Discussing Substance Use with College Students: Incorporating Brief Intervention Approaches into Conversations on Campus and Addressing Marijuana in a Changing Legal Climate 3 of 3
In this workshop, we will discuss the theory behind and reasons for a brief intervention approach, will provide training in and practice with specific motivational interviewing strategies, and will consider ways to incorporate these approaches into conversations already taking place with students across campus.
Additionally, there is recent research on marijuana and the clear implications for college student health that we will review, including impacts on cognitive functioning, mental health, risk for addiction, and other unwanted effects. Along with lessons learned from a legal state, we will discuss these findings in the context of the brief intervention content from earlier in the day.
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[00:00:03.930]So, post lunch,
[00:00:06.780]the two things we wanted to be able to do
[00:00:09.200]was more practice with motivational interviewing,
[00:00:11.780]more bringing this to life,
[00:00:13.490]and a bit more around marijuana use.
[00:00:17.150]I can't stress enough how important it is
[00:00:19.160]to make sure that what doesn't get lost
[00:00:21.250]in the shuffle with MI is doing reflections.
[00:00:23.960]And the more practice you get thinking reflectively
[00:00:26.600]the easier it is to make reflections.
[00:00:28.680]I am so confident that you can reflect back
[00:00:30.840]absolutely anything that what I've done is
[00:00:33.410]compiled a series of song lyrics,
[00:00:36.490]some of which actually reflect different
[00:00:38.750]levels of readiness to change,
[00:00:39.870]some of which reflect change talk.
[00:00:41.720]And I'd like you to respond to
[00:00:42.820]these statements with reflections.
[00:00:46.540]I gotta feelin' that tonight's gonna be a good night.
[00:00:49.380]What could you do as a reflection here?
[00:00:53.339]Excited about tonight.
[00:00:54.172]You feel excited about tonight
[00:00:55.170]is a fantastic reflection.
[00:00:57.350]I don't wanna be anything other than
[00:00:58.830]what I've been tryin' to be lately.
[00:01:03.280]What's a reflection you could do here?
[00:01:06.091]You're happy with where you're at.
[00:01:07.331]You're happy with where you're at
[00:01:08.300]is a fantastic reflection.
[00:01:09.990]What else, if anything?
[00:01:18.250]Say it again.
[00:01:19.183]You're a Gavin DeGraw fan.
[00:01:20.439]You're a Gavin DeGraw fan.
[00:01:22.559]That is true and not a good reflection
[00:01:26.580]what do we think the person means?
[00:01:32.091]I like the one we already heard.
[00:01:33.600]So I told him if you liked it
[00:01:35.050]then you should have put a ring on it.
[00:01:41.580]What could you do as a reflection here?
[00:01:44.553]You wanted a commitment.
[00:01:45.600]That's a fantastic reflection.
[00:01:47.520]I'm gonna keep, well, there's only
[00:01:48.730]a few of these, but the truth is
[00:01:50.050]I started this in response to
[00:01:52.290]a training with peer health educators.
[00:01:53.940]Their director said these peers love
[00:01:56.510]when you put this stuff up,
[00:01:57.550]but they're worried about their ability
[00:01:58.590]to do it in the real world.
[00:01:59.940]So I said, lemme back in with them,
[00:02:02.290]and we came up with 50 song lyrics with these students.
[00:02:05.890]But, I mean, really
[00:02:08.700]that was not a lie about
[00:02:10.400]the Michael Jackson lyrics in the car.
[00:02:12.410]We do this stuff when we drive.
[00:02:14.830]The more practice you get thinking reflectively
[00:02:16.930]the easier it is to do it.
[00:02:18.190]Moving along the commitment continuum,
[00:02:19.980]I told her, I won't hesitate no more, no more.
[00:02:23.170]It cannot wait, I'm yours.
[00:02:27.600]What could we do here as a reflection?
[00:02:35.100]You're ready to commit.
[00:02:37.410]I told him, I knew you were trouble
[00:02:39.170]when you walked in, so shame on me now.
[00:02:46.570]That's a close-ended question,
[00:02:47.810]but you could make that a reflection.
[00:02:49.280]How would you make that exact
[00:02:50.350]close-ended question a reflection?
[00:02:53.024]How do you feel about this person?
[00:02:54.680]That's an open-ended question.
[00:02:56.080]You're just going for the trifecta.
You did a close-ended.
[00:02:58.310]You did it open-ended.
[00:02:59.470]How could you make that a reflection?
[00:03:03.450]You wish you would've trusted your gut.
[00:03:04.680]Your initial assumption was correct.
[00:03:06.030]You could've said you're upset
[00:03:08.320]with the decision you made.
[00:03:09.470]That could be a reflection.
[00:03:11.150]Are you upset with the decision you made?
[00:03:12.540]Close-ended, yes, no.
[00:03:13.690]How do you feel about it, open-ended.
[00:03:15.420]Or, we can make the hypothesis.
[00:03:18.050]You're upset with the decision you made.
[00:03:19.520]We could even be more directive
[00:03:21.830]and get at the shame on me now.
[00:03:23.490]You wish you trusted your gut.
[00:03:24.910]You wish you'd have trusted your initial assumptions.
[00:03:27.670]I told him I got one less problem without ya.
[00:03:35.900]You think you're better off now.
[00:03:39.200]A little Seattle love here.
[00:03:40.690]They be like, oh, that Gucci.
[00:03:42.573]I'm like, yo, that's $50 for a tee shirt.
[00:03:48.210]What do we think the speaker means,
[00:03:49.900]and what's a reflection we could make here?
[00:03:52.773]Place a high value. (faint speaking)
[00:03:54.940]You don't place a high value on expensive things.
[00:03:56.940]That's a great reflection.
[00:03:58.177]$50 for a tee shirt's ridiculous.
[00:04:00.730]There's the reflection.
[00:04:03.370]I was doing this with one of our programs
[00:04:06.660]in the med school, and there was a person
[00:04:08.180]that didn't know that hella-tight was slang.
[00:04:11.360]And his reflection was if you spend $50 on a tee shirt,
[00:04:14.050]you want it to fit and not to be hella-tight.
[00:04:19.693]I was like, that's the greatest thing
[00:04:20.610]I've ever heard in my life.
[00:04:23.420]There must be more than this provincial life.
[00:04:28.039](laughs) That's hilarious.
You want adventure
[00:04:29.302]in the great wide somewhere.
[00:04:30.460]You want adventure in the great wide.
[00:04:32.370]That's great that you're,
[00:04:33.203]that's actually, you want more.
[00:04:35.500]What's another, instead of just moving along
[00:04:37.740]the song lyric from Beauty and the Beast,
[00:04:39.680]which does work, what could you do as a reflection here?
[00:04:45.220]You're unsatisfied with your life as it is.
[00:04:47.030]Good reflection, what else?
[00:04:52.440]You're curious about what else is out there.
[00:04:54.430]This is fantastic.
[00:04:56.030]So for those of you still kind of trying this on,
[00:04:58.060]you're hearing some fantastic examples.
[00:05:00.180]Those of you playing along,
[00:05:01.040]there's only a few left, and thank you.
[00:05:02.890]Every little thing she does is magic.
[00:05:07.920]She excites you.
[00:05:10.553](laughs) Someone just said she's a magician.
[00:05:14.814]That's (laughs) fantastic.
[00:05:19.010]You're a wizard, Harry.
[00:05:25.420]What else would we do here, if anything?
[00:05:29.940]Think fondly of her.
[00:05:30.773]You think fondly of her, nice.
[00:05:31.870]I kissed a girl and I liked it.
[00:05:33.180]I hope my boyfriend don't mind it.
[00:05:38.610]This would be a good double-sided
[00:05:39.720]'cause their ambivalence.
[00:05:40.610]What could you do here as a double-sided reflection?
[00:05:53.170]And instead of a but.
[00:05:55.580]Order here probably matters less,
[00:05:57.060]and it's just a fantastically worded
[00:06:00.540]I came in like a wrecking ball.
[00:06:08.460]You feel like you came on a little strong.
[00:06:10.400]That's a good reflection.
[00:06:11.780]What else could we do 'cause this requires a hypothesis
[00:06:15.490]in the sense that there was an image used,
[00:06:17.147]and we may not understand the context,
[00:06:19.530]but we can make a hunch given the wrecking ball image.
[00:06:22.360]What else could we do?
[00:06:23.662]You feel like you did damage.
[00:06:24.611]You feel like you did some damage.
[00:06:25.840]You feel like you were aggressive.
[00:06:28.168]Stood up for yourself.
[00:06:29.001]You stood up for yourself, which is a cool reflection that
[00:06:31.380]also has an affirm element to it.
[00:06:33.920]I told my friend, say what you wanna say,
[00:06:35.680]and let the words fall out.
[00:06:36.940]Honestly, I wanna see you be brave.
[00:06:48.580]You wanna see your friend stand up
[00:06:49.660]for themselves, nice.
[00:06:52.430]I told my ex, I guess I should have known
[00:06:54.070]by the way you parked your car sideways
[00:06:55.910]that it wouldn't last.
[00:07:01.350]I swear, some of you are like,
[00:07:02.410]what reflection should I make,
[00:07:03.243]and some of you are like, what song is that?
[00:07:08.293]Everyone should know Prince.
[00:07:15.480]What's a reflection we could do here?
[00:07:23.900]You wished you would've listened to the signs.
[00:07:26.103]What else could we do?
[00:07:32.840]Your values are being challenged.
[00:07:34.040]That's interesting, and it has,
[00:07:35.100]again, kind of a cool affirm element.
[00:07:37.490]Last one, it's so insane 'cause when
[00:07:39.160]it's going good it's going great.
[00:07:40.410]I'm Superman with the wind at his back.
[00:07:41.820]She's Lois Lane.
[00:07:42.900]But when it's bad, it's awful.
[00:07:44.100]I feel so ashamed.
[00:07:53.419]Kinda like there's been a lot of ups and downs
[00:07:54.330]relationship is a fantastic reflection.
[00:07:57.030]So now you've done just the O, just the R.
[00:08:01.110]Now you can do O-A-R-S.
[00:08:03.460]I think most likely you would do an O or an R
[00:08:05.530]since these are single phrases out of context,
[00:08:08.070]but what would you do here?
[00:08:10.020]So tolerance doesn't mean I actually handle alcohol better?
[00:08:12.440]Wow, that means I'm getting pretty intoxicated when I drink.
[00:08:16.150]What could you do here?
[00:08:38.100]Pretend it's a song lyric.
[00:08:39.230]You guys owned the song lyric exercise.
[00:08:41.867]What would you do?
[00:08:42.700]What would you do here?
[00:08:45.542]Feel about that?
[00:08:46.375]How do you feel about that, open-ended question.
[00:08:48.794]You're concerned about that.
[00:08:49.627]You're concerned about that.
[00:08:50.460]That's a great reflection.
[00:08:58.130]How does being intoxicated impact you?
[00:09:00.140]Good open-ended question.
[00:09:07.859]How would you like to move forward?
[00:09:09.020]How would you like to move forward with that
[00:09:09.853]I think is good, getting at the change talk.
[00:09:12.915]How does knowing that change?
[00:09:15.109]How does knowing that change the way
[00:09:15.968]that you think, if at all?
[00:09:18.560]Good open-ended question.
[00:09:20.560]The other thing you could reflect back
[00:09:21.680]because of that wow is the degree of
[00:09:23.660]that's way different than you thought.
[00:09:24.680]That's surprising to you,
[00:09:26.668]and it gets at that element you could look at as well.
[00:09:29.720]Sometimes I feel like I drink too much.
[00:09:31.170]I mean, how normal is it to be drunk all the time?
[00:09:46.400]How much is all the time?
[00:09:47.360]We wanna get a little bit more information here
[00:09:48.810]since we're hearing this from a student.
[00:09:50.410]Good open-ended question.
[00:09:51.660]What else could we do?
[00:09:55.310]What's making you think that you drink too much,
[00:09:56.950]also good open-ended question.
[00:09:57.980]Let's get a reflection since
[00:09:59.010]we've gotten two great open-ended questions.
[00:10:01.000]You have concerns that you're drinking too much.
[00:10:03.510]You're concerned you're drinking too much.
[00:10:08.080]What else, if anything?
[00:10:13.470]Especially if you have data on norms,
[00:10:15.290]you can reflect back, you're wondering
[00:10:17.140]how your drinking compares to other people.
[00:10:19.460]You're wondering how your drinking matches
[00:10:21.360]with what most people do.
[00:10:22.870]And if it's in the context of a session
[00:10:24.730]where you have norms, you could even
[00:10:26.220]use that to lead into the intro there.
[00:10:29.520]Everyone on my dad's side of the family
[00:10:30.810]has a problem with alcohol.
[00:10:32.200]My grandma has always told me to watch out for myself,
[00:10:34.460]and maybe there's something to that.
[00:10:44.090]That's a cool thing to explore.
[00:10:45.430]What steps have you taken to watch out for yourself?
