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The Importance of Coalitions and Health Associations in Putting Science Into Action: Addressing College Student Substance Use

Jason R. Kilmer, Ph.D.University of WashingtonAssociate Professor

Psychiatry & Behavioral SciencesLiveWell Assistant Director for Alcohol & Other Drug Education

Division of Student Life

• Special thank you to Linda Dudman and Dolores Cimini

• What I said I’d do…▫ “The purpose of this keynote is to highlight key steps in

evidence-based decision making for established fields (e.g., alcohol prevention) and fields with emerging needs demands (e.g., cannabis/marijuana prevention and intervention).”

Overview of this presentation

What you do to address substance use will pay dividends elsewhere

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⚫Relationship between alcohol, sleepiness, and GPA exists in college (Singleton & Wolfson, 2009)

⚫Heavy drinking associated with lower GPA, and students at research universities who are heavy episodic drinkers are less likely to be engaged in interactions with faculty (Porter & Prior, 2007)

⚫Frequency of binge drinking associated with lower grades in college setting (Pascarella, et al., 2007)

Relationship Between Alcohol Use and Academic Success

⚫More frequent marijuana use is associated with more discontinuous enrollment, skipping more classes, and lower GPAs (Arria, et al., 2013, 2015)

⚫Any marijuana use is associated with lower GPA, and decreasing and frequent marijuana use over time is associated with less current enrollment and being less likely to graduate on time (Suerken, et

al., 2016)

Relationship Between Cannabis Use and Academic Success

⚫Alcohol and marijuana are both associated with lower GPA; when entered in same regression, effects of alcohol became non-significant (Bolin,

Pate, McClintock, 2017)

⚫Students using both marijuana and alcohol at moderate to high levels have significantly lower GPAs over two years (Meda, et al., 2017)

⚫Students who moderate or curtail substance use improved GPA (Meda, et al., 2017)

Relationship Between Cannabis Use, Alcohol Use, and Academic Success

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Past month alcohol use and relation to suicide among adults over 18 years of age

Percentage endorsing

item

https://www.samhsa.gov/data/sites/default/files/NSDUH-DR-FFR3-2015/NSDUH-DR-FFR3-2015.pdf

Percentage endorsing item as a function of past year substance use Note: all prescription drug use reflected here is non-medical use

https://www.samhsa.gov/data/sites/default/files/NSDUH-DR-FFR3-2015/NSDUH-DR-FFR3-2015.pdf

Percentage endorsing item as a function of having (or not having) a substance use disorder

https://www.samhsa.gov/data/sites/default/files/NSDUH-DR-FFR3-2015/NSDUH-DR-FFR3-2015.pdf

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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

▪ Identify students with psychological difficulties

▪ Potentially difficult to spot with irregular sleep patterns, heavy episodic alcohol use, and other drug use

Manza & Sher (2008)

Alcohol Prevention is Suicide Prevention: Articles that Also Make This Assertion

Understand factors that go into evidence-based decision

making

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Environment and

organizational context

Best available research evidence

Resources, including

practitioner expertise

Population characteristics, needs, values,

and preferences

DECISION MAKING

Domains that influence evidence-based decision makingSatterfield, et al., (2009)

Constructing a strategic plan for alcohol prevention

STRATEGIC PLANNING

• What seems to be clear from the scientific literature?

• There’s no one “right way” or “right model” for strategic planning

• Pick the approach that best meets your needs and makes the most sense for your community!

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www.collegedrinkingprevention.gov/CollegeAIM

Select

PlanTake

action

Assess

Where does College AIM fit in the planning process?

Assess behavior on campus and

set priorities

Select

PlanTake

action

Assess

Where does College AIM fit in the planning process?

Assess behavior on campus and

set priorities

Select strategies

after exploring evidence-

based interventions

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Select

PlanTake

action

Assess

Where does College AIM fit in the planning process?

Assess behavior on campus and

set priorities

Select strategies

after exploring evidence-

based interventions

Plan how to carry out

strategies and measure results

Select

PlanTake

action

Assess

Where does College AIM fit in the planning process?

