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Youth Perspectives on the Changing Landscape of Legalized Recreational Marijuana: Reframing Risk and Harm ReductionTranscriptNCTCFP:Thank you for joining us today for the Youth Perspectives on the Changing Landscape of Legalized Recreational Marijuana: Reframing Risk and Harm Reduction. We're going to go ahead and get started while people keep trickling in. Next slide. A quick note of today's webinar, is now live and being recorded. This webinar will be available for future viewing along with a copy of today's slides. Audio will stream through your computer device. If you prefer to call in, the phone numbers are included in your registration confirmation. You may type questions for our presenter at any time in the Q&A feature. We'll also host a Q&A session after the slide presentation. You're also welcome to use the chat feature for comments and questions. Next slide.NCTCFP:All right. A quick note in the chatting in the Zoom webinar... To make sure all attendees can see your comment, make sure you go to To: at the bottom of your chat feature and select To: All Panelists and Attendees. You may have to select this a couple of times because it automatically goes to all panelists, but you want to make sure everyone can see your comments. Next slide.NCTCFP:All right. The speakers and planning committee members have disclosed commercial interests and financial relationships with companies whose products or services may be discussed during this program. Our speaker today and planning committee have nothing to disclose. Jacki Witt serves on the advisory panel for Afaxys, and she's resolved. Kristin Metcalf-Wilson serves on the Afaxys Pharmaceuticals advisory board, which is also resolved. The presentation was supported by Grant #5 FTPA006029-02-00 from the U.S. Department of Health and Human Services, Office of the Assistant Secretary of Health, Office of Population Affairs. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of HHS, OASH, or OPA. Next slide.NCTCFP:This webinar offers one contact hour for nurses. To receive contact hours, participants must complete the Evaluation and Request for Credit Form. For the recorded version, participants must complete the course with a satisfactory grade of 80% or higher on the quiz and complete the Evaluation and Request for Credit Form. CNE and CME certificates as well as Certificates of Attendance will be emailed within three to four weeks. There's no commercial support for this training. The University of Missouri-Kansas City School of Nursing, the Office of Population Affairs, the American Nurses Credentialing Center's Commission on Accreditation, and the American Academy of Family Physicians do not approve or endorse any commercial products associated with this activity. Next slide.NCTCFP:For Continuing Medical Education, the AAFP has reviewed Youth Perspectives on the Changing Landscape of Legalized Recreational Marijuana: Reframing Risk and Harm Reduction and deemed it acceptable for up to 1.0 online only, live AAFP elective credits. Term approval is from today until today. Physicians should claim only the credit commensurate with the extent of their participation in this activity. Continuing Nursing Education, the University of Missouri-Kansas City School of Nursing and Health Studies is accredited as a provider in continuing nursing professional development by the American Nurses Credentialing Center's Commission on Accreditation.NCTCFP:This program offers up to 1.0 contact hours for nurses for this activity. Certified health education specialists, sponsored by the University of Missouri-Kansas City School of Public Health... Or I'm sorry. School of Nursing and Health Studies, a designated provider of Continuing Education contact hours in health education by the National Commission of Health Education Credentialing. This webinar is designated for CHES to receive up to 1.0 Category 1 Continuing Education hours. Next slide.NCTCFP:We've completed the housekeeping. I'd like to introduce you to our speaker. Jenni Lane has worked in the field of positive youth development and adolescent health for the past 20 years in varied settings, including traditional classrooms, outdoor experiential education, sexual health education, peer education programs, and youth leadership and social change programs. She is the Senior Program Manager at the University of Michigan Adolescent Health Initiative, where she provides professional development for providers and health center staff, implementing evidence-based approaches to adult learning with a focus on adolescent-centered care.NCTCFP:Her interdisciplinary approach to organizational change invites both individuals and teens to engage in creative continuous quality improvement. Jenni is committed to strengthening youth and adult interactions through expanding adults' capacity to partner with young people in authentic ways. As a parent of two teens, she's particularly interested in the ways parents and healthcare professionals prepare young people for a lifetime of engaging in their own health through dialogue, practices, policies, and procedures. With that, I'll let you take it away, Jenni.Jenni Lane:Thanks, Carissa. It's really great to be here today. As Carissa said, my name is Jenni. I'm the Senior Program Manager at the Adolescent Health Initiative. We are going to take a look at the context for the Adolescent Health Initiative now with this map, which just shows that even though we're based at Michigan Medicine at the University of Michigan in Ann Arbor, we serve more like a national nonprofit providing training, and TA, and coaching to health centers, really, anyone who's providing care to adolescents around the country. Our vision is to transform the healthcare landscape to optimize adolescent and young adult health and wellbeing.Jenni Lane:In this talk, we're going to hear from young people about the most common forms of marijuana that they're using. We're going to consider their values, and their