[00:10:47.860]There's the change talk in there,
[00:10:49.320]and we're getting at what those things would be.
[00:10:51.680]That's a great thing to explore, nice.
[00:10:53.560]What else could we do?
[00:11:03.290]Tell me about alcohol use on your dad's side.
[00:11:05.040]Good open-ended question,
[00:11:06.477]and it avoided the word problem.
[00:11:08.670]They said it first, but when we say it back
[00:11:10.580]it has kind of a different oomph to it,
[00:11:12.930]so you're avoiding that label.
[00:11:25.290]You're worried about your alcohol consumption.
[00:11:27.440]Good reflection, and potentially,
[00:11:29.550]if we're even more directive,
[00:11:30.590]what else are they worried about?
[00:11:36.690]You're worried about your family history with drinking.
[00:11:40.520]'Cause we wanna be mindful about not,
[00:11:42.300]again, saying alcoholic, problem,
[00:11:44.047]but you're worried about your family history.
[00:11:46.090]Can this blood alcohol level chart be right?
[00:11:47.820]That's a really high blood alcohol level.
[00:12:00.340]You're surprised by that.
[00:12:02.200]Yeah, that's a lot of exclamation points right there.
[00:12:06.640]Honestly, that's the main thing we would reflect there.
[00:12:08.610]You wanna be careful about not always
[00:12:09.840]reflecting surprise if it's not surprise.
[00:12:11.980]That reaction seems like surprise.
[00:12:15.350]So if we say that's surprising to you,
[00:12:17.170]wait and see what the reaction is.
[00:12:18.200]If all I say is yeah, you can say,
[00:12:19.817]well, you know, these are just estimates.
[00:12:21.930]Here's what we think.
[00:12:23.030]But if they go, yeah because I get
[00:12:24.620]to this level five times a week.
[00:12:26.920]See what their reaction might be.
[00:12:28.750]After the person wouldn't wake up,
[00:12:30.110]the paramedics had to come.
[00:12:31.560]She was hospitalized,
[00:12:32.393]and it really freaked everyone out.
[00:12:44.980]That was difficult for everyone.
[00:12:47.820]What else could we do?
[00:12:50.660]How are you feeling?
How are you feeling?
[00:12:52.640]So we could make the hypothesis,
[00:12:53.990]that was difficult, that was scary,
[00:12:55.810]or if we're not sure how they felt,
[00:12:58.030]everyone was freaked out,
[00:12:58.910]we could ask them, how are you doing?
[00:13:01.630]What else would we do here, if anything?
[00:13:16.406]In my job, I would ask how the person
[00:13:17.730]is doing now just 'cause I'd wanna know
[00:13:19.460]how the student's doing now, but.
[00:13:22.563]Hopefully you've seen how this can,
[00:13:24.930]you know, you've got choices,
[00:13:26.320]and now I showed you with the flu shot example
[00:13:29.510]kind of a choose your own adventure.
[00:13:31.110]By no means is what I mapped out
[00:13:32.730]over the next three slides the gold standard.
[00:13:35.090]I just tried to pick a way of
[00:13:36.480]modeling each of the OARS,
[00:13:38.440]but a student sits down across from you
[00:13:40.110]and says, wow, I had another rough weekend.
[00:13:44.300]All of the OARS at your disposal.
[00:13:46.160]What would we do?
[00:13:49.790]Tell me about your weekend.
[00:13:51.640]Everyone seems to be doing better than me.
[00:13:53.170]I got upset, and, like I always do
[00:13:54.780]when I get depressed, I drank.
[00:14:11.640]Who is everyone?
[00:14:13.380]So we wanna get more, shed more light on
[00:14:15.730]who is the everyone that's doing better than them.
[00:14:18.030]What else could we do here?
[00:14:19.389]Why do you think they're doing better than you?
[00:14:20.807]Why do you think that they're doing better than you?
[00:14:25.040]We didn't talk about this this morning,
[00:14:26.690]but just very briefly, there's been some research
[00:14:28.990]that looks at micro-level analysis of the word used.
[00:14:33.050]And some people ever so slightly hear the word why
[00:14:36.210]with a different level of sass
[00:14:38.050]than that's really there.
[00:14:39.370]And so when there's the option
[00:14:42.250]I think it's encouraged to use what in place of why.
[00:14:45.170]The way you said it I thought was perfect.
[00:14:47.020]But some people when you say,
[00:14:48.650]why do you say that, they hear it as like a
[00:14:50.770]why would say that, even though
[00:14:51.910]you never said it with that tone.
[00:14:53.770]So what makes you say that tends
[00:14:55.840]to be heard in a more neutral way.
[00:14:57.770]So do with that as you wish,
[00:14:59.190]but since it came out and since you pulled it off,
[00:15:01.570]I think, in a way that didn't sound weird.
[00:15:04.650]Some people read an element into why that's never there.
[00:15:08.950]And so when in doubt, if you can pick a what,
[00:15:11.110]what makes you say that over a
[00:15:12.290]why would you say that, that can be recommended.
[00:15:16.221]I'd try to model a reflection.
[00:15:17.490]If you had to do a reflection here, what would you do?
[00:15:24.320]So you could, the I imagine that makes it my opinion,
[00:15:28.190]so you would leave that part out
[00:15:29.410]and just say that's really frustrating.
[00:15:30.860]That would be the reflection.
[00:15:31.766](audience member sneezes)
[00:15:33.433]I said, you feel like you're
[00:15:34.340]struggling more than everyone else
[00:15:35.670]and want things to feel different.
[00:15:38.520]Everyone else seems to be handling academics
[00:15:40.660]as well as having a social life.
[00:15:42.410]I can't do both very well.
[00:15:52.610]What makes you say that?
[00:15:54.400]Nice open-ended question.
[00:15:55.420]What else can we do?
[00:15:58.970]You're struggling to find balance.
[00:16:00.330]You'd like more of a balance.
[00:16:12.065]What would that look like?
[00:16:13.903]What would that look like?
[00:16:14.736]Get out of my head, brother.
[00:16:18.600]What number am I thinking?
[00:16:22.291]I kinda wanna know if you know what number I'm thinking.
[00:16:23.978](audience member laughs)
[00:16:25.810]Now you're just not playing.
[00:16:28.630]I'm not sure, but work hard,
[00:16:29.710]play hard is not working for me.
[00:16:38.010]You feel like you need a new strategy.
[00:16:39.490]That's a great reflection.
[00:16:41.360]I'd try to do an affirm just to model an affirm.
[00:16:44.200]If you were gonna make an affirm
[00:16:45.480]in response to this statement,
[00:16:47.200]a statement that speaks to the strength
[00:16:48.550]or characteristic of the individual,
[00:16:50.090]what would you do as an affirm?
[00:16:59.630]One more time.
[00:17:00.614]You see the importance of academics.
[00:17:04.497]You see the importance of academics
[00:17:05.830]as well as developing a social life in college.
[00:17:08.930]That's good, absolutely.
[00:17:10.310]I, in response to this statement,
[00:17:12.020]said, you know what works for you and what doesn't.
[00:17:14.690]I just need to be more disciplined during the week.
[00:17:16.410]Then I can play more on the weekend
[00:17:17.620]without feeling guilty.
[00:17:29.140]What could you do differently during the week?
[00:17:31.140]I could pick a time for studying and stick to it,
[00:17:33.080]every day, Monday through Friday.
[00:17:34.870]Then I can let myself off the hook
[00:17:36.280]Friday night and Saturday.
[00:17:40.036]What would that look like?
[00:17:43.441]I think that's a good opening question.
[00:17:44.445]What would that look like?
[00:17:47.400]What else could we do here?
[00:18:02.660]You found a plan that works for you.
[00:18:04.570]Done with the reflection.
[00:18:06.390]Can we schedule a time to talk about this
[00:18:08.680]is a close-ended yes/no,
[00:18:10.050]and it, unfortunately, kind of cuts off
[00:18:11.570]a really good reflection.
[00:18:12.810]You found a plan that works for you.
[00:18:14.600]Done, wait for their reaction.
[00:18:17.080]And then make that invitation in a more open-ended way.
[00:18:20.720]I had this reflection.
[00:18:21.700]Having a schedule lets you pace yourself
[00:18:23.630]will give you that balance you're looking for.
[00:18:25.030]I really think it would.
[00:18:26.460]So although the last few weekends have been rough,
[00:18:28.370]you have a plan for moving forward
[00:18:29.560]that you feel good about.
[00:18:30.393]If it's okay with you, let's talk more about
[00:18:32.200]what your schedule could look like.
[00:18:33.300]Or, if it's okay with you,
[00:18:35.160]we can check in about that next time we talk.
[00:18:37.350]Something like that.
[00:18:38.183]So I really like your reflection.
[00:18:40.210]Earlier we talked about the concept
[00:18:41.500]of a spoiled reflection where we reflect
[00:18:44.490]and then we bail on the reflection
[00:18:45.597]and move to something else.
[00:18:46.750]I would just give it the chance.
[00:18:47.910]That was a good reflection.
[00:18:48.950]Just give it the chance to do what it does.
[00:18:51.990]Hopefully, this various kind of stem practices
[00:18:54.730]and bring it together kind of
[00:18:56.670]brings it all to light.
[00:18:58.630]What I mentioned I would do then
[00:18:59.663]is just show you that with resistance,
[00:19:02.550]the research shows that as resistance goes up
[00:19:04.680]outcome goes down, and the good news is
[00:19:06.730]we have MI to focus on reducing resistance.
[00:19:09.980]Miller and Rollnick talk about
[00:19:11.040]four categories of resistance,
[00:19:13.380]arguing, interrupting, ignoring,
[00:19:16.480]and what's classically referred to as denial.
[00:19:19.780]Arguing would include challenging
[00:19:21.200]the information you have;
[00:19:23.800]discounting you as the person delivering it;
[00:19:26.930]outwardly being hostile,
[00:19:27.930]which I hope no one would encounter;
[00:19:30.020]interrupting you; talking over you or cutting you off;
[00:19:32.770]ignoring; not paying attention; not responding;
[00:19:36.340]not answering; or changing the topic.
[00:19:38.560]And the concept of denial,
[00:19:40.000]either blaming someone else
[00:19:42.510]or why something is happening;
[00:19:44.700]disagreeing with reasons for change;
[00:19:46.940]making excuses for why a behavior
[00:19:48.520]should be allowed to continue;
[00:19:50.010]being reluctant to change.
[00:19:51.880]Claiming impunity means you should worry about
[00:19:54.130]any other student in my shoes but not me.
[00:19:56.350]I got this.
[00:19:58.330]Minimizing reasons for concern,
[00:20:00.800]being pessimistic about the potential for change,
[00:20:03.450]or overtly seeming unwilling to change.
[00:20:06.660]Here's the deal.
[00:20:07.493]The way it was explained to me
[00:20:09.140]is if a conversation's going pretty well
[00:20:10.520]and then resistance shows up,
[00:20:12.580]imagine you've got a little Geiger counter thing,
[00:20:14.230]and everything's going great.
[00:20:15.660]Resistance shows up,
[00:20:17.070]and now that Geiger counter's up here.
[00:20:18.850]Every question you ask,
[00:20:20.100]every statement that you make,
[00:20:21.560]this has now nowhere to go but up.
[00:20:23.860]When resistance goes up,
[00:20:25.710]we can either change topics and roll,
[00:20:27.890]you know, not make a response,
[00:20:29.080]or one of our best friends can be a reflection.
[00:20:32.210]If you can reflect in response
[00:20:34.630]to a resistance statement
[00:20:36.360]in a way that it can reduce the resistance,
[00:20:38.630]then you have a fork in the road,
[00:20:40.520]and you can either explore that further
[00:20:42.510]or you can just move on at that point.
[00:20:45.820]But when you see resistance,
[00:20:48.620]if you ask a question,
[00:20:49.740]that probably will only dig in further.
[00:20:51.600]It'll probably only get solidified.
[00:20:57.741]Yeah, more than anything, when you see that,
[00:20:59.480]anything that kind of engages without
[00:21:01.310]addressing their resistance is likely gonna
[00:21:04.740]not lead to that reducing.
[00:21:06.180]So I tried to pick some statements
[00:21:08.720]that are very common we see in our research
[00:21:11.140]that students could make,
[00:21:13.170]and I'd like to know what reflections
[00:21:15.330]you would do in response to them.
[00:21:17.460]If a student says, I've seen the research
[00:21:19.340]on alcohol and brain damage.
[00:21:20.850]That's all with animals and with doses
[00:21:22.540]a person would never take.
[00:21:24.930]That's a challenging type of resistance.
[00:21:27.790]What's a reflection we could make
[00:21:29.880]that gets at what we think the person means
[00:21:31.960]that would likely reduce the resistance at that point?
[00:21:39.523]You don't think the research applies to humans is perfect.
[00:21:42.070]You don't think the research applies to us,
[00:21:43.660]to you, however you wanna word that,
[00:21:45.700]is literally perfect.
[00:21:48.700]If we say, what research have you looked at?