Assess behavior on campus and

set priorities

Select strategies

after exploring evidence-

based interventions

Plan how to carry out

strategies and measure results

Implement the chosen strategies,

evaluate them, and refine the

program

“A mix of strategies is best (p. 5)”

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Start with a compilation of what is already offered

Then, consult College AIM!

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Implications for coalitions

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Implications for coalitions

• Coalitions can bring key stakeholders (both on-and off-campus) to the table

•Many of the environmental strategies require the involvement of off-campus partners

•Reduce barriers to disseminating best practices by raising awareness of “what works”

•Any one thing we do is a part of an overall puzzle

“The use of effective interventions without implementation strategies is like serum without a syringe; the cure is available, but the delivery system is not.”

Fixsen, Blase, Duda, Naoom, & Van Dyke (2010)

Five main stages of successful implementation (Fixsen, et al., 2005; NREPP/SAMHSA, 2012)

Barriers to Implementing Evidence-Based Strategies

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Possible Barriers to Implementing Effective Interventions

• Barriers can exist to dissemination, adoption, implementation, and maintenance (Rogers, 1995)

Source: Larimer, Kilmer, and Lee, 2005

Possible Barriers to Dissemination in Implementing Effective Interventions

• Published findings appear in journals not oriented to clinicians (Sobell, 1996)

▫ Often little description of steps needed to apply a treatment or intervention

Source: Larimer, Kilmer, and Lee, 2005

• Some publications or evaluations are not “user friendly” (Backer, 2000)

Source: Larimer, Kilmer, and Lee, 2005

Possible Barriers to Dissemination in Implementing Effective Interventions

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Possible Barriers to Adoption in Implementing Effective Interventions

• Reactions from key individuals involved in the process (DeJong and Langenbahn, 1996)

• Diversity of opinion around how to proceed▫ Could lead to difficulty in committing

Source: Larimer, Kilmer, and Lee, 2005

• Unreasonable expectations (Liddle, et al., 2002)

• Insufficient “buy-in” (Liddle, et al., 2002)

• Not enough time working with directors, administrators, staff, or students

Source: Larimer, Kilmer, and Lee, 2005

Possible Barriers to Adoption in Implementing Effective Interventions

Possible Barriers to Implementation in Implementing Effective Interventions

• Proper training of those delivering a program

• A tendency to “reinvent” innovations (Rohrbach,

D’Onofrio, Backer, & Montgomery, 1996)

Source: Larimer, Kilmer, and Lee, 2005

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• Organizational factors (Simpson, 2002)

▫ Resources, issues impacting effective delivery, attitudes among leaders, etc.

• Resistance among staff familiar and comfortable with a prior approach (Liddle, et al.,

2002)

Source: Larimer, Kilmer, and Lee, 2005

Possible Barriers to Implementation in Implementing Effective Interventions

Possible Barriers to Maintenance in Implementing Effective Interventions

• Therapist drift (i.e., issues of fidelity)

• Need for ongoing assessment and continued training

Source: Larimer, Kilmer, and Lee, 2005

Possible Administrative Barriers in Implementing Effective Interventions

• Tendency to move toward “next best thing”▫ One approach being pursued at the expense of

another

• Concern that directing attention or funds toward a behavior indicates that “problem” exists

Source: Larimer, Kilmer, and Lee, 2005

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What do you do when the “real world” gets ahead of

what the science says?

Environment and

organizational context

Best available research evidence

Resources, including

practitioner expertise

Population characteristics, needs, values,

and preferences

DECISION MAKING

Domains that influence evidence-based decision makingSatterfield, et al., (2009)

Emerging science and trends related to cannabis use

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First, we have to consider that research on

cannabis needs to “catch up” with what people are

actually using, since potency is at never before seen rates

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ElSohly, M.A., Mehmedic, Z., Foster, S., Gon, C., Chandra, S., & Church, J.C. (2016). Changes in cannabis potency over the last 2 decades (1995-2014) –Analysis of current data in the United States. Biol Psychiatry, 79, 613-619.

