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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, Ph.D.jkilmer@uw.eduhttps://depts.washington.edu/cshrbhttp://livewell.uw.edu