[00:21:50.370]Game on. I will show you. (audience laughs)
[00:21:52.523]I took a research methods class, boom.
[00:21:56.696]Right, I mean, we can't win.
[00:21:59.130]We can't win.
[00:22:01.330]What research would you find compelling?
[00:22:03.190]They'll turn it into a fight.
[00:22:04.950]The research you've seen doesn't apply to you,
[00:22:06.850]doesn't apply to us as people.
[00:22:09.460]You get that resistance down.
[00:22:12.030]At that point, we either just move on
[00:22:13.950]or we explore something.
[00:22:15.170]I would explore something here
[00:22:16.890]'cause either this student seriously needs a hobby,
[00:22:20.360]they had a homework assignment,
[00:22:22.060]or they were worried about something.
[00:22:23.960]So I would do exactly what you did.
[00:22:26.540]You don't see that the research applies to us as people?
[00:22:29.070]Hopefully, resistance down.
[00:22:30.770]Wait for a reaction.
[00:22:31.820]You've looked into that.
[00:22:32.653]What prompted that?
[00:22:35.605]And if they say, well, I was getting headaches
[00:22:37.190]every time I drink and I was worried about
[00:22:38.470]what that meant, wow, that's way different.
[00:22:40.550]You've avoided a fight about reliability and validity.
[00:22:43.220]You avoided a who knows more about the research.
[00:22:47.190]It's a perfect reflection to do there.
[00:22:50.960]Discounting you as the person delivering a message.
[00:22:53.950]Have you ever been hammered?
[00:22:55.130]I bet you don't even drink.
[00:23:00.720]What do we think the person means?
[00:23:02.320]What's a reflection we could make in response to that?
[00:23:12.730]Any version of that,
[00:23:13.900]you don't think I know what you're going through.
[00:23:15.290]You're wondering if I've been in your shoes.
[00:23:17.070]You're wondering if I've been where you've been.
[00:23:19.470]Here's the deal.
[00:23:20.590]If you're careful and inclusive
[00:23:21.940]with the language you use,
[00:23:23.180]you probably won't get this anyway.
[00:23:27.320]What results in this even being said?
[00:23:30.220]Someone probably feeling judged or confronted.
[00:23:32.770]And the problem with this question
[00:23:34.180]is it's the unwinnable,
[00:23:35.900]no answer you give is good enough.
[00:23:38.800]I mean, you'd never be like I'm drunk now, son.
You could never do that.
[00:23:43.380]But if you say,
[00:23:46.970]if you say, yes, I have been.
[00:23:48.980]If they're like, you literally have the job I want.
[00:23:52.793]I'm going to school to do what you do.
[00:23:54.800]You turned out fine, so what's the big deal?
[00:23:57.040]If you say, no, I haven't, they could turn it into a, well,
[00:23:59.660]how could you relate to where I'm coming from?
[00:24:01.770]You're wondering if I understand
[00:24:03.710]what you're going through.
[00:24:06.180]Again, it's unlikely you'll get this
[00:24:08.070]if you're non-confrontational, non-judgmental anyway.
[00:24:09.960]If you get it, we train our facilitators
[00:24:12.340]and all our federally funded grants
[00:24:14.180]if this comes up to say exactly that.
[00:24:16.990]And once that resistance is down,
[00:24:18.420]what we've told them is at that point,
[00:24:20.310]based on your own history,
[00:24:22.070]you can either blame it on the project or whatever.
[00:24:24.480]But the general rule with self-disclosure
[00:24:26.840]is to whose benefit is the self-disclosure.
[00:24:29.200]If you have all these phenomenal stories
[00:24:30.730]from when you were a sophomore,
[00:24:31.900]not a good reason to self-disclose.
[00:24:33.920]And if you've got 10 minutes with a student
[00:24:35.217]and you spend two minutes talking about you,
[00:24:37.410]that's 20% of the session talking about you.
[00:24:40.410]So what we've trained our facilitators
[00:24:41.820]who are abstainers, if they worry about
[00:24:44.540]I don't want my credibility to be blown,
[00:24:46.890]we'll say reflect first and then blame it on your job.
[00:24:50.930]You're wondering if I can relate
[00:24:51.763]to where you're coming from.
[00:24:54.070]Because of my position, I'm asked
[00:24:55.450]not to talk about what I do or don't do.
[00:24:57.740]Knock on wood, that's worked 1000% of the time.
[00:25:01.330]If they have been hammered,
[00:25:02.410]we had a facilitator, this came up once
[00:25:04.640]with a project where the student said,
[00:25:06.700]well, what about you, have you ever been hammered?
[00:25:08.760]Do you even drink?
[00:25:10.240]And the guy said, you're wondering
[00:25:12.655]if I can relate to where you're coming from.
[00:25:14.590]And the person said, actually,
[00:25:17.400]this is just really hard to talk about.
[00:25:20.090]But if it's okay, can I ask.
[00:25:22.150]And the guy said, you know, I do drink.
[00:25:25.373]I've found some of this stuff useful for me.
[00:25:27.030]Whatever you choose to do with it though,
[00:25:28.600]that's up to you.
[00:25:30.273]That was perfectly said.
[00:25:32.420]But if all you do is answer the question
[00:25:34.077]and you don't respond to the resistance,
[00:25:36.180]we've missed it, right, we've missed that.
[00:25:38.730]Hopefully, this is making sense for people.
[00:25:40.150]I'm gonna guess it is 'cause I've heard
[00:25:41.640]two of the best reflections in response
[00:25:43.800]to these that I've heard period.
[00:25:45.920]How about this third one?
[00:25:46.970]All my friends drink. What am I gonna tell all of them
[00:25:49.190]if I can't drink when they do, which is reluctance.
[00:25:52.070]What do we think the person means?
[00:25:53.570]What's a reflection we can make
[00:25:54.840]in response to this statement?
[00:25:59.290]You're concerned about what your
[00:26:00.123]friends are gonna think of you.
[00:26:03.250]There was something else someone was saying.
[00:26:04.829]You're worried about fitting in.
[00:26:06.040]You're worried about fitting in,
[00:26:08.360]also good reflection.
[00:26:10.290]Nice, what else would you do here, if anything?
[00:26:18.590]That's cool because in this statement
[00:26:20.300]is not that I don't wanna change.
[00:26:21.820]They're saying, well, what am I gonna tell them
[00:26:23.530]if I can't drink when they do?
[00:26:25.760]So that's a part we don't wanna
[00:26:27.080]get lost in the shuffle,
[00:26:27.920]and that preserves that.
[00:26:29.450]You're worried about what you wanna do
[00:26:30.327]and your friends are gonna want you to do.
[00:26:33.710]All three of those are fantastic.
[00:26:36.490]You'd drink every night, too,
[00:26:37.470]if you had the sleep problems I have.
[00:26:48.230]That's a good question, but if they're
[00:26:49.680]really, really, really resistant here,
[00:26:52.010]the rest of the time all we'll hear about is that
[00:26:53.647]and we've probably lost the chance to talk about this.
[00:26:56.000]So you could ask that, but I would reflect first.
[00:26:58.100]What would you reflect before asking that question?
[00:27:02.330]You'd like your sleep quality to be better.
[00:27:04.560]You'd like your sleeping habits to be different.
[00:27:07.020]What are you noticing with your sleep?
[00:27:08.470]So do the reflection first,
[00:27:10.130]then ask that question.
[00:27:14.470]I know my limit.
[00:27:15.320]I know not to do something dumb
[00:27:16.480]even if everyone else has had too much.
[00:27:29.940]You feel in control.
[00:27:31.310]I think that's a good reflection.
[00:27:34.540]Anything that gets at that.
[00:27:35.580]You found a limit that works for you.
[00:27:37.490]You feel in control.
[00:27:40.560]Wait for their reaction,
[00:27:41.980]and then probably the thing I'd wanna explore here
[00:27:43.890]is the open-ended question, what's your limit.
[00:27:46.610]They may have a horrifying limit.
[00:27:48.230]They may have a limit that they know
[00:27:49.510]but do a miserable job sticking to,
[00:27:51.550]or they may be right.
[00:27:53.710]The hard part about resistance is,
[00:27:55.570]I mean, a lot of times we inherit it.
[00:27:58.740]If the last person to talk to them
[00:28:00.160]was super confrontational,
[00:28:02.320]they sit down and say this to us
[00:28:03.980]because they came in expecting us
[00:28:05.950]to also be confrontational and judgmental.
[00:28:08.060]So that, you feel in control.
[00:28:10.090]I do, thank you.
[00:28:13.250]What does your limit look like?
[00:28:16.420]How's this feeling for folks in terms of
[00:28:17.740]what you would do with,
[00:28:18.890]good, I see a lot of heads nodding.
[00:28:22.290]Alcohol's not my problem.
[00:28:23.410]All the stuff I gotta do for class,
[00:28:24.730]on the other hand, that's a big problem.
[00:28:34.570]You got a lot on your plate, fantastic reflection.
[00:28:40.840]I don't wanna say there's no magic wand
[00:28:42.470]with this but obviously this does take practice.
[00:28:45.230]My examples, when Meg and I talked about
[00:28:47.700]me focusing on marijuana in the content,
[00:28:50.630]I want to make as many of the examples
[00:28:52.160]keep alcohol in the forefront as possible
[00:28:53.980]because here's the deal.
[00:28:55.210]I mean, even in my state,
[00:28:56.410]alcohol remains the primary substance
[00:28:58.270]of choice among college students.
[00:29:00.210]So when people say, well,
[00:29:01.090]what should we be doing about marijuana,
[00:29:02.740]I definitely think it should be
[00:29:03.610]a compliment to, not in lieu of
[00:29:05.740]what you're doing around alcohol.
[00:29:07.560]And certainly, what do we know from the alcohol world,
[00:29:09.940]a mix of individual and environmental strategies is key.
[00:29:12.720]That remains true in the marijuana world.
[00:29:14.700]We have spent time today focusing
[00:29:16.100]on an individual strategy.
[00:29:19.080]If your sense is, yeah, you know what,
[00:29:21.380]I'm gonna leave the motivation and everything
[00:29:22.780]to the therapist, that's completely okay,
[00:29:24.467]and that's completely your call.
[00:29:26.120]But do what you can to meet people where they are
[00:29:28.900]in terms of their level of readiness to change.
[00:29:31.020]If you're concerned about a student
[00:29:32.770]and you wanna explore what's going on,
[00:29:34.650]try to talk to them when they're free of distractions.
[00:29:37.160]As much as humanely possible,
[00:29:38.520]ask open-ended questions.
[00:29:40.350]Don't make assumptions.
[00:29:43.180]I've literally had someone say to me,
[00:29:44.717]"there's a student in my class with super red eyes.
[00:29:46.987]"Isn't that a sign of marijuana use?"
[00:29:48.400]I'm like, yes, so glad you asked.
[00:29:50.350]It's also a sign of allergies.
[00:29:54.690]Not sleeping, new contacts, anything.
[00:29:57.670]So you wanna be careful about not making assumptions.
[00:30:01.103]Don't judge behavior.
[00:30:02.120]Remain calm, empathic, and understanding.
[00:30:04.230]What you can do is describe
[00:30:06.010]behavior or specific consequences.
[00:30:09.630]Start of the quarter or semester,
[00:30:11.810]didn't miss a single assignment.
[00:30:13.260]You've missed three in the last two weeks.
[00:30:15.010]What's going on?
[00:30:17.000]Or, I've seen a change in your ability
[00:30:20.300]to stay awake and alert during class
[00:30:23.630]in the last two weeks.
[00:30:26.320]So the more you can describe,
[00:30:28.690]that would even include student meetings with you.
[00:30:32.520]If someone starts, things are crazy,
[00:30:35.540]like another crazy weekend, that's data,
[00:30:37.890]and if you say, the last four times I've talked
[00:30:40.490]to you, you started with that, what's happening?
[00:30:43.970]You're not labeling.
[00:30:44.803]You're not judging it.
[00:30:45.930]You're describing it.
[00:30:47.150]Ask their thoughts and concerns about
[00:30:48.610]what they wanna do, if anything.
[00:30:50.250]Definitely be aware of resources.
[00:30:52.140]Barring a life-threatening situation,
[00:30:53.930]be okay with a person not wanting
[00:30:55.380]to talk or accept your referral.
[00:30:58.360]Do consult with a supervisor or other staff when needed.
[00:31:01.090]In the spirit of your own self-care,
[00:31:02.910]be careful not to take on too much.
[00:31:05.840]So with that and with the time we have left,
[00:31:07.670]I wanted to be able to talk more about
[00:31:09.430]what the science says about marijuana.
[00:31:11.860]That said, I don't wanna crush
[00:31:13.660]and end questions people might have
[00:31:15.620]about MI if there are questions,
[00:31:17.510]so with that we'll take some questions.
[00:31:20.599]We talked about last time
[00:31:34.140]I think you can by saying it seems like
[00:31:36.870]you're having a really tough time being here right now.
[00:31:40.380]If they say, what do you mean,
[00:31:41.490]you can describe what you're seeing.