El Sohly, M.A., Mehmedic, Z., Foster, S., Gon, C., Chandra, S., & Church, J.C. (2016). Changes in cannabis potency over the last two decades (1995-2014) – Analysis of current data in the United States. Biol Psychiatry, 79, 613-619.

Washington State Impact Report

www.mfiles.org

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Average potency (nation) = 13.18%Average potency (Seattle) = 21.62%

Concentrates average potency (nation) = 55.85%Concentrates average potency (Seattle) = 71.71%

El Sohly, M.A., Mehmedic, Z., Foster, S., Gon, C., Chandra, S., & Church, J.C. (2016). Changes in cannabis potency over the last two decades (1995-2014) – Analysis of current data in the United States. Biol Psychiatry, 79, 613-619.

DiForti, M., Quattrone, D., Freeman, T.P., Tripoli, G., et al. (2019). The contribution of cannabis use to variation in the incidence of psychotic disorder across Europe (EU-GEI): A multicenter case-control study. Lancet Psychiatry, 6 (5), 426-436.

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Conclusions

• 20% of new cases of psychotic disorder “could have been prevented if daily use of cannabis had been abolished (page 433)”

• If high-potency cannabis were no longer available, 12.2% of cases of first-episode psychosis could be prevented

• Numbers for Amsterdam?

▫ 50.3% of cases attributed to high potency cannabis

Second, we have to separate out placebo effects from pharmacological effects

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Expectancies

Loflin, et al., 2017

• Asked participants to refrain at least 8 hours before study

• Told to plan for a variable end (1.5-6 hours depending on dose they would receive)

• Told they would be in one of three rooms (no dose, low THC, high THC)

• Cubicles (no interaction), and had to rate music and comedy clips, color designs, and compute math problems

Loflin, et al. (2017)

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• Used Hemp Pops▫ Hemp seed oil (no active elements of THC or CBD), glucose

syrup, citric acid, sugar, natural flavors, and colors #2 and #5

Loflin, et al. (2017)

• For example…▫ Sativa – typically described as uplifting and energetic▫ Indica – typically described as relaxing and calming

• “We would all prefer simple nostrums to explain complex systems, but this is futile and even potentially dangerous in the context of a psychoactive drug such as cannabis” (Piomelli & Russo, 2016, Cannabis and Cannabinoid Research)

• Differences in observed effects could be due to other content (which is rarely assayed) or what is reported to potential consumers

Placebo effects need to be explored

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A sample of additional scientific findings relevant to

today’s topic:Cognitive effects

Mental health effectsAddiction risk

Driving under the influence

Impact on attention, concentration, and

memory

Marijuana and cognitive abilities

• Effects on the brain

▫ Hippocampus

Attention, concentration, and memory

▫ Research with college students shows impact on these even 24 hours after last use (Pope & Yurgelun-Todd, 1996)

▫ After daily use, takes 28 days for impact on attention, concentration, and memory to go away (Pope, et al., 2001)

▫ Hanson et al. (2010):

Deficits in verbal learning (takes 2 weeks before no differences with comparison group)

Deficits in verbal working memory (takes 3 weeks before no difference with comparison group)

Deficits in attention (still present at 3 weeks)

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A sample of additional scientific findings relevant to

today’s topic:Cognitive effects

Mental health effectsAddiction risk

Driving under the influence

REM

Stage 1

Stage 2

Stage 3

Stage 4

With marijuana…Extension of Stage 4 or “deep” sleep and REM deprivation

Angarita, et al., 2016

REM

Stage 1

Stage 2

Stage 3

Stage 4

Angarita, et al., 2016

Next day, increase in:•Daytime sleepiness•Anxiety•Irritability•Jumpiness

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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

• Screening suggestions

▫ Cannabis Use Disorder Identification Test-Revised (CUDIT-R)▫ http://www.warecoveryhelpline.org/wp-content/uploads/2018/04/CUDIT.pdf

Source: Washington Recovery Helpline

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MARIJUANA USE – effects after use

• With high doses, may experience acute toxic psychosis▫ Hallucinations▫ Delusions▫ Depersonalization

