The ATTC Network LEARNING OBJECTIVES. Clinical Skills in the Era of Legal Cannabis. Clinical Skills in the Era of Legal Cannabis 6/30/2015

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1 Clinical Skills in the Era of Legal Cannabis Jennifer Wyatt, LMHC, MT-BC, CDP: Northwest Institute of Addiction Studies Conference July 22, 2015: Clackamas, OR The ATTC Network Ten Regional Centers FourNational Focus Area Centers SBIRT Hispanic and Latino Native American- Alaska Native Rural and Frontier LEARNING OBJECTIVES Participants will: 1.Gain an understanding of the varied forms of cannabis available for consumption 2.Understand rates of use and current research findings on the effects of cannabis on mental and physical health 3.Learn about cannabinoids and their interest to medical science 4.Practice evidence-based clinical skills to talk with clients about cannabis 5.Increase their knowledge of multimedia educational resources Jennifer Wyatt, LMHC, MT-BC, CDP 1

2 NATIONAL SURVEY ON DRUG USE AND HEALTH (NSDUH) National and state-level data on the use of tobacco, alcohol, illicit drugs (including non-medical use of prescription drugs) and mental health in the US Began in 1971 Conducted annually In 2013, approximately 70,000 individuals, age 12 and older, were randomly selected from all 50 states plus the District of Columbia NATIONAL YOUTH SURVEYS: MTF AND YRBS YOUTH SURVEYS: MTF AND YRBS Monitoring the Future(MTF): Measures drug, alcohol, tobacco use, and related attitudes of approximately 50,000 8 th, 10 th, and 12 th grade students, annually 12 th graders since 1975; and 8 th and 10 th graders since Youth Risk Behavior Survey (YRBS): Established in 1990 by the CDC to help monitor the prevalence of behaviors that put youth at risk Administered to high school students nationwide, it examines a minimum of six categories, including alcohol and drug use, sexual behaviors, and physical activity. OR and WA do not participate with the exception of Seattle Public Schools Jennifer Wyatt, LMHC, MT-BC, CDP 2

3 OREGON YOUTH SURVEYS: OHT & SWS YOUTH Oregon SURVEYS: Healthy Teens MTF (OHT) AND Survey: YRBS Conducted with 8 th & 11 th graders in odd years, separated by counties, starting in s/surveys/oregonhealthyteens/pages/index.aspx Addiction & Mental Health s Student Wellness Survey (SWS): Administered to 8 th & 11 th graders in even years, separated by counties, introduced in 2010 Conducted by the Oregon Health Authority First specific drug associated with initiation of illicit drug use among past year illicit drug initiates aged 12+: 2013 Marijuana Pain relievers Inhalants Tranquilizers Stimulants Hallucinogens Sedatives Cocaine 2.7% 2.6% 0.2% 0.1% 5.2% 6.3% 12.5% 70.3% National Survey on Drug Use and Health, 2013 Mean Age at first use for specific illicit drugs among past year initiates aged 12 to 49: 2013 Age in years TRANQUILIZERS SEDATIVES HEROIN PAIN RELIEVERS STIMULANTS ECSTASY COCAINE LSD INHALANTS MARIJUANA PCP National Survey on Drug Use and Health, 2013 Jennifer Wyatt, LMHC, MT-BC, CDP 3

4 Daily or almost daily marijuana use MORE HIGHLIGHTS (Use on 20 or FROM more days THE in the NSDUH, past month) 2013 In millions National Survey on Drug Use and Health, NSDUH: COMPARING OREGON & NATIONAL ADULT USE RATES 70% 60% 50% 40% 30% 20% 10% 0% Current user (Used one or more times in the past 30 days) US AGES OR AGES US AGES 26+ OR AGES 26+ US Ages OR Ages US Ages 26+ OR Ages 26+ Cannabis 19% 23% 6% 10% Alcohol 60% 62% 56% 62% Binge drinking 38% 39% 22% 21% Cigarettes 31% 29% 22% 22% 2013 NSDUH: ADULT USE TRENDS IN OREGON FROM Percentage of current users Percentage of current users 2013 ages NSDUH: in TRENDS OR IN WA (2003 ages & ) in OR 65% 62% 62% 56% 41% 29% 22% 23% 24% 7% 22% 10% Cannabis Alcohol Cigarettes Cannabis Alcohol Cigarettes Jennifer Wyatt, LMHC, MT-BC, CDP 4