[00:31:44.690]The main thing is I wouldn't be like,
[00:31:47.510]did you use something, 'cause that's
[00:31:49.180]a close-ended yes/no that says
[00:31:50.690]I think you used something.
[00:31:51.523]But I think describing what you're seeing
[00:31:53.900]as physical discomfort with being there
[00:31:55.330]is completely appropriate.
[00:31:58.500]What else in terms of questions or comments?
[00:32:11.280]Is there a certain balance that you suggest
[00:32:12.810]on thinking about what you're wanting to say or.
[00:32:19.580]Right, the question was sometimes
[00:32:22.470]the open-ended questions and reflections
[00:32:23.970]don't come as readily as you'd like,
[00:32:25.350]and is there a certain kind of set of rules to follow.
[00:32:29.120]Miller and Rollnick say if you're doing
[00:32:30.370]true MI there's a three question rule.
[00:32:31.990]If you ask three questions in a row,
[00:32:33.260]don't ask a fourth.
[00:32:34.610]You'd either wanna reflect, affirm, summarize.
[00:32:38.230]Otherwise it can trickle into
[00:32:39.600]sounding too interrogatish,
[00:32:40.680]if it's like question, question, question, question.
[00:32:43.740]So there's that three-to-one rule.
[00:32:45.610]With reflections, you want the complex
[00:32:47.670]to be greater than the number of simple.
[00:32:49.500]But most important is be yourself.
[00:32:53.350]So often people get anxious about
[00:32:55.040]making reflections because they're like,
[00:32:56.000]I feel like I'm gonna sound super clinical.
[00:32:58.220]Then don't sound super clinical.
[00:33:00.523]Use the language you normally would.
[00:33:01.940]If someone takes on a different tone
[00:33:03.280]when they reflect, that's kinda weird,
[00:33:05.100]and it would probably feel as less genuine.
[00:33:07.310]And so I think the more practice you get
[00:33:09.600]thinking reflectively and making reflections
[00:33:11.660]the easier it is to do.
[00:33:15.260]And, again, we really do try and do that in our lab.
[00:33:17.670]No one asks anymore, did you have a good day?
[00:33:19.360]Did it go well?
[00:33:20.193]How'd it go?
[00:33:21.140]Practice with one another and that makes it
[00:33:23.540]a lot easier when you're actually doing it
[00:33:24.790]with a real live student.
[00:33:30.446]So I think one of the examples.
[00:33:39.004]Instead they're speaking of a lot.
[00:33:48.478]Yeah, yeah, no.
[00:33:49.370]So the question was what if they're
[00:33:50.600]looking at lots of different topics.
[00:33:53.010]If it feels like looking at lots of
[00:33:54.410]different topics 'cause they're super motivated,
[00:33:56.310]that's different than if it feels like side-tracking.
[00:33:59.970]If it feels to you like it's more
[00:34:02.350]different topics because they're resistant
[00:34:04.740]to talking about the main topic,
[00:34:07.090]I think that's where you can still,
[00:34:09.590]you could still make the reflection that,
[00:34:12.780]you know, we're talking about a lot of stuff
[00:34:14.220]and it's hard to stick with one,
[00:34:15.600]or anything like that.
[00:34:16.930]If your sense is it's because they're
[00:34:18.190]super motivated about a bunch of things,
[00:34:20.520]you could ask if there was one thing
[00:34:22.230]to kind of look at right now,
[00:34:24.880]what would it be?
[00:34:25.713]What's the most important thing we address for you?
[00:34:27.915]And if they pick one thing,
[00:34:30.260]in the spirit of supporting their self-efficacy,
[00:34:32.040]we would meet them with what they requested.
[00:34:34.440]But the beauty of if it's a situation
[00:34:37.010]where you can appropriately see them
[00:34:39.010]a second, third, fourth, fifth time,
[00:34:41.050]then you can re-check in on that.
[00:34:42.167]And if it's okay with you,
[00:34:43.520]we'll check-in on those other things
[00:34:44.700]you brought up next time we talk.
[00:34:46.430]That's how you would go that route.
[00:34:48.390]That slide from early this morning
[00:34:50.320]with the different levels of readiness to change,
[00:34:52.210]if they're ready to do something
[00:34:53.330]we meet them where they're at.
[00:34:55.100]If they're all over the board with ambivalence,
[00:34:57.240]it could be, you know, just being more directive
[00:34:59.320]in terms of picking something kind of to start with.
[00:35:04.931]Are there any things that.
[00:35:16.555]The question was are there things
[00:35:17.580]to be mindful of cross-culturally.
[00:35:19.750]We've looked as much as that in the research as possible.
[00:35:24.610]We certainly wanna be respectful of,
[00:35:27.030]you know, if what it means to talk about feelings
[00:35:29.610]varies based on family history or culture,
[00:35:32.040]we wanna not go, we don't want anyone
[00:35:34.290]doing something that they don't feel comfortable doing.
[00:35:37.430]We've published research as a team
[00:35:39.390]on norms to look at if you have normative feedback
[00:35:42.100]on what most people do.
[00:35:43.660]What if you don't identify with most people?
[00:35:46.020]We wanna be mindful of where some of
[00:35:48.460]those differences might come.
[00:35:50.280]Thus far on motivation interviewing
[00:35:53.070]has shown that this is,
[00:35:55.090]the findings are certainly both generalizable across,
[00:35:59.520]as well as allowing to be sensitive to
[00:36:01.990]cultural differences in part because
[00:36:03.990]it is so personally focused.
[00:36:05.770]It's not about what I think is best.
[00:36:07.910]It's about what you find most
[00:36:09.470]personally relevant to you.
[00:36:11.810]I think of research on,
[00:36:14.430]again, not only the pieces on norms,
[00:36:15.840]but even looking at translating this
[00:36:17.023]into different languages where this has
[00:36:18.980]continued to, the findings continue to hold.
[00:36:21.760]But I think it's, you know,
[00:36:22.593]when we're not clear on what would
[00:36:24.610]a student be comfortable with, we can ask,
[00:36:26.320]and it's exploring that based on
[00:36:28.440]what we're talking about here
[00:36:29.357]and what you bring to the table.
[00:36:31.780]How comfortable do you feel about discussing this?
[00:36:33.520]How would you like to proceed?
[00:36:34.650]And when in doubt, ask the student.
[00:36:36.780]It's a great question.
[00:36:42.230]All right, so with that, with the time we have left,
[00:36:44.930]I'm realizing I have a ton of slides
[00:36:46.630]and I'm hoping I can get through them.
[00:36:48.560]I just tried to pick stuff that to me
[00:36:50.930]we're either getting super excited about
[00:36:52.470]in the research or we're getting super blown away by.
[00:36:55.170]I also tried to pick some real world examples.
[00:37:00.270]The last time I had the chance to
[00:37:01.370]present in this room, I talked about
[00:37:02.880]Alan Marlatt's expectancy research.
[00:37:04.970]Our bar lab at the University of Washington,
[00:37:07.140]you tell people we're gonna give you alcohol
[00:37:09.480]but then give them alcohol-free drinks,
[00:37:11.150]and what do we see?
[00:37:12.030]They get more funny.
[00:37:13.030]They get more talkative.
[00:37:14.110]They get more outgoing.
[00:37:15.220]They get more flirty.
[00:37:16.470]They play drinking games with water.
[00:37:19.730]We've done the opposite where we tell them
[00:37:21.010]we're gonna give you water
[00:37:21.890]but we actually give them alcohol.
[00:37:23.630]They don't act any different.
[00:37:26.100]When the effects kick in,
[00:37:27.180]they make attributions other than the fact
[00:37:29.010]that they've been drinking.
[00:37:30.550]Jane Metrik has done some
[00:37:31.820]feasibility research on placebos,
[00:37:34.050]but I wanted to show you,
[00:37:35.410]based on a question that came up even earlier today,
[00:37:38.180]there's an article that came out
[00:37:39.490]in 2017 that I think is fascinating.
[00:37:41.960]And they said ideally what we'd wanna do,
[00:37:44.393]they balance placebo design at two-by-two,
[00:37:47.140]like Marlatt's team did, sure.
[00:37:49.270]But for ethical reasons,
[00:37:50.310]let's just start with the lower
[00:37:51.390]left-hand corner of that two-by-two.
[00:37:53.840]Expect a drug but don't get the drug.
[00:37:57.090]In Loflin and colleagues' study,
[00:37:59.080]they recruited people that used marijuana
[00:38:00.940]and said, we're gonna have you be in a study
[00:38:03.450]where we test the effects of cannabis, edibles.
[00:38:06.720]We're either gonna get you randomly assigned
[00:38:08.560]into the no dose condition, the low dose condition,
[00:38:11.160]or the high dose condition.
[00:38:13.560]They told people he used at least,
[00:38:16.290]I mean, these were all people that used marijuana
[00:38:18.710]at least monthly if not weekly,
[00:38:21.620]and for many of them multiple times per day.
[00:38:23.890]They said, we're gonna need you
[00:38:24.723]to refrain at least eight hours.
[00:38:26.440]Depending on which condition you wind up in,
[00:38:28.710]we're either gonna need you to stay here
[00:38:30.110]for one and a half up to six hours, so plan ahead.
[00:38:33.610]You're gonna be in one of three rooms,
[00:38:34.860]no dose, lose dose THC, or high THC.
[00:38:38.810]They brought people into the room.
[00:38:40.280]Right in front of them,
[00:38:41.580]they opened the envelope and said,
[00:38:43.480]well, congratulations, you're in the high THC condition.
[00:38:47.180]They all applauded. (claps)
[00:38:48.690]And they said we're about to give you an edible.
[00:38:51.530]We want you to eat it.
[00:38:52.567]And then they were in cubicles.
[00:38:54.560]That was on purpose.
[00:38:55.400]They didn't want people to lean over
[00:38:56.510]to the person next to them and say, hey, what do you feel?
[00:38:58.640]They were in cubicles and had to watch
[00:39:00.300]music videos, comedy clips, color in designs,
[00:39:04.050]and compute math problems.
[00:39:05.590]What was the catch?
[00:39:06.423]There was no high dose condition.
[00:39:08.170]They gave people Hemp Pops,
[00:39:10.060]which are made of hemp seed oil
[00:39:11.880]that have no active cannabinoids in them at all.
[00:39:14.490]Glucose syrup, citric acid, sugar,
[00:39:16.770]natural flavors, and colors number two and five,
[00:39:19.320]which are the most delicious colors.
[00:39:24.610]What did they find?
[00:39:25.630]These were people that were seasoned
[00:39:27.820]folks around using marijuana.
[00:39:30.310]And they wanted to know when people said,
[00:39:32.080]well, when I use weed, my mood gets better.
[00:39:34.770]I feel high.
[00:39:35.810]What did they find?
[00:39:36.700]They found a significant difference over time
[00:39:39.160]on negative mood improving.
[00:39:41.000]They found a significant difference over time
[00:39:43.260]on people reporting that they feel intoxicated.
[00:39:46.850]We know there are placebo
[00:39:47.970]and expectancy effects for alcohol.
[00:39:50.140]We absolutely have to do more research
[00:39:51.610]on it, but there are placebo
[00:39:52.920]and expectancy effects for marijuana,
[00:39:54.920]which is why when a student says,
[00:39:56.220]well, marijuana makes me more creative.
[00:39:57.940]Does it, or is that an expectancy
[00:39:59.960]no different than saying, well,
[00:40:01.200]when I drink I'm funnier.
[00:40:02.470]When I drink, I can interact with people better.
[00:40:06.180]And we have to explore placebo effects
[00:40:08.560]including with different types.
[00:40:09.950]You made the point earlier that sometimes
[00:40:12.030]you'll hear some of your clients say,
[00:40:13.350]well, it depends on what strain you use.
[00:40:15.530]The second someone says to someone,
[00:40:17.500]well, if use Sativa, that's uplifting and energetic,
[00:40:20.180]but Indica is more relaxing and calming.
[00:40:22.340]The second you tell someone that,
[00:40:23.620]you've planted an expectancy.
[00:40:25.210]You've planted the potential for a placebo effect.
[00:40:28.520]I love this quote from Piomelli and Russo.
[00:40:30.597]"We would all prefer simple nostrums
[00:40:32.097]"to explain complex systems,
[00:40:34.267]"but this is a futile
[00:40:35.337]"and even potentially dangerous in
[00:40:37.177]"the context of a psychoactive drug such as cannabis."
[00:40:40.360]They point out the differences
[00:40:41.730]in what people show could be due to
[00:40:43.830]other content that we rarely measure,
[00:40:45.990]or what you tell a potential consumer before they use.
[00:40:49.610]If you tell someone, oh, this stuff?
[00:40:51.240]Here's what it's gonna do.
[00:40:53.720]That can be a placebo effect at that point.
[00:40:56.990]Now a lot of this research,
[00:40:57.990]I had to fine tune because I worked with,
[00:41:02.570]with no disrespect to this group,
[00:41:03.750]a far more intimidating group.