attitudes, and how these might impact our communication with them. We're going to identify some strategies to take a strengths-based approach to helping youth with positive behavior change. We'll also be looking into how our own personal views towards marijuana can impact our interactions with adolescent patients.Jenni Lane:One thing that this session is not is a specific training on motivational interviewing or a training on SBIRT, which is screening, brief intervention, and referral to treatment. If you haven't participated in either of these types of trainings before or if you could benefit from a refresher, I highly recommend them. I will share resources about how to get connected at the end of this presentation.Jenni Lane:I also recognize that most of you have significant expertise in eliciting positive behavior change around sexual health and around risk behaviors, and many of these same skills are involved. Also, as a piece of my background, I worked at a Planned Parenthood for seven years, from 1999 to 2006. Working in family planning is near and dear to my heart. Before I move on from objectives though, a quick note about language, which is that I will mostly be using the term marijuana as it is the most commonly used term, although I will use cannabis and marijuana interchangeably.Jenni Lane:To start us off here, it's kind of important for us to really take a look at what we are bringing to this conversation, each individually. The way that we feel about young people using marijuana can influence how we message them and how we communicate with them. As healthcare professionals, our experiences with patients and our knowledge of the evidence base inform our professional beliefs and our practices, but our own experiences can also play a really significant role. For example, having positive experiences with cannabis without any negative consequences may influence our attitudes in a certain way. The converse of this is true as well, right? If we've lost a family member to a substance use disorder, it might make us more cautious.Jenni Lane:We're going to do a brief activity to help us tune into what might be conscious or unconscious biases. What I'm going to do is we're going to do a poll, but right now, we're not going to actually do it sort of Zoom-poll style. What we're just going to do is I'm going to read a statement, and then I want you to kind of think about where you think you fall along the liker continuum here, from strongly agree to strongly disagree. Then we'll pause for just a little bit of discussion. Again, in lieu of being in person together today, we'll be discussing sometimes throughout. I've tried to work in the chat box a little bit here. I'll have some opportunities for you to chat in some of your thoughts about this.Jenni Lane:When I read a statement, just kind of think about your own feelings about this. Don't spend too much time worrying about where it is exactly on the continuum. This first statement: Marijuana use is a significant problem among youth in my practice and work. Again, actually, in a moment, we're going to do the actual poll, but I just want you to take a moment to think about this first. Where do you feel like you fall? Do you think that marijuana use is a significant problem among the youth that you interact with in your practice or work setting? Okay. Next statement: Marijuana use is a significant problem among youth in my community. Okay. Just think for a moment about where you stand on those.Jenni Lane:For these first two statements, another question: Are the youth that you serve professionally different from the youth in your personal community? This is just a reflection question, so you don't need to chat in about this. Kind of think about, are those different groups? Do you feel that marijuana is a bigger problem in one group, or the other, or in specific communities? How might your feeling of that or even your knowledge of some of the data around that... How might that influence your approaches? Okay. Just reflect on it.Jenni Lane:Next statement: I would rather counsel a young person with disordered use of alcohol than marijuana. Just pause for a moment. Think about where you stand on that, how much you agree or disagree with that statement. I also want to pause for a second and just acknowledge that I recognize that we have a multidisciplinary audience here. I recognize that most folks here are providers and have clinical day-to-day experiences with young people, but also acknowledging that maybe not everyone on this webinar has that kind of direct-service interaction with young people. As best as you can, kind of try to apply these to your work. For this last statement about kind of whether you would rather counsel a young person with disordered use of alcohol or marijuana, how might your concerns about alcohol and marijuana use among adolescents be different from each other? How might your approaches to counseling be different?Jenni Lane:Next statement: I believe there are potential benefits to destigmatizing marijuana use. Okay. Just thinking about whether you agree or disagree. Then some of the thought questions that go with this one... I think the question I ask myself is, in what ways is there stigma around marijuana within the U.S.? How might it be both cool for young people to use and still have shame associated with it? How might stigma impact an adolescent's interactions with a provider? We will come back to that one when we do the poll.Jenni Lane:Next statement we'll do... I believe that it is possible for someone over 25 to use marijuana safely. Just thinking to yourself whether you agree or disagree with that statement: possible for someone over 25 to use marijuana safely. Then you guessed it. The next statement is, I believe that it is possible for someone under 25 to use marijuana safely. Okay. Most people feel that it's safer for adults to use marijuana than it is for adolescents. We know that cannabis can have adverse effects on adolescents in particular due to the plasticity