5 2014 STUDENT WELLNESS SURVEY (SWS): OREGON 35% HEALTHY YOUTH SURVEY: 2014 HIGHLIGHTS 30% 25% 20% 15% 10% 5% 0% Current user (Used one or more times in the past 30 days) 6TH 8TH 11TH 6th 8th 11th Cannabis 1% 8% 19% Alcohol 5% 17% 34% Binge drinking 1% 7% 19% Cigarettes 1% 5% 10% 2013 YRBS & 2014 SWS: COMPARING NATIONAL 12 TH GRADERS & OREGON 11 TH GRADERS Current user (Used one or more times in the past 30 days) 12 TH 50% GRADERS: CURRENT USERS 45% 40% 35% 30% 25% 20% 15% 10% 5% 0% YRBS OR STATE MULTNOMAH CLACKAMAS YRBS OR State Multnomah Clackamas Cannabis 28% 19% 21% 24% Alcohol 47% 34% 31% 36% Binge drinking 29% 19% 16% 21% Cigarettes 19% 10% 9% 11% STATE COMPARISON: OR 11 TH GRADERS & WA STATE 12 th GRADERS Percentage of current 11 TH grade users in Oregon Percentage of current 12 th grade users in WA State 2013 NSDUH: TRENDS IN WA (2003 & 2013) 36% 36% 40% 34% 36% 27% 33% 24% 26% 27% 22% 19% 20% 14% 16% 12% 13% 10% Cannabis Alcohol Cigarettes Cannabis Alcohol Cigarettes Jennifer Wyatt, LMHC, MT-BC, CDP 5

6 HOW MIGHT DATA BE USEFUL TO YOU IN CLINICAL PRACTICE? FACTORS ASSOCIATED WITH MARIJUANA USE BY ADOLESCENTS Adolescents who use marijuana are at greater risk of adverse health and psychosocial consequences including: Risky sexual behavior which can lead to STIsor unplanned pregnancy Academic problems (e.g., dropout, increased absences) Legal problems, delinquency Driving under the influence of MJ more than doubles the risk of an accident Increased likelihood of suffering mental illness such as depression, anxiety, psychosis, or other mental illness Lowered educational and occupational aspirations Budney, Roffman, Stephens, & Walker. (2007); UW ADAI Fact Sheet: Marijuana & Adolescents, Jennifer Wyatt, LMHC, MT-BC, CDP 6

7 The younger they start, and the more NEGATIVE frequently IMPACT an adolescent OF MARIJUANA uses USE marijuana, ON the ADOLESCENTS more likely they are to suffer significant problems. RISK OF ADDICTION 9% of those who experiment with marijuana will become addicted About 17% for those who start using as teenagers 25-50% among those who smoke daily Source: Volkow et al., NEJM, IS THERE A LINK BETWEEN MARIJUANA USE AND MENTAL ILLNESS? Several studies have linked marijuana use to increased risk for mental illnesses, including psychosis (schizophrenia), depression, and anxiety, but whether and to what extent it actually causes these conditions is not always easy to determine. The amount of drug used, the age at first use, and genetic vulnerability have all been shown to influence this relationship (p. 8) NIDA Research Report Series: Marijuana Jennifer Wyatt, LMHC, MT-BC, CDP 7

8 Most people who use marijuana do notgo on to use other harder drugs. People who are more vulnerable to using drugs might start with readily available substances, including nicotine, alcohol, and marijuana. FEDERAL STATUS OF MARIJUANA The Administration steadfastly opposes legalization of marijuana and other drugs because legalization would increase the availability and use of illicit drugs, and pose significant health and safety risks to all Americans, particularly young people. Office of National Drug Control Policy: Marijuana OREGON: STATUS OF MARIJUANA Legal medical and recreational marijuana Starting Jul 1, 2015, Measure 91 permits possession of up to 8 oz of marijuana, and up to 4 plants per residence for adults 21+ In public, an individual may carry up to 1 oz of marijuana, but may not consume it. Oregon Liquor Control Commission will accept retail licenses in January 2016 with retail sales expected to begin in Fall As of Jun 2015, the Medical Marijuana Dispensary Program has approved 310 dispensary applications. Sources: Medical MJ: Retail: Jennifer Wyatt, LMHC, MT-BC, CDP 8

9 VIDEO How does marijuana affect the body? From Marijuana Lit: Fact-Based Information to assist you in providing SUD services: Video: EDIBLES Jennifer Wyatt, LMHC, MT-BC, CDP 9

10 DEFINITION: Inhaling vapors from THC-rich resins, or concentrates, extracted from the marijuana plant Hash oil or honey oil (BHO) Wax Shatter CONCERNS: Very high in THC (50-80%) ED visits from getting too high FORMS Preparation OF MARIJUANA involves FOR butane CONSUMPTION (lighter fluid) VAPING: Causes the essential oils in the VAPORIZERS extract to heat up to the point where they become vapors Photo from Grenco Science Cannabis tinctures and creams Source: Jennifer Wyatt, LMHC, MT-BC, CDP 10

11 ENDOCANNABINOID SYSTEM Endocannabinoid system Cannabinoid receptors Anandamide 2-AG (2-arachidonoyl glycerol) Source: The Science of Marijuana: How THC Affects the Brain VARIED USER EXPERIENCES OF MARIJUANA Pleasant euphoria Sense of relaxation Heightened sensory perception Laughter Altered time perception Increased appetite Anxiety Fear Distrust Panic Acute psychosis (Rare) Source: NIDA Research Report Series: Marijuana, 2015 Jennifer Wyatt, LMHC, MT-BC, CDP 11