[00:41:06.095]It was a bunch of eighth graders.
[00:41:08.755](audience laughs) I also had the chance to work with
[00:41:11.490]a bunch of ninth graders,
[00:41:12.350]and this particular question came from a ninth grader.
[00:41:15.090]I got asked if I would speak to
[00:41:16.270]all the ninth grade students at
[00:41:17.710]one of our local high schools.
[00:41:19.100]And I was like, that's not really my age group, but sure.
[00:41:22.100]And a teacher said, hey,
[00:41:23.440]I had the students turn in
[00:41:24.390]their questions ahead of time.
[00:41:25.260]Do you want them?
[00:41:26.093]I'm like, of course.
[00:41:27.330]And they had over 50 questions.
[00:41:29.080]I was delighted that I knew the answer
[00:41:30.450]to all but one of them.
[00:41:31.670]One of them I genuinely didn't understand.
[00:41:34.480]And I cut and paste it
[00:41:35.410]straight from the teacher's email.
[00:41:36.950]The student asked, is it true that
[00:41:38.580]smoking marijuana turns your lungs into orange slices?
[00:41:45.140]And I was like, I do not get that.
[00:41:48.340]I didn't know if that was slang for something,
[00:41:49.890]like, what up, orange slice?
[00:41:52.995]If it's not slang it should be.
[00:41:55.270]I forwarded it to one of my colleagues
[00:41:56.460]in the med school, and she's like,
[00:41:57.610]I think he's messing with you.
[00:41:59.290]I'm like, I don't wanna believe that
[00:42:00.370]some ninth grader is like, oh ho ho,
[00:42:01.930]I'm gonna mess with this professor, send.
[00:42:04.439]So I did what anyone would do.
[00:42:05.410]I went on Reddit, which is the hotbed
[00:42:07.360]of all things science-based
and I saw that
[00:42:10.150]totally as a joke on Reddit
[00:42:12.350]a guy posted this picture.
[00:42:13.500]He said, please forward this picture and save a life.
[00:42:16.780]Here are the lungs of a teenager
[00:42:18.660]who died from smoking marijuana,
[00:42:20.760]and it was just this picture.
[00:42:25.460]The first person who responded said,
[00:42:26.770]dude, that's an orange.
[00:42:28.940]And he wrote back in all capital letters
[00:42:30.440]that said, stop being disrespectful.
[00:42:32.460]That's a dead teenager's lungs.
[00:42:35.830]We can laugh about that,
[00:42:36.850]but ninth graders were like, oh no.
[00:42:40.070]More than anything, I just have trouble
[00:42:41.550]eating oranges now 'cause they're disgusting.
[00:42:43.210]They look like lungs.
[00:42:45.520]But one of them asked,
[00:42:46.480]who is the primary consumer of marijuana?
[00:42:48.330]It tends to be the age group we work with.
[00:42:51.769]18 to 25 year-olds,
[00:42:54.200]over and above 12 to 17, and those over 26
[00:42:57.570]have higher past year marijuana use
[00:42:59.257]and past month marijuana use.
[00:43:01.220]And not just by a little bit.
[00:43:02.870]This is the heaviest using group.
[00:43:05.150]26 and older, 10.4% have used in the last year,
[00:43:08.570]6 1/2% in the past month.
[00:43:10.840]12 to 17 year-olds, 12.6% in the past year,
[00:43:14.590]7% in the past month.
[00:43:16.130]18 to 25 year-olds, it's about a third
[00:43:18.960]used in the past year.
[00:43:20.520]One in five used in the past month.
[00:43:24.270]Legalization in states
[00:43:25.401]such as Vermont and Colorado.
[00:43:28.770]I got that coming up.
[00:43:30.090]I got that coming up. The question was what we see
[00:43:31.756]in states with legalization.
[00:43:32.980]The short answer is yes.
[00:43:34.370]The longer answer is it's even changing over time,
[00:43:36.440]so I will show that to you.
[00:43:37.800]We also know, this is the thing.
[00:43:40.920]So often when we do prevention stuff,
[00:43:43.450]we'll ask people, what are the times
[00:43:45.340]that are the biggest drinking times on your campus?
[00:43:47.880]And they'll say Halloween,
[00:43:50.230]spring break, football games.
[00:43:52.760]The not good news is obviously
[00:43:54.630]some unwanted consequences can go along with those.
[00:43:56.830]What's the better news?
[00:43:57.830]We know when all of those are,
[00:43:59.830]so the opportunity to do some event
[00:44:01.360]specific prevention absolutely is there.
[00:44:03.920]What do we know?
[00:44:04.872]4/20 is a high-risk event.
[00:44:06.570]April 20th, which tends to be for
[00:44:08.900]big fans of marijuana kind of the national holiday.
[00:44:12.850]Bravo and colleagues show that
[00:44:14.090]more people used on 4/20 than any other days.
[00:44:17.460]More people reported more unique sessions
[00:44:19.990]of use on 4/20 than on weekdays or weekends,
[00:44:23.130]and people used a greater amount on 4/20
[00:44:26.120]than other weekdays or weekends.
[00:44:28.760]One of the kids asked, and I loved how
[00:44:30.810]this cracked me up, the wording.
[00:44:32.350]One of the kids asked, what was weed
[00:44:33.680]or savage cabbage like when you were in high school?
[00:44:39.400]Outside that kid, I've never heard
[00:44:41.060]a person call it savage cabbage.
[00:44:44.990]That sounds like a bad Pokemon character or something.
[00:44:48.640]Here's the deal.
[00:44:49.473]The main thing we look at, THC.
[00:44:51.240]You heard me reference anandamide
[00:44:52.560]earlier is an endogenous cannabinoid.
[00:44:54.920]THC binds to where endogenous cannabinoid receptors are.
[00:44:59.490]Anandamide is involved in everything
[00:45:00.850]from pleasure to memory, to thinking,
[00:45:02.710]to concentration, to movement,
[00:45:04.440]to coordination, and perception.
[00:45:07.660]If you orient the brain this way,
[00:45:09.450]so, front here, back on the right,
[00:45:11.800]everywhere you see a magenta dot
[00:45:13.450]is where THC binds.
[00:45:15.050]Here's where THC binds.
[00:45:17.895]This is a widespread,
[00:45:18.960]very powerful psychoactive ingredient.
[00:45:21.700]I've talked to students that
[00:45:22.950]I asked them about their substance use,
[00:45:24.380]and they say, well, I don't use drugs.
[00:45:26.030]But then they tell me they use weed every day.
[00:45:28.560]I'm like, hold up.
[00:45:29.780]You said you don't use drugs.
[00:45:30.740]And they're like, it's not a drug, it's an herb.
[00:45:33.786]And it's like, well, tomato, tomato.
[00:45:35.530]It's something with very widespread impact on the brain.
[00:45:38.650]THC will bind to an endogenous cannabinoid receptor,
[00:45:42.100]send a message to a surrounding neuron
[00:45:45.040]to release neurotransmitters.
[00:45:47.410]I show you this because when people ask,
[00:45:50.500]has marijuana potency changed over time, absolutely yes.
[00:45:54.380]We're done debating this.
[00:45:55.760]This is an article that came out at the end of 2016.
[00:45:59.170]Along with this article
[00:46:00.190]and Nora Volkow's 2014 article,
[00:46:03.940]they look at people in the 70s
[00:46:06.300]who identified as, in quotes,
[00:46:07.800]hippies who smoked grass.
[00:46:10.070]It's 'cause it was practically grass.
[00:46:11.960]It was like 1 1/2% THC.
[00:46:14.770]In the 80s, maybe two to 3% THC.
[00:46:18.900]What have we seen since 1995?
[00:46:21.540]We've seen potency change a lot.
[00:46:23.870]In 1995, THC content was a never before seen 4%.
[00:46:27.889]It hit 6% by 2001, 2002,
[00:46:31.564]8% by 2005, double-digits by 2009, 10,
[00:46:35.390]and then we finally saw it hit over 12%.
[00:46:38.950]This came out a year ago this week
[00:46:41.880]in the state of Washington,
[00:46:43.340]and it was our Marijuana Impact Report.
[00:46:47.170]This was a 2017 report.
[00:46:48.580]In 2016, THC content in the United States
[00:46:51.390]was higher than it's ever been, 13.18%.
[00:46:54.960]Higher than we've ever seen
[00:46:56.410]until you go to my state.
[00:46:59.260]In the city of Seattle, one store in particular
[00:47:01.290]opened its doors and says, you can analyze
[00:47:03.240]all the product that we have for potency.
[00:47:05.550]What is the average,
[00:47:06.670]not sold but the average available
[00:47:09.020]in the state of Washington?
[00:47:10.360]In Seattle stores, 21.6%.
[00:47:14.470]I love research.
[00:47:15.340]If you gave me a million dollars and said,
[00:47:16.980]for a million dollars, what does the science say
[00:47:19.420]on Seattle weed in the human brain?
[00:47:21.290]First, good job for having a million dollars,
[00:47:23.180]and second, we don't know
[00:47:25.550]'cause this is a potency
[00:47:26.490]that has never been looked at.
[00:47:28.490]We do not know what this does to people.
[00:47:30.760]Hash oils, concentrates which people use for dabbing,
[00:47:33.530]nationwide is a never before seen 55.85%.
[00:47:37.190]On average, Seattle stores pushing 72%.
[00:47:41.290]I'm not trying to get cute when I do this.
[00:47:43.290]The y-axis didn't go above 14.
[00:47:45.410]If you put us on this map, here's where we are.
[00:47:49.540]And so when we look at some of the things
[00:47:52.130]we talked about prior to lunch
[00:47:53.450]about mental health, driving risks,
[00:47:56.480]impact on attention, concentration, memory,
[00:47:59.110]I almost feel like when we talk about
[00:48:00.260]some of this research there has to be
[00:48:01.430]a big asterisk by it because will it translate?
[00:48:04.810]Theoretically yes, but the key is
[00:48:06.210]is that it could translate even more
[00:48:08.220]in a not so good direction.
[00:48:09.840]I don't think it's the case that
[00:48:11.060]as potency gets stronger that somehow
[00:48:13.280]these effects are lessened.
[00:48:15.090]But what makes it hard to know is
[00:48:16.530]could we say that if someone abstains
[00:48:19.040]they won't have cognitive impacts for four weeks?
[00:48:22.723]It could be longer.
[00:48:23.556]That's a research question that we just don't know.
[00:48:26.170]One of the students asked,
[00:48:27.210]how addictive is marijuana?
[00:48:28.470]All I can say is very.
[00:48:30.900]In the DSM-IV, we had cannabis use disorder,
[00:48:35.480]pardon me, cannabis dependence and cannabis abuse.
[00:48:38.130]In the DSM-V, the criteria were changed
[00:48:41.890]to look at cannabis use disorder.
[00:48:43.920]There were still some of the symptoms
[00:48:45.120]of dependence that continued but they looked
[00:48:47.500]at the presence of a number of different issues.
[00:48:51.260]And what you do is you rate the severity
[00:48:53.830]of the cannabis use disorder
[00:48:55.460]based on the presence of the symptoms.
[00:48:59.220]One of the things we're struggling with
[00:49:00.850]is knowing how many people are reporting
[00:49:02.670]medical marijuana use or actually managing addiction.
[00:49:06.160]And before I get into that,
[00:49:07.100]I just wanna say a quick word about
[00:49:08.560]medical cannabis use and I hope you hear me
[00:49:11.660]as loud and clearly as possible.
[00:49:13.660]If you personally, if a family member,
[00:49:15.760]a loved one, a friend has a gravely disabling
[00:49:19.320]or potentially life-threatening condition
[00:49:21.700]and has had medical marijuana recommended to them
[00:49:24.570]and they're using as recommended,
[00:49:26.290]then God bless that person.
[00:49:27.540]That's not who I'm talking about.
[00:49:29.800]But we worry, especially among college students,
[00:49:31.980]how many of them are declining
[00:49:33.740]referrals to counseling or health
[00:49:35.610]because they decide I'd rather go
[00:49:37.270]the medical marijuana route.
[00:49:39.520]The research on this is tough to look at
[00:49:41.730]because it highlights the emotional component
[00:49:44.510]of this and how much more we need to do.
[00:49:47.391]I work with college students,
[00:49:48.350]not with little kids.
[00:49:49.320]But I looked in an epilepsy journal
[00:49:51.740]where they looked at CBD,
[00:49:53.087]and the conclusion was so good
[00:49:55.590]I thought I can't say this better than them,
[00:49:57.320]so I will let them say their conclusion for us.
[00:50:00.047]"At this time, there does seem to be
[00:50:01.907]"a growing body of basic pharmacologic data
[00:50:04.797]"suggesting there may be a role for CBD,
[00:50:07.147]"especially in the treatment of refractory epilepsy.
[00:50:09.587]"However, given the lack of well-controlled trials,
[00:50:12.577]"we must also ask if we're getting ahead of ourselves.
[00:50:15.607]"Clearly, this is an emotionally
[00:50:17.037]"and politically charged issue."