of their brains and brain development. Adolescents may be more vulnerable to disordered use than adults. It's not uncommon to have a bit of a difference in those answers.Jenni Lane:Number seven: I am seriously concerned that loosening attitudes toward marijuana will increase adolescent use. Think about your thoughts about that one. I'm going to read it again. Agree to disagree, I am seriously concerned that loosening attitudes toward marijuana will increase adolescent use. Some questions that go with this one... How might your level of concern be conveyed to an adolescent? In what ways could your concern have a positive effect on them? How could our concern possibly have a negative effect on young people?Jenni Lane:Last statement: When communicating with youth, I think it's important to acknowledge that using marijuana can be pleasurable. Think for a moment how much you agree or disagree with this statement: When communicating with youth, I think it's important to acknowledge that using marijuana can be pleasurable. I'll just say this is a tough one for me. In some ways, I think about comparing this to messages around sex since there's been a fair amount of discussion in the past few years, particularly around the value of adults acknowledging that sex is pleasurable. That comparison is tricky, right, because sexual behavior can be a very healthy component of adolescent experience, and marijuana use in and of itself is not. Why should we or why should we not acknowledge pleasure? What would be an appropriate way to do so?Jenni Lane:Again, I know I'm putting all these questions out to the ether for your reflection. Now we're going to loop back and do an actual poll. We're going to launch a poll. When the poll is launched, you're going to see all of these statements that we just sort of discussed, one-sided discussed. Here's your chance to just put down, remember this is anonymous, where your gut said you were along the continuum. We're going to do this because I want to take a pulse. It'll be interesting just to see a snapshot of where everyone is. Carissa and Shelby, if you can launch the poll, please. Thank you. Participants, have at it. Go ahead and answer these questions based on what your thoughts were when we went through these statements. Go ahead. We're going to take just a moment here for you to fill in your responses to the poll. Work your way down and fill out all eight.NCTCFP:The last option is strongly disagree. For some reason, the poll duplicated strongly agree twice. It just really wants you to agree, so make sure the last option is strongly disagree, just so you all know.Jenni Lane:Thanks, Carissa. On my end, it looks accurate. It looks like it goes... Oh, I see. It's just one or two of those first statements where it pops up as agree. The rest look okay. Great. Please go ahead if you haven't already and start entering because I know we have a lot more people on this webinar than is showing up yet. Make your votes. Great. We'll take just another few seconds for people to keep entering. I'm seeing feedback still coming in, so we're going to take another moment. Go ahead and enter if you haven't entered yet. Okay. It looks like we've got most of our responses in. Go ahead if you haven't entered. We'll still see it coming up. In order to share the poll results, Carissa, are you able to do that on your end?NCTCFP:Sure thing.Jenni Lane:Great. Thanks. I see a comment here that says, "Would like for neither agree or disagree for a couple of questions." I hear you. These are complex, multi-dimensional issues that I always want to add qualifiers to, right? It depends. It's always that it depends, right, and that is totally fair. I think for the purpose of this is to kind of force some of those thoughts to be narrowed into spots that aren't so accurately narrowed in real life. Okay. Let's see. We see for this first statement, marijuana use is a significant problem, the majority of people, just about 52%. Just over half of the people agreed. When we combine that with strongly agree, then over half either agree or strongly agree with that. Just under a third disagree that it's a significant problem in your work community.Jenni Lane:In your personal community... Let's see. It looks pretty similar, maybe a little bit more concern. The third one: I'd rather counsel a young person with disordered use of alcohol than marijuana. It looks like we have mostly disagree. 58% of people saying that they... Kind of the flip side of that, right, is that people would rather counsel a young person around marijuana than around alcohol. I believe there are potential benefits to destigmatizing marijuana use. This is one of those tricky ones that I think that we could have such good conversation around. If we combined strongly agree and agree, then we've got about 75%, agree that there are potential benefits to destigmatizing marijuana use.Jenni Lane:Let's put that chat box to use for a minute here. Can someone chat in or anyone who wants to chat in some of the ideas around, what are some of the potential benefits of destigmatizing marijuana use? I see that someone commented about the topic of pleasure, which I want to read this. "A thought on the topic of pleasure... When counseling someone who battles obesity, we don't try to pretend eating ice cream isn't pleasurable." Thank you for that metaphor or parallel, really. As a sexuality educator for years, one of the things that I often would say is that if a parent is telling their child that sex isn't pleasurable and then the kid finds out that it is, they either kind of lose trust in their parent or kind of worry, "Aw, poor Dad, poor Mom, whatever."Jenni Lane:Yes. Agreement here on that one. Some great comments here. Wow. Since we've got a lot of participants, I'm going to do my best to kind of look through here. Benefits of destigmatizing: decreased involvement with the criminal justice system, can be medicinal, ability to adequately study it. Certainly, we have had a lot of restrictions on marijuana