuana has stronger negative relationship to GPA and other outcomes and risk for dropout than alcohol use
• “The more severe the substance use, the more likely the impact on academic performance and risk for dropout.”
http://www.cls.umd.edu/docs/AmerDropoutCrisis.pdf
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Four recommendations from Dupont, et al (2013)
• Place more attention on at-risk students.
– Act early to identify and address variety of problem behaviors:
• Truancy
• Drug and alcohol use
• Delinquency
• Academic “disengagement”
• Focus resources on empowering parents
• Identify and study policies and programs that deliver on the goal of helping youth sustain long-term abstinence
• Develop and evaluate new personalized approaches to intervening with students at risk for dropout.
DuPont, R. L., Caldeira, K. M., DuPont, H. S., Vincent, K.B., Shea, C. L., & Arria, A. M.(2013). America’s dropout crisis: The unrecognized connection to adolescent substance use. Rockville, MD: Institute for Behavior and Health, Inc.
Marijuana use trajectories: relationship to “discontinuous” enrollment
40.8% stop-out
36.1% stop-out
24.9% stop-out
Chronic/Heavy marijuana users were 2.0 times as likely as “minimal users” to have discontinuous enrollment……even after controlling for demographics, personality, and high school GPA.
Source: Arria, 2013
Potentially lessening experience of trauma through norms
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• Rape myth acceptance can impact bystander behavior –
– Individuals who were more likely to accept rape myths had lower intentions to intervene in a potential sexual assault situation (Hust, et al., 2013)
– Those who perceived their peers would intervene in a potential sexual assault situation were more likely to intervene themselves
Rape Myth Acceptance
Illinois Rape Myth Acceptance Scale (IRMA)(Payne, Lonsway, & Fitzgerald, 1999; McMahon & Farmer, 2011)
Sample items:
Subscale 1: “She asked for it”1) If a girl is raped while she is drunk, she
is at least somewhat responsible for letting things get out of hand
Subscale 2: “He didn’t mean to”12) If both people are drunk, it can’t be
rape.
Subscale 3: “It wasn’t really rape”17) If a girl doesn’t say “no” she can’t
claim rape.
Subscale 4: “She lied”19) Rape accusations are often used as a
way of getting back at guys.
• The most striking findings with implications for positive community norms come from Paul and colleagues (2009).
– Hypothesized that if survivors of sexual assault feel others hold “victim blaming” beliefs, they may be less likely to disclose an assault and may experience more post-assault trauma/distress
Rape Myth Acceptance
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• Paul and colleagues (2009) documented that college students overestimate the RMA of their peers
• They found that among survivors of sexual assault, PTSD symptoms were significantly correlated with estimated peer RMA (r=.37).
Rape Myth Acceptance
• They conclude that social norms campaigns may be used to correct misperceptions that individuals have regarding RMA to potentially lessen distress for survivors of assault and increase bystander behavior among peers.
Rape Myth Acceptance
Wrapping up and looking forward
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Keep up with efforts to reduce high risk drinking
Implement evidence-based programs
Wrapping up and Looking Forward
Domains that influence evidence-based decision makingSatterfield, et al., (2009)
Environment and
organizational context
Best available research evidence
Resources, including
practitioner expertise
Population characteristics, needs, values,
and preferences
DECISION MAKING
Keep up with efforts to reduce high risk drinking
Implement evidence-based programs
Efforts should be complementary, not competing
There are opportunities to provide norms in everything from PCN media campaigns to personalized feedback interventions
Parents and communities can make a huge difference
Wrapping up and Looking Forward
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Source: Washington Healthy Youth Survey
Keep up with efforts to reduce high risk drinking
Implement evidence-based programs
Efforts should be complementary, not competing
There are opportunities to provide norms in everything from PCN media campaigns to personalized feedback interventions
Parents and communities can make a huge difference
Changing culture by promoting healing
Wrapping up and Looking Forward
• Special thanks to:– Al Fredrickson
– Tom Koplitz
– Trent Jensen
– Jeff Linkenbach
• Thanks to all of you for what you do with and for your communities!
Contact info:Jason Kilmer, [email protected]://depts.washington.edu/cshrbhttp://livewell.uw.edu