[00:50:19.280]I love this sentence.
[00:50:20.113]"If this were any other uninvestigated
[00:50:22.157]"pharmaceutical compound, would we feel
[00:50:24.317]"as compelled to make the agent widely available
[00:50:26.747]"before a statistically valid class one
[00:50:28.637]"evidence was available for review?
[00:50:31.207]"Until data from well-designed clinical trials
[00:50:33.387]"are available and reliable,
[00:50:35.137]"and standardized CBD products that are produced
[00:50:37.887]"using good manufacturing practices are available,
[00:50:41.517]"caution must be exercised in any consideration
[00:50:43.817]"of using CBD for the treatment of epilepsy.
[00:50:46.227]"In the meantime, based upon promising
[00:50:48.757]"preliminary data, further research
[00:50:50.677]"should be whole-heartedly pursued."
[00:50:53.490]This article came out in 2017,
[00:50:55.520]and they said we're gonna look at
[00:50:57.290]every article that's been published
[00:50:59.950]that has the keywords of cannabis,
[00:51:02.290]along with a number of different references
[00:51:03.990]for potential medical uses, cancer, and pain.
[00:51:07.110]They said we want any study that has
[00:51:09.060]at least looked at a control group
[00:51:11.370]and has at least looked at monitoring side effects.
[00:51:14.920]What's the key to every medication?
[00:51:17.720]You wanna have the benefits of the medication
[00:51:19.530]outweigh the side effects or risks.
[00:51:22.370]And certainly when testing a medication
[00:51:24.580]you wanna control for placebo effects.
[00:51:26.430]We just got done showing there are placebo effects.
[00:51:28.760]And you wanna randomize people to condition
[00:51:31.010]because if I'm saying, well, I want this treatment,
[00:51:33.640]the second I pick that it means
[00:51:35.010]in some ways I do have some expectancies in mind.
[00:51:38.230]How many studies are out there
[00:51:39.660]from 1975 to the end of 2017
[00:51:42.660]that track side effects
[00:51:44.390]and have any element of a control group?
[00:51:46.460]Five, that's it.
[00:51:51.310]The authors acknowledge that one of
[00:51:52.750]the challenges to doing this research
[00:51:54.250]is federally it's a Schedule I drug.
[00:51:56.370]What does that mean?
[00:51:57.990]Federally, there are no recognized medical uses.
[00:52:00.850]So if what drives really well-funded
[00:52:02.660]research is federal funding,
[00:52:05.120]there's a disconnect there.
[00:52:06.730]Lack of dosing guidelines.
[00:52:08.060]Ideally, research would need to find a dose
[00:52:09.780]that provides maximum release
[00:52:11.450]with minimal side effects.
[00:52:12.640]And as it is, optimal doses seem to
[00:52:14.730]vary from person to person.
[00:52:16.590]The other challenge is a lot of times
[00:52:17.790]people are doing a ton of stuff.
[00:52:19.900]Someone says I'm going through this treatment.
[00:52:21.390]My herbalist gave me this.
[00:52:22.910]I'm also doing that.
[00:52:24.740]If they improve, they say it was because of this,
[00:52:27.170]but it could be these confounding variables.
[00:52:29.810]Generalized ability is challenging.
[00:52:31.600]Three of the five studies had less than 50 people in them.
[00:52:35.200]I see people shaking their heads.
[00:52:38.550]It goes back to if this were any other
[00:52:41.760]substance, would people be so in a hurry
[00:52:44.700]to kind of get it out there.
[00:52:46.070]Obviously, someone who's struggling
[00:52:47.530]we want relief for them, obviously.
[00:52:50.700]But there's being a little bit of a push back,
[00:52:53.010]especially from medical folks,
[00:52:54.460]on how much we still need to research this.
[00:52:56.680]Trials need to be done to look at
[00:52:58.420]differences in cannabinoid pharmacokinetics
[00:52:59.570]and pharmacodynamics among people,
[00:53:02.450]and standardized and validated evaluation
[00:53:04.290]and reporting of side effects is needed.
[00:53:06.090]I did a screenshot of the side effects,
[00:53:08.050]not 'cause I expected them to be interpretable
[00:53:10.170]but just to make the point that
[00:53:11.280]in all five studies they documented side effects.
[00:53:14.530]None of these were side effect free.
[00:53:17.690]This came out in February.
[00:53:21.130]Canada's getting a lot of attention now globally
[00:53:23.430]because in October they're moving toward
[00:53:26.050]recreational availability of cannabis
[00:53:28.040]in their country as a nation.
[00:53:30.820]But what's so mind-blowing is
[00:53:32.140]their medical community have said
[00:53:33.740]we need to slow down a lot.
[00:53:36.420]The Canadian Physicians, the equivalent of
[00:53:38.160]the American Medical Association,
[00:53:39.470]they're a Canadian Family Physician Group,
[00:53:41.650]published an article and they said
[00:53:43.650]these are our recommended guidelines.
[00:53:45.570]And they actually put a figure
[00:53:47.450]that's a flowchart for every healthcare
[00:53:49.530]provider in Canada to be considering.
[00:53:52.260]What did they say in that flowchart?
[00:53:54.200]They said if medical marijuana's
[00:53:56.470]even on the table, first, is it for
[00:53:59.790]neuropathic pain, palliative end-of-life pain,
[00:54:03.050]chemotherapy-induced nausea and vomiting,
[00:54:05.210]or spasticity due to multiple sclerosis
[00:54:07.000]and spinal cord injury?
[00:54:08.270]If no, we're done.
[00:54:10.880]Nothing else to talk about
[00:54:13.380]because there are so many other treatment options
[00:54:15.800]that would be recommended first and foremost.
[00:54:18.020]Only if yes move to the next step.
[00:54:20.880]Has the person tried three or more
[00:54:22.460]medications for neuropathic pain,
[00:54:24.320]two or more medications for palliative pain,
[00:54:26.410]or have they done refractory to standardized treatment?
[00:54:28.680]If no, not recommending it yet.
[00:54:31.360]Only if yes consider those different cannabinoids.
[00:54:36.180]So, again, I say that not to
[00:54:39.570]dismiss the potential medical value
[00:54:41.390]but to highlight, my goodness,
[00:54:42.540]we have so much more research that needs to be done.
[00:54:45.250]And people looking for answers for folks
[00:54:47.020]who are struggling, bless them,
[00:54:47.853]and I get that, and let's go back to
[00:54:50.470]what I mentioned earlier about college students.
[00:54:52.490]Especially if we've got college students
[00:54:54.150]that are reporting medical marijuana for headaches.
[00:54:57.250]That's not on this list.
[00:54:59.310]My arm hurts 'cause my backpack's really heavy,
[00:55:01.900]so I use medical marijuana for that.
[00:55:03.630]Come on, I mean, we look at some of these issues,
[00:55:06.340]but especially around mental health
[00:55:07.480]we have to explore that a bit further.
[00:55:10.860]Whenever I talk about really heavy content,
[00:55:12.600]I feel like both for me and for everyone else,
[00:55:14.370]I do something a little bit more light-hearted.
[00:55:16.210]I'm super proud of this
[00:55:18.470]'cause I didn't know what this was
[00:55:20.690]in my computer, the Stylus.
[00:55:22.500](audience laughs) I was like, look at that.
[00:55:24.273]There's a pen, and I kinda messed
[00:55:26.820]around with it, just clicking it,
[00:55:27.760]to drive people next to me on planes crazy
[00:55:30.070]'cause that doesn't get annoying after a while.
[00:55:32.430]But once I learned you could draw with this,
[00:55:33.970]it opened up a whole new world for me.
[00:55:35.450]So to celebrate the release of Jurassic World,
[00:55:37.540]here's a raptor that I made.
[00:55:41.661]And this is my friend Amanda's basset hound,
[00:55:43.430]so there you go.
[00:55:46.660]I'll draw pictures for anyone else who wants them later.
[00:55:48.920]This is the part that I really think
[00:55:50.560]we have to be mindful of on college campuses.
[00:55:52.390]You heard me talk about being mindful
[00:55:53.710]of cannabis use disorder.
[00:55:55.900]Christine Lee asked incoming first-year students
[00:55:58.530]to a large northwest university,
[00:56:00.360]as the article said, and said,
[00:56:02.170]tell us why you use marijuana,
[00:56:03.530]and they said lots of things.
[00:56:05.170]They said I like getting high.
[00:56:07.350]I like the feeling.
[00:56:09.340]Helps me bond with friends.
[00:56:10.740]Helps me when I'm bored.
[00:56:13.170]Helps me enhance experiences.
[00:56:14.730]Music sounds better.
[00:56:16.730]Helps me celebrate.
[00:56:18.000]But they also said it helps me relax.
[00:56:19.860]It helps me sleep.
[00:56:20.940]It helps me cope when I'm depressed.
[00:56:22.340]It helps me to relieve stress.
[00:56:24.070]Helps when my appetite sucks.
[00:56:25.840]Helps me reduce anxiety.
[00:56:27.270]Helps when I have physical pain.
[00:56:28.660]Helps when I have a headache.
[00:56:30.160]In DSM-V, which came out in 2013,
[00:56:32.820]for the first time in our planet's history
[00:56:35.420]there were the published criteria
[00:56:36.980]for cannabis withdrawal.
[00:56:38.270]It is a diagnosable disorder
[00:56:39.980]that people can get treatment for
[00:56:41.560]and that providers can bill for.
[00:56:43.530]What are the criteria for cannabis withdrawal
[00:56:45.890]and what do they include?
[00:56:47.030]Well, they include anxiety, sleep problems,
[00:56:49.500]appetite problems, depressed mood, and headaches.
[00:56:54.630]If you've got a college student saying,
[00:56:56.160]I know medical marijuana helps my depression.
[00:56:58.220]And you ask them, how do you know?
[00:56:59.660]Good open-ended question.
[00:57:01.670]If they say, well, I use weed every day,
[00:57:04.020]and last week I was sick
[00:57:05.080]and so I took two, three days off,
[00:57:07.030]and my depression got terrible.
[00:57:08.730]Then I started using again
[00:57:09.563]and my depression got better.
[00:57:11.490]That's not medical marijuana for depression.
[00:57:13.320]That's resuming use,
[00:57:14.970]making withdrawal symptoms stop.
[00:57:19.310]What does using marijuana do?
[00:57:20.480]Interferes with REM sleep.
[00:57:21.720]What happens when you try and stop?
[00:57:23.290]Severe REM rebound.
[00:57:25.980]More time in REM, what do you get?
[00:57:27.720]Not only the rapid onset in REM
[00:57:29.250]means difficultly falling asleep, insomnia,
[00:57:31.720]but the time spent in REM,
[00:57:32.700]more dreaming and often weird content
[00:57:34.510]of that dream, disturbing dreams.
[00:57:37.890]There's a lot of education we can do
[00:57:39.380]about this with medical providers.
[00:57:41.650]The mere act of screening for cannabis
[00:57:44.340]use disorder I think counts as prevention.
[00:57:47.650]Why are you asking me these questions?
[00:57:50.280]Because marijuana can be very addictive.
[00:57:53.210]It can be?
[00:57:54.230]People might right there off the bat
[00:57:55.950]not even realize that.
[00:57:57.150]And then if you can identify the students
[00:57:58.610]who are struggling with addiction,
[00:58:00.050]we can look at these other issues.
[00:58:02.300]I've thrown a lot at you.
[00:58:03.670]Let me just call timeout for a sec
[00:58:05.000]to see questions or comments people have
[00:58:07.460]since we're on our final 26 minutes of the day.
[00:58:13.840]I'll keep moving.
[00:58:15.080]I also want people to know,
[00:58:16.587]and this is a compliment to what
[00:58:18.170]we talked about pre-lunch,
[00:58:20.230]you have to look at the context of marijuana use.
[00:58:25.900]Scientists call it potentiation.
[00:58:27.500]I would argue most college students
[00:58:28.630]call it cross-fading.
[00:58:29.580]It's drinking and using weed at the same time.
[00:58:32.000]So it's the effects overlap.
[00:58:34.260]It's a case where one plus one is greater than two.
[00:58:36.570]You take the effects of alcohol,
[00:58:38.110]the effects of marijuana, and then some.
[00:58:40.120]As a field, we stink at predicting
[00:58:41.670]how much the and then some part is.
[00:58:44.870]Anyone that says, well, I need evidence
[00:58:48.280]from published research that this holds.
[00:58:51.160]Seamon and colleagues, 2007,
[00:58:52.840]marijuana and alcohol used at the same time
[00:58:54.890]can result in excessive CNS depression.
[00:58:57.580]Breathing can slow and stop.
[00:58:58.970]Heart rate can slow and stop.
[00:59:00.370]Go right ahead.
[00:59:01.203]A lot of those withdrawal symptoms.
[00:59:08.590]The question about withdrawal was
[00:59:09.700]how long people typically experience those.
[00:59:12.170]I mean, a lot of it depends on
[00:59:14.360]how long they've been using for
[00:59:15.990]and how potent what they were using was.