• Seem more likely when high dose is consumed in food/drink rather than smoked

• Specific causes of symptoms unknown

A sample of additional scientific findings relevant to

today’s topic:Cognitive effects

Mental health effectsAddiction risk

Driving under the influence

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DSM-5 Cannabis Use Disorder Criteria

MaCoun (2013), Frontiers in Psychiatry

Mild: 2-3 symptomsModerate: 4-5 symptomsSevere: 6+ symptoms

A quick word about medical cannabis use

(particularly if adolescents/young adults are declining

referrals for counseling)

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Welty, et al., 2014 (p. 251) GMP = “Good Manufacturing Practices”

Authors reviewed published literature and conducted a lit review on Medline for all articles between 1975 and 2017 that included key words of “cannabis,” “THC”, “CBD”, “Nabiximol”, “cancer”, or “pain.”

Found five studies that met criteria for inclusion.

• Schedule I substance • Lack of dosing guidelines▫ Ideally, research would need to find a dose that provides

maximum relief with minimal side effects

• As it is, optimal doses seem to vary person to person• Often are taking many other treatments (medical, herbal, or

otherwise)• Generalizability is challenging (e.g., 3 of the 5 studies had less

than 50 participants)• Trials need to consider differences in cannabinoid

pharmacokinetics and pharmacodynamics among individuals• Standardized and validated evaluation and reporting of side-

effects is warranted

Challenges with medical cannabis research

Blake, et al., (2017)

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Side effects documented across the five studies evaluated in Blake, et al., (2017), p. 220

Source: Gizmodo.com

Source: CTVNews.com

Source: ScienceDaily.com

Only are recommending for neuropathic pain, palliative and end-of-life pain, chemotherapy-induced nausea and vomiting, and spasticity due to multiple sclerosis or spinal cord injury…

AND

If tried traditional therapies/treatments first…

Allan, et al. (2018)

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“This study suggests that oral CBD does not alter responses to emotional stimuli, or produce anxiolytic-like effects in healthy human subjects. (p. 112)”

Arndt & de Wit (2017)

Separating reported medical use from management of

withdrawal

• 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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Motivations for Use

Lee, Neighbors & Woods (2007)

Enjoyment/fun

Social enhancement

Boredom

Altered perception

Activity enhancement

Celebration

Image enhancement

Lee, Neighbors & Woods (2007)

Motivations for Use

Relaxation (to relax, helps me

sleep)

Coping (depressed,

relieve stress)

Anxiety reduction

Medical use (physical pain,

have headache)

Habit

Food motives

Withdrawal: Cannabis

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A sample of additional scientific findings relevant to

today’s topic:Cognitive effects

Mental health effectsAddiction risk

Driving under the influence

Impaired driving and duration of effects

• Effects on the brain Authors of I-502 set DUI at 5 ng THC/ml of blood for those

over 21 (any positive value for those under 21)

Why 5 ng? Similarities in impairment to .08% for alcohol

How long does it take to drop below 5 ng?

Grotenhermen, et al., (2007) suggest it takes 3 hours for THC levels to drop to 4.9 ng THC/ml among 70 kg men

From a public health standpoint, Hall (2013) recommends waiting up to 5 hours after use before driving

New article encourages waiting at least 6 hours after use (Fischer, et al., 2017)

Driving after marijuana use decreasing (though still at high rates)

**There are declines in driving after marijuana use between cohort 3 and cohort 1 (p<.05), between cohort 4 and cohort 1 (p<.01), and between cohort 5 and cohort 1 (p<.05), as well as a significant linear trend (p<.01).**

Source: Washington Young Adult Health Survey (Kilmer, PI)

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Released 4/26/17: http://www.ghsa.org/resources/drugged-driving-2017

So what can coalitions do?