12 CANNABINOIDS IN CANNABIS SATIVA Cannabinoids in Marijuana THC CBD CBC CBG CBN, CBDL And others Note that these compounds exist in varying percentages; they are NOT equally represented in marijuana. There are varying ratios in certain strains. Jennifer Wyatt, LMHC, MT-BC, CDP 12

13 Medical marijuanarefers to the whole unprocessed marijuana plant or its extracts; not approved as medicine MEDICAL MARIJUANA by the FDA, currently. Two FDA-approved drugs that contain THC are used to treat nausea (chemotherapy) and wasting disease (AIDS): Dronabinol & Nabilone Other medications containing THC and CBD are in development. Source: NIDA: Apr Is Marijuana Medicine? CBD moderates the psychoactive effects of THC. Mr. Mackey, the School Counselor from South Park, says Jennifer Wyatt, LMHC, MT-BC, CDP 13

14 TREATMENT FOR CANNABIS USE DISORDERS IN ADOLESCENTS AND ADULTS Cannabis use disorders appear to be very similar to other substance use disorders, although to a lesser severity. Adults seeking treatment for cannabis use disorder average more than 10 years of near daily use and more than six serious attempts at quitting. About half of people who enter treatment for marijuana use are under 25 years of age. Budney, Roffman, Stephens, & Walker (2007); NIDA, AVAILABLE TREATMENTS FOR CANNABIS USE DISORDERS Individual and group interventions: Marijuana Check-up (for adults) and Teen Marijuana Check-up 1 Motivational Enhancement Therapy (MET) 2, 3, 4 Cognitive Behavioral Therapy (CBT) 2, 3, 4 Contingency Management (CM) 2, 3, 4 Adolescent Assertive Continuing Care 1, 4 Sources: 1 WA State Institute for Public Policy, Oct 2014; 2 NIDA, 2015; 3 Budney et al 2007; 4 Hogue AVAILABLE TREATMENTS FOR CANNABIS USE DISORDERS Family intervention Multidimensional Family Therapy for Substance Abusers 1, 4 (RBP) Multisystemic Therapy (MST) 3, 4 SAMHSA Manuals (Available free) Cannabis Youth Treatment Study Volumes 1 5 Brief Counseling for Marijuana Dependence: A Manual for Treating Adults Sources: 1 WA State Institute for Public Policy, Oct 2014; 2 NIDA, 2015; 3 Budney et al 2007; 4 Hogue Jennifer Wyatt, LMHC, MT-BC, CDP 14

15 TALKING WITH PEOPLE ABOUT THEIR USE BE: Transparent Neutral (tone) Inviting A resource Curious Patient Present Ready HOW DO PEOPLE TEND TO RESPOND WHEN OFFERED SOLUTIONS TO THEIR PROBLEMS? Jennifer Wyatt, LMHC, MT-BC, CDP 15

16 MOTIVATIONAL INTERVIEWING TOOL FOR EXCHANGING INFORMATION ELICIT Existing knowledge Interest Permission PROVIDE Affirmations Information one piece at a time Autonomy support ELICIT Reactions Additional questions Next steps Source: Rollnick & Miller, 2013 WHAT ARE WE TRYING TO ELICIT? DESIRE ABILITY REASON NEED I wish I could quit smoking. I want to feel better. I quit before; I can do it again. My PO would get off my back. I might do better in school. I ve got to keep my driver s license. ELICIT: ASK PERMISSION. CLARIFY NEEDS. Would you like to know about What do you already know about What information can I help you with? Miller & Rollnick, 2013, p. 139 Jennifer Wyatt, LMHC, MT-BC, CDP 16

17 PROVIDE: PRIORITIZE. BE CLEAR. SUPPORT AUTONOMY. Focus on what the person wants to know. Avoid jargon; use plain language. Offer small amounts, with time to reflect. Acknowledge freedom to disagree/ignore. Miller & Rollnick, 2013, p. 139 ELICIT: ASK FOR THE PERSON S UNDERSTANDING AND RESPONSE. Reflect reactions that you see. Ask open-ended questions. Allow time to process and respond. Miller & Rollnick, 2013, p. 139 TIME TO PRACTICE! TIME TO PRACTICE! Groups of 3: Client, Counselor, Observer Choose one of the scenarios. Practice EPE. Take your time. Observers: Give feedback. Switch roles until everyone has played the Counselor. Jennifer Wyatt, LMHC, MT-BC, CDP 17

18 How was using EPE different from the usual way of providing information? How might this tool impact your conversations about cannabis use? NORTHWEST RESOURCES Oregon Liquor Control Commission: Oregon Health Authority t.aspx University of Washington Alcohol & Drug Abuse Institute: Medical Cannabis and Chronic Pain Project (CME Modules for Medical Practitioners): NATIONAL RESOURCES National Institute on Drug Abuse: NIDA for Teens: ATTC Network: Drug Policy Alliance: Americans for Safe Access (Medical marijuana): Jennifer Wyatt, LMHC, MT-BC, CDP 18

19 Visit Us Online! Upcoming trainings The range of training and technical assistance services we offer Resources and links on key topics Jennifer Wyatt, LMHC, MT-BC, CDP 19