[00:59:17.850]It sounds flakey to say but it has to be.
[00:59:20.110]Keep in mind that they say the symptoms
[00:59:21.420]typically develop within one week.
[00:59:24.490]But for the most part you'll hear people
[00:59:26.020]report everything from three to seven days,
[00:59:28.010]to people saying for really heavy use
[00:59:30.190]even pushing the 10-day-ish mark.
[00:59:33.220]But once you get over that hump,
[00:59:35.250]you start to see things improve.
[00:59:37.010]Even going to the research that Pope's team has done,
[00:59:40.770]I mean, you can see even after daily use,
[00:59:42.920]four weeks of absence you see
[00:59:45.060]those cognitive things match that
[00:59:46.620]of people who don't use at all.
[00:59:49.350]So it's a flakey answer but it kinda has to be
[00:59:51.250]just because it varies based on
[00:59:52.430]how often someone was using
[00:59:53.850]and how strong what they were using was.
[01:00:00.900]In terms of what to do with this
[01:00:02.420]from a prevention standpoint,
[01:00:03.550]we certainly know that how you talk
[01:00:05.350]about marijuana matters a lot.
[01:00:07.480]I don't know if people have noticed this.
[01:00:09.340]I'm at the point now where it's no longer deliberate.
[01:00:11.100]I just do it now.
[01:00:13.100]We don't talk about marijuana users.
[01:00:14.720]That's a label.
[01:00:15.720]We talk about those who report marijuana use
[01:00:17.380]or those who use marijuana.
[01:00:19.520]So anytime we talk about users,
[01:00:22.140]heavy users, those who use heavily,
[01:00:24.230]it's being careful and mindful of
[01:00:25.530]not being judgmental or confrontational there either,
[01:00:28.100]and that includes the labels we
[01:00:29.670]described around cannabis use.
[01:00:32.180]But what's most important is we see so many,
[01:00:35.680]even published measures, just need to be updated.
[01:00:40.320]People who are screening and asking people,
[01:00:42.160]do you smoke marijuana?
[01:00:43.630]A person who uses edibles daily
[01:00:45.300]can look you in the eye, be 1000% honest,
[01:00:47.330]and say, nope, and you missed their daily marijuana use.
[01:00:51.060]So if you're using a yes/no, asking,
[01:00:53.860]do you use marijuana or have you used marijuana.
[01:00:56.810]The gold standard screening measure
[01:00:58.560]for dependence is the cannabis use disorder's
[01:01:00.840]identification test revised, the CUDIT-R.
[01:01:03.710]I starts with a single question.
[01:01:05.140]Have you used cannabis in any form
[01:01:06.840]in the last six months?
[01:01:08.010]If no, you're done.
[01:01:10.080]If yes, there are eight questions.
[01:01:12.500]But if you ask, do you use or have used,
[01:01:16.000]only after they say yes,
[01:01:17.640]what does your marijuana use look like?
[01:01:18.940]If no, it can be okay being done.
[01:01:22.900]In our Young Adult Health Survey,
[01:01:24.440]what we've also found is it's not the case
[01:01:26.770]that people just wanna be left alone to use marijuana.
[01:01:30.230]We asked in a sample of 18 to 25 year-olds.
[01:01:34.203]We are seeing signs of some efforts of wanting to change.
[01:01:38.440]Those that were using two to three times
[01:01:39.990]per month or less, 34% of them said,
[01:01:42.260]I've tried to set some limits on my use.
[01:01:44.430]Those using weekly are more.
[01:01:45.780]Over half of them have said,
[01:01:47.860]I need to put some limits on my use.
[01:01:50.660]So I think when people's perception is,
[01:01:52.370]well, you can't talk with people about weed
[01:01:54.250]'cause A, they don't see any negative consequences,
[01:01:56.320]not true, and B, they just wanna be
[01:01:58.280]left alone 'cause they love it.
[01:02:00.360]We're seeing over half saying I've tried to set limits.
[01:02:03.530]Those using two to three times per month or less,
[01:02:05.460]27% of them said I've tried to cut down.
[01:02:08.510]Almost 40% of those using weekly
[01:02:10.390]or more have tried to cut down.
[01:02:12.560]So I think being open to the fact
[01:02:13.970]that some of the students you're working with,
[01:02:15.610]if they're struggling with marijuana,
[01:02:16.910]are, in fact, open to change, important.
[01:02:20.350]Part of the things is, especially if
[01:02:21.670]you're in a counseling context,
[01:02:22.790]is to explore healthy alternatives
[01:02:24.960]to what they're seeking.
[01:02:26.940]If you ask them, what are the good things
[01:02:28.140]about marijuana use for you?
[01:02:29.810]It helps me sleep.
[01:02:30.643]It helps me relax.
[01:02:31.730]If their marijuana use is gonna go away,
[01:02:33.750]what are some healthy substance-free ways
[01:02:35.840]for them to relax and to bring on
[01:02:37.630]an improved sleep quality?
[01:02:38.950]That's something you can explore with the student.
[01:02:42.610]We can also increase motivation to change
[01:02:44.680]for those using more heavily
[01:02:46.320]or at risk for addiction.
[01:02:47.750]We do see that brief motivational
[01:02:49.290]interventions show promise.
[01:02:51.950]I've been collecting pilot data
[01:02:53.900]on a marijuana and other drug workshop
[01:02:56.520]using motivation interviewing,
[01:02:58.100]using Marlatt's alcohol skills training program
[01:03:00.240]as the model, and have worked with
[01:03:03.490]Dolores Cimini's team at the University at Albany
[01:03:05.890]to look at behavioral outcome data.
[01:03:08.380]I was second author on an article
[01:03:09.860]that Christine Lee published looking at
[01:03:11.510]an in-person personalized feedback intervention
[01:03:14.640]using motivational interviewing.
[01:03:16.450]Among people that used marijuana
[01:03:17.840]five times per month or more
[01:03:19.730]up to multiple times per day,
[01:03:21.350]this showed significant reductions
[01:03:23.000]in use and even consequences.
[01:03:26.040]I also stand by my claim that I think
[01:03:27.810]there's a chance to provide education
[01:03:29.220]about addiction and withdrawal.
[01:03:32.660]From a lessons learned standpoint,
[01:03:34.150]I do think there's an opportunity
[01:03:35.640]to look at talking about norms.
[01:03:37.420]We've known since the 40s
[01:03:39.540]that people are far more influenced by
[01:03:41.510]their subjective sense of a situation
[01:03:43.330]than what's actually going down.
[01:03:45.030]If you walk into a room and you're like,
[01:03:46.360]this is sketchy, I'm outta here, you leave,
[01:03:49.010]even if nothing sketchy is happening.
[01:03:51.100]Your sense that I don't wanna be here leads to leaving.
[01:03:55.480]We are influenced by our perception
[01:03:57.030]of what other people think, do, and say
[01:03:58.337]more than what they actually think, do, and say,
[01:04:00.850]and unfortunately our perceptions are often inaccurate.
[01:04:04.080]It was in the 80s that Alan Berkowitz,
[01:04:06.490]Wes Perkins, Jeff Linkenbach, Koreen Johannessen,
[01:04:10.210]Michael Haines, Pat Fabiano, and others
[01:04:13.050]started saying we're seeing a consistent trend
[01:04:16.310]on college campuses in three domains.
[01:04:19.120]One, students way overestimate
[01:04:21.520]the acceptability of excessive behavior.
[01:04:25.070]What does that mean?
[01:04:26.640]On alcohol, if you ask people,
[01:04:27.890]how do you personally feel about someone
[01:04:30.030]staying up on a school night until 3:00
[01:04:31.490]in the morning playing their music loud
[01:04:33.560]in the Res Hall 'cause they're partying?
[01:04:35.750]I hate that.
[01:04:37.480]How do you think the typical student
[01:04:38.990]at this school feels?
[01:04:41.770]Well, you know, this is college.
[01:04:43.510]I don't wanna be the one buzzkill.
[01:04:44.660]They're probably cool with it.
[01:04:45.930]When you pool all the data together,
[01:04:47.620]99% of people disapprove of it.
[01:04:50.320]The 1% of people who do it are like, that's cool.
[01:04:52.970]But the 99% of people who disapprove of it
[01:04:54.603]mistakenly think they're in the minority
[01:04:56.580]and mistakenly think I would not be
[01:04:58.460]supported by my peers if I said,
[01:05:00.450]hey, could you turn that down?
[01:05:02.910]When we look at attitudes,
[01:05:04.170]we call these injunctive norms.
[01:05:06.200]Jen Jacobsen at Grinnell College has collected
[01:05:08.580]some of the coolest injunctive norm data
[01:05:11.370]about marijuana use that I've ever seen.
[01:05:14.330]Her team at Grinnell has looked at
[01:05:16.010]asking about people's approval of
[01:05:18.810]and desire for living on a floor
[01:05:20.880]where you don't smell weed now and then.
[01:05:24.150]What do we know about marijuana use?
[01:05:25.440]Most people aren't using.
[01:05:28.300]And, probably not surprisingly,
[01:05:30.260]even more say I really don't like
[01:05:32.260]being in my room as someone not using
[01:05:33.830]and smelling weed next door.
[01:05:35.580]But when you ask them how do you think
[01:05:37.650]most people are with it,
[01:05:38.760]they assume most people are okay with it.
[01:05:40.380]They overestimate the acceptability
[01:05:42.360]of excessive behavior.
[01:05:44.130]We have less guidance on what do with
[01:05:45.990]injunctive norms than we do with descriptive norms,
[01:05:48.200]but there's an opportunity there,
[01:05:49.540]particularly for anything you would
[01:05:50.500]do around norms campaigns.
[01:05:53.080]But what we find is that people
[01:05:54.350]way overestimate how many people do a behavior,
[01:05:57.660]and they think that those that do it
[01:05:59.400]do it more than they really do.
[01:06:01.870]And we can see that for some people
[01:06:03.420]that misperception can actually be
[01:06:05.170]associated with their own behavior.
[01:06:07.960]We know that's true for drinking.
[01:06:09.690]We know that's true for marijuana.
[01:06:11.840]Sandra Wolfson did a study that showed
[01:06:14.490]that the most significant perceptions,
[01:06:16.700]misperceptions of marijuana use
[01:06:18.550]come from those that use most heavily.
[01:06:21.370]Along with Wes Perkins's research,
[01:06:22.780]we were super impressed by her work and Wes's work.
[01:06:25.620]So 2006, I was lead author on an article
[01:06:28.260]where we asked almost 6,000 people,
[01:06:30.960]what do you do around marijuana use?
[01:06:34.040]A third of students had used marijuana.
[01:06:36.340]Two-thirds had not.
[01:06:37.640]So when you ask them,
[01:06:38.550]what does the typical student do?
[01:06:40.360]The right answer is the typical student doesn't use.
[01:06:43.250]Only 2% of people get that right.
[01:06:46.010]98% of people say, well, everyone uses weed.
[01:06:49.316]And in our study, the more significant
[01:06:51.410]the misperception, the more that was
[01:06:53.150]associated with people's own use and consequences.
[01:06:58.790]I had a undergrad say to me,
[01:07:00.480]no offense but that article is old now.
[01:07:02.320]I'm like, you're old,
[01:07:04.983]which was not true.
[01:07:07.210]But he's like, does that hold now?
[01:07:09.150]I'm like, well, let's look at that.
[01:07:11.020]In the state of Washington,
[01:07:12.320]you asked the question,
[01:07:13.160]in states where there's legalization,
[01:07:15.260]have we seen use go up?
[01:07:17.290]In the state of Washington,
[01:07:18.360]in our 2016 report,
[01:07:20.550]any past year marijuana use,
[01:07:22.170]our past year rates are a lot higher
[01:07:24.190]than those national rates.
[01:07:26.240]It's still the case, though,
[01:07:27.340]that most people aren't using.
[01:07:29.343]43, 46, 45, no change over time in those three years.
[01:07:33.600]When we ask them, what do you think
[01:07:35.780]the typical 18 to 25 year-old
[01:07:37.570]in Washington does, there's that same 2%.
[01:07:43.550]You know, 'cause my old research
[01:07:44.890]is completely not valid anymore.
[01:07:47.536]It's the same 2%.
[01:07:48.730]98% of people say the typical person uses.
[01:07:51.380]Half of them thought the typical person
[01:07:53.190]uses once a week or more.
[01:07:55.530]The brand new data, this is the first time
[01:07:57.110]I've shown this outside the state of Washington.
[01:07:59.730]Past year personal marijuana use by age group,
[01:08:02.400]sadly, we showed this in June
[01:08:04.970]for the first time in our state,
[01:08:06.690]our Young Adult Health Survey data
[01:08:08.090]is showing for the first time
[01:08:09.710]a significant increase in past year marijuana use
[01:08:14.060]by those with legal access to it.
[01:08:17.250]Among 21, 22, 23, 24, 25 year-olds,
[01:08:19.820]among the 21 to 25 year-olds,
[01:08:21.810]we see a significant interaction,
[01:08:23.370]such that there's no change in
[01:08:25.100]past year prevalence for those under 21.