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Consider event-specific prevention,

education, and enforcement

High-risk events are on the horizon

Neighbors, et al. (2011), sample of 1,124 students who had turned 21

Sample of over 100,000 BAC results aggregated; BACtrack Consumption Report, 2014

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High-risk eventsBravo et al (2017) found:• More people used

on 4/20 than weekdays or weekends

• People reported more unique sessions of use on 4/20 than weekdays or weekends

• People used more grams on 4/20 than weekdays or weekends

Staples & Redelmeier (2018)• Obtained data from US NHTSA’s

Fatality Analysis Reporting System• Began first full year after High

Times popularized 4/20 up to most recent year with complete data (1992 through 2016)

• Analyzed drivers involved in fatal crashes between 4:20 p.m. and 11:59 p.m. on 4/20 compared to same interval on 4/13 and 4/27• Controlled for weekday,

season, year, and minimized bias from changes in vehicle design, travel distances, medical care, etc.

• Drivers involved in fatal crashes on 4/20: 1,369 (7.1 per hour)• Drivers involved in fatal crashes on control days: 2,453 (6.4 per hour)

• The risk of a fatal crash was significantly higher on April 20 (relative risk 1.12, p<.001)

Staples & Redelmeier (2018)

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Coalitions can explore ways to implement

SBIRT to identify students who might

otherwise slip through the cracks

There are people who could benefit from services who might not be getting them

•72% of college students who screened positive for major depression felt they needed help

•Only 36% of students received medication or therapy of any kind

Source: Eisenberg, et al., (2007)

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Depression

•Factors related to access:▫Unaware of or unfamiliar with service options

▫Questioned helpfulness of therapy or medication

▫Uncertainty about insurance coverage for mental health visits

▫ Less use by students who reported growing up in “poor family”

▫ Less use by those identifying as Asian or Pacific Islander

Source: Eisenberg, et al., (2007)

Depression

•Factors related to access:▫ Reasons identified by students:

Lack of perceived need

Belief that stress is normal

Lack of time

Source: Eisenberg, et al., (2007)

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Health Center

Counseling Center

Academic Advising

Meetings with coaches

or trainers

Wellness Center

Meetings with RAs

ConductOther

Student Life offices

They may not seek help for these issues, but they do go to…

Coalitions can mobilize and uncover our hidden partners

in prevention --parents

Examining role of parents and peers

Family

Friends

• Fairlie, Wood, & Laird (2012) collected data during summer before starting college, 10 month follow-up (spring semester of first year), and 22 month follow-up (spring semester of second year)

• Looked at social modeling (e.g., # of close friends who drink heavily, perceived friend approval of drinking and getting drunk) and parental permissiveness

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Heavy episodic drinking as a function of high or low social modeling + high or low parental permissiveness

Source: Healthy Youth Survey, 2016

Source: Healthy Youth Survey, 2016

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Where 18-20 year olds get marijuana decreasing for medical sources, increasing for family, parents, and paying someone

Source: Washington Young Adult Health Survey (Kilmer, PI)

Coalitions can help remind people of the context of substance

use

Project PHARM: Collecting the data

• Partnered with 7 colleges/universities during 2015-2016 academic year

– 2,989 undergraduates between 18-25 years of age

– 17.2% reported past year use of a prescription ADHD stimulant medication not prescribed to them

Kilmer, et al., (under review)

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Marijuana use•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%

Kilmer, et al., (under review)

Heavy episodic alcohol use (4+ drinks last 30 days for women, 5+ drinks last 30 days for men)

•Among those with no past year non-medical use of prescription stimulants

– Women (4+ at least once past 30): 47.1%– Men (5+ at least once past 30): 47.0%

•Among those with past year non-medical use of prescription stimulants

– Women (4+ at least once past 30): 88.4%– Men (5+ at least once in past 30): 85.6%

Kilmer, et al., (under review)

Coalitions can bring key stakeholders

together to impact enforcement,

education, prevention, and

messaging

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Remember, any one thing you do is part of

an overall puzzle

Know that, together, we have an important

voice and message that deserves to be

heard

“The strength of the team is each individual member. The strength of each member is the team.”

-- Phil Jackson

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• Special thanks to:▫ Linda Dudman▫ Dolores Cimini▫ Estela Rivero▫ NYSCHA▫ NECHA

Jason Kilmer – jkilmer@uw.edu

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