[01:08:27.290]But for those over 21, there's an increasing
[01:08:30.020]trend in marijuana use over time,
[01:08:32.810]plus, cohort four, 2017,
[01:08:36.080]is significantly different than cohort one.
[01:08:39.000]What's a little disappointing from,
[01:08:40.830]again, from a public health standpoint,
[01:08:42.230]is that past month personal marijuana use
[01:08:44.830]is also significantly going up
[01:08:46.740]among 21 to 25 year-olds.
[01:08:49.190]Again, no trend for those 18 through 20.
[01:08:52.000]But those with legal access,
[01:08:53.860]we're seeing that those that are using
[01:08:55.610]are using more, more frequently.
[01:08:57.760]Outside the scope of the time we have
[01:08:59.750]is me getting into our longitudinal data.
[01:09:02.980]We've been able to follow the same people over time,
[01:09:04.990]and what we're finding is
[01:09:06.820]those people we're following over time,
[01:09:08.380]those that are using are using more heavily.
[01:09:11.200]So when we look at things like risk for addiction,
[01:09:13.340]we're very, very concerned about what that can mean.
[01:09:16.060]What are some of the things that contribute to norms?
[01:09:17.940]And, again, do with this as you wish.
[01:09:20.760]Who knows where your state and other states might go.
[01:09:23.640]But just in terms of kind of
[01:09:25.120]if you were me doing prevention work
[01:09:26.590]in the state of Washington,
[01:09:27.640]here's some of the things that we are up against.
[01:09:29.880]One of the things I think that we are
[01:09:31.060]up against is people saying, quote,
[01:09:32.840]it's just weed or it's not addictive.
[01:09:36.340]I would never out the state in which this came from,
[01:09:39.130]but a state legislator outside of
[01:09:41.420]the state of Washington said,
[01:09:42.253]"Maybe we should do what Washington did."
[01:09:44.420]And in that state representative's letter,
[01:09:47.030]they wrote it has low dependence rates.
[01:09:49.480]A study by researchers at the National Institute
[01:09:51.230]on Drug Abuse found that among people
[01:09:53.010]who had ever used marijuana,
[01:09:53.930]9% had experienced marijuana dependence
[01:09:55.890]at some point in their life.
[01:10:00.580]I'm not trying to criticize necessarily this
[01:10:02.690]other than the first thing I saw was,
[01:10:04.330]well, first of all, in 1994 it was marijuana
[01:10:07.420]with a way different potency,
[01:10:08.500]and it was even different criteria
[01:10:11.130]for how we diagnose substance use disorder.
[01:10:14.880]DSM-V came out in 2013.
[01:10:15.890]DSM-IV text revision was 2000.
[01:10:18.507]DSM-IV was '94.
[01:10:20.090]My hypothesis was they must have
[01:10:21.510]been using the DSM-III-R.
[01:10:23.350]I found the article.
[01:10:24.520]I was able to showoff my mad Stylus skills
[01:10:26.950]and show yet again, in fact,
[01:10:28.750]they used the DSM-III-R,
[01:10:30.310]and they were citing evidence
[01:10:31.850]on low dependence with marijuana
[01:10:33.440]that was a way lower potency than we see now.
[01:10:36.780]I think one of the other struggles
[01:10:37.750]that we see is, in quotes, news articles,
[01:10:40.540]particularly alongside pro-health messages.
[01:10:44.950]This is not me trying to pick and choose.
[01:10:46.660]This is me as I encounter them
[01:10:48.680]just putting 'em in my little file here.
[01:10:51.520]From our Seattle Metropolitan Magazine,
[01:10:53.830]Trending Now: High-End Pet Travel
[01:10:55.340]and Marijuana for Dogs.
[01:10:59.500]This is the magazine along with
[01:11:00.820]Seattle Magazine that's in every hotel room
[01:11:02.790]in the city of Seattle.
[01:11:03.950]This is our kind of like,
[01:11:05.240]here's what's happening in town.
[01:11:07.000]Seattle Times, March 16th, 2017,
[01:11:09.800]our state launched a big Start Talking Now campaign.
[01:11:13.890]Where there's a little clip
[01:11:15.840]ended with teens are under the influence of you.
[01:11:19.250]That same day, scroll down about a third of the page,
[01:11:23.170]and the human interest story was,
[01:11:24.900]Personalize your French toast with
[01:11:26.220]cannabis, spices, and toppings.
[01:11:30.300]So I think it's hard when we look at
[01:11:32.100]if we're giving a prevention message alongside this,
[01:11:35.390]does that undo the prevention message potentially
[01:11:37.410]or at least give a mixed message?
[01:11:39.830]That made me look and decide I wanted to find out how often
[01:11:42.400]are they giving these kind of recipes?
[01:11:43.990]Holiday food, wine, and cannabis pairings.
[01:11:46.720]What did we look at earlier?
[01:11:48.060]When you combine alcohol and marijuana,
[01:11:49.640]that is a drug interaction.
[01:11:52.300]I found this one,
[01:11:53.290]Cannabis kale chips that will make your weekend.
[01:11:55.630]No one's ever used the work kale
[01:11:57.040]and make your weekend in the same sentence ever.
[01:12:03.970]My mom, I love my mom so much,
[01:12:05.520]and my mom's adorable 'cause she's on
[01:12:06.980]all types of social media, and I am not.
[01:12:09.060]And she would often send me things,
[01:12:10.560]like, check this out.
[01:12:11.393]I'm like, mom, I can't.
[01:12:12.226]I'm not on this.
[01:12:13.059]I can't see this.
[01:12:13.892]So she's gotten really good at doing screenshots
[01:12:15.510]of stuff and sending them to me.
[01:12:16.730]My mom sent me this that she saw on Pinterest
[01:12:19.310]'cause she's way cooler than me,
[01:12:20.550]and it said, pro tip, if you stir
[01:12:22.420]coconut oil into your kale,
[01:12:23.650]it makes it easier to scrape into the trash,
[01:12:25.330]which I think is (laughs)
[01:12:31.000]But we have to mindful about that
[01:12:33.100]because when it's published online,
[01:12:35.490]it gives a legitimacy to the message.
[01:12:38.830]In fact, I saw a really important
[01:12:40.170]quote that highlights this.
[01:12:41.170]It said, the trouble with quotes on the internet
[01:12:43.350]is that you can never know if they're genuine,
[01:12:45.150]from Abraham Lincoln.
[01:12:48.203](laughs) One of the things we've seen
[01:12:50.730]a significant increase in among
[01:12:52.800]18, 19, and 20 year-olds is when we ask them,
[01:12:55.150]where have you gotten marijuana,
[01:12:57.211]we've seen a significant increase in minors saying
[01:12:59.490]I got it from my parents with their permission.
[01:13:04.140]Significant increase in minors saying
[01:13:06.140]I got it from family.
[01:13:07.610]In our brand new report that we just
[01:13:09.290]presented to the state, we've seen among
[01:13:11.890]18, 19, and 20 year-olds significant decreases
[01:13:15.090]in people saying they got it from
[01:13:16.180]someone with a medical card 'cause
[01:13:17.210]we closed our medical dispensaries.
[01:13:19.050]But an increase in people saying
[01:13:21.150]I got it from parents with permission.
[01:13:22.810]I got it from family.
[01:13:24.580]Also, gave money to someone.
[01:13:27.230]Our Healthy Youth Survey in Washington,
[01:13:29.220]which is not run by us,
[01:13:30.740]but it's the sixth, eighth,
[01:13:31.870]tenth, and twelfth graders.
[01:13:33.220]The most compelling slide I've seen is this one.
[01:13:37.440]They say, do you, this is tenth graders,
[01:13:40.090]high school kids, do you think your parents
[01:13:42.170]would think it's wrong for you to use marijuana?
[01:13:44.520]Those that think my parents would care,
[01:13:45.900]only 13% of them have used
[01:13:47.730]marijuana in the last 30 days.
[01:13:49.300]Those who think my parents don't care,
[01:13:51.090]59% of them have used in the last 30 days.
[01:13:54.900]Those who think the community norm
[01:13:56.210]is that it's not wrong
[01:13:57.300]versus those who do, 37 to 16.
[01:14:04.770]When we look at tenth graders saying,
[01:14:06.420]do you live with someone who uses marijuana,
[01:14:07.720]if you live with someone who uses marijuana,
[01:14:09.830]you're more likely to regularly use marijuana,
[01:14:12.090]almost over threefold.
[01:14:13.810]And, finally, the presence of other
[01:14:15.170]pro-marijuana content outside designated stores.
[01:14:18.430]You know, I find at you guys's airport,
[01:14:20.120]and there's the In Frost We Trust
[01:14:21.550]and all this enthusiasm for football,
[01:14:25.610]walked into a bookstore where the first thing
[01:14:27.170]you see is this display.
[01:14:29.910]Holiday cards for people,
[01:14:32.200]rain and coffee and salmon and weed.
[01:14:35.060]I was on my way to a marijuana symposium
[01:14:37.080]where I ran out of gas almost,
[01:14:38.470]and I had to fuel up at a gas station.
[01:14:40.330]In the gas station was all these hats,
[01:14:43.930]addicted to weed.
[01:14:49.890]So when we consider why norms matter,
[01:14:52.330]in our Young Adult Health Survey,
[01:14:54.620]we worked with our epidemiologist
[01:14:56.110]to see other data we can look at.
[01:14:58.780]At year one, it could literally predict use
[01:15:01.050]two years later, we have it.
[01:15:03.730]Predicting year three marijuana use by five factors.
[01:15:06.810]We can predict if someone uses marijuana
[01:15:08.790]by knowing their perceived physical risk
[01:15:10.740]of marijuana, using marijuana regularly,
[01:15:13.110]and there are physical harms.
[01:15:14.920]The perceived risk of regular marijuana use
[01:15:16.610]psychologically or emotionally.
[01:15:18.290]Perceived ease of access, unfortunately,
[01:15:20.160]ease of access because of outlets
[01:15:22.250]has gone up and there's less we can do there,
[01:15:24.580]with the exception of certainly
[01:15:26.190]cracking down on illicit means
[01:15:28.220]and making sure minors aren't getting it.
[01:15:30.860]But norms, anything you can do to address norms matters.
[01:15:34.170]We can predict any marijuana use,
[01:15:35.950]at least weekly use, and a number of
[01:15:40.370]It is 2:30.
[01:15:42.110]I told you we had a lot of slides.
[01:15:43.620]We've gone through 250 slides.
[01:15:46.400]If it felt that way, I am horribly sorry.
[01:15:49.320]If it did not, then I'm glad.
[01:15:51.120]I will end by saying this.
[01:15:52.430]My youngest brother was talking with me
[01:15:54.500]about an anthropology class he took as an undergrad,
[01:15:58.730]and I loved what he said about this.
[01:16:00.120]He said, Margaret Mead was asked,
[01:16:03.340]what is the first sign you look for
[01:16:04.800]to tell you of an ancient civilization?
[01:16:06.900]How do you know they were civilized?
[01:16:08.120]Was it some instrument, a tool,
[01:16:10.150]an article of clothing?
[01:16:11.630]And her answer was a healed femur,
[01:16:14.320]the thigh bone.
[01:16:15.300]If you broke your thigh bone,
[01:16:16.410]you were out of luck unless someone
[01:16:17.777]was there to take care of you, help you,
[01:16:19.340]get food for you, that type of thing.
[01:16:21.650]That's how she saw signs of civilization.
[01:16:24.520]I hope it's not a dramatic image when I say
[01:16:26.750]we're seeing a lot of broken femurs these days,
[01:16:29.990]not only on college campuses
[01:16:31.100]but in our communities.
[01:16:32.120]And I'm convinced that the very people
[01:16:33.790]to help heal those are not only in this room
[01:16:37.210]but it's our, in some ways,
[01:16:38.400]hidden partners in prevention, parents of folks.
[01:16:41.670]It's our primary healthcare providers
[01:16:43.250]in the community that our students are also seeing.
[01:16:45.253]There's a lot that can be done.
[01:16:47.140]I hope none of you ever question
[01:16:48.950]the value of what you do
[01:16:49.990]from a prevention standpoint,
[01:16:51.510]and never question the value of what you do
[01:16:53.200]on the potential impact on people in your community.
[01:16:56.470]I started by thanking Megan.
[01:16:57.910]I will thank Megan again.
[01:16:59.850]That's my email address.
[01:17:01.170]If any of the articles I mentioned
[01:17:03.110]people wanna have sent to you,
[01:17:05.130]please don't hesitate to ask.
[01:17:07.340]I'm a big fan of not keeping people late on a Friday,
[01:17:10.540]but I'm an even bigger fan of making sure
[01:17:12.340]I was neither misheard nor if there were
[01:17:15.250]lingering questions that didn't get answered.
[01:17:17.170]So before we officially break for the day,
[01:17:19.010]what final questions, comments,
[01:17:20.860]anything that people have?
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