research because of the stigma. With less stigma, there's more openness in discussing actual use, and risks, and benefit, easier to be honest in talking about, medicinal use for anxiety, ADHD, pain, nervous system function, more honesty from clients under use, to increase honesty about usage... If you think they're going to freak out, they're more likely to lie or not fully disclose. Again, that stigma or shame... We know it's not a good motivator for change, right?Jenni Lane:Here's someone who says, "My patients don't see it stigmatizing." It's important to acknowledge that certainly not all young people recognize the stigma. I think it's an interesting and, again, complicated topic where in some settings, young people may feel like there's no stigma. It's very cool. Family acceptance... Family usage is open, and may still feel like, "But I could get in trouble for it, or I wouldn't want a teacher to know." There's a different kind of reason for stigmatizing. "Less stigma can mean youth are more willing to be honest with providers." The question about referring to marijuana use, is substance use disorder a recreational use? for question four. That benefits to destigmatizing marijuana use. Certainly, I think I'm talking about, generally speaking, disordered use. I think I'd even put that in there too, thinking about stigma with any use of marijuana.Jenni Lane:Brings people in chronic pain out of the shadows, right? If something is in the shadows or there's stigma, then shining a light on it is often a helpful and healthy kind of way to address it. Gives validity to your message, especially in public health. You have to acknowledge that there are people that use marijuana and can use it safely. Otherwise, your message can get lost. Again, if a young person is seeing someone who's using it, say, medically for something that it's having medical benefits, it's managed by a medical professional, then it can feel contradictory if they're hearing from an authority that it's never good, right?Jenni Lane:Yes. Brings it forward, opens up the conversation, and teens are likely to be much more skeptical when you portray something as all bad. Really great comments. Thank you for these comments. Here's one more that I'm going to read. There's a study done referring to the benefits with boosting metabolism and energy with certain strains that will help you to be able to work out and stay athletic. We've certainly heard a lot of claims recently about benefits of CBD, about benefits of THC. We're going to talk about both of those in a minute. Then some of those claims are dubious, I wonder about, and some of those claims, we certainly need more research around. Then there's some research to support that there can be positive health outcomes for medical use.Jenni Lane:That was a nice detour with number four. That was the main one I really wanted to go deep on. Number five, just looking at people's responses and coming back to the poll, I believe it's possible for someone over 25 to use safely. That's curious. I wanted to see what that difference would be. About 83% agreed that it's possible for adults over 25 to use safely, and a smaller number for adolescents. For sure, agreeing with that. There's still a sizable portion of people who are saying that they believe it's possible for someone under 25 to use marijuana safely, just under half.Jenni Lane:I'm seriously concerned that loosening attitudes towards marijuana will increase adolescent use. The agree and strongly agree are just over half here as well. That is something we're going to talk about more too, is normalization. What is the connection between normalization and possible increased user negative health outcomes? When communicating with youth, I think it's important to acknowledge that marijuana use can be pleasurable. That's our final statement. Again, it looks like most people agree with that statement, with about 20, 25% disagreeing with that.Jenni Lane:All right. Then I'm reading this one last comment here, "Destigmatizing marijuana will inadvertently reduce the number of children who use it. A plethora of children tend to try something because they are told it's bad." That's an important point that we haven't really touched on in this discussion yet, is that sort of when something is taboo or something that's bad, it feels riskier in some ways. The element of risk that's appealing can be even more appealing if it feels like there's something edgy about it, right?Jenni Lane:Thank you very much for all of that excellent feedback. I'm going to close the poll and stop sharing the results. We will move on. Just a couple of other final thoughts here about just reflecting about personal bias and our own attitudes... Just really want to acknowledge that for some of our messaging, there can be multiple truths. I think that often, having multiple truths is hard for people to hold. It's certainly not a really conventional way of looking at things. A lot of times, that's not the way that we were trained. For instance, acknowledging that being high can feel good and it's best that you delay use until your brain is more developed, or that you don't use it often or frequently, or you don't use it at all, depending on what your values are and what your approach to your messaging is.Jenni Lane:That can feel contradictory to people. There are various schools of thought in the evidence base around the best ways to discourage youth from using. Are you aiming for abstinence only? Something to think about. A researcher who I really respect in this field is Dr. Leslie Walker-Harding. She's an adolescent medicine clinician and a researcher out of Seattle Children's. She suggests that it's ideal to give really clear messages early on, that it's best to never try it or never use it, so there's never a problem you have to address. It's interesting to think about and think about what your own personal thoughts about that are.Jenni Lane:I want to close this activity by taking a moment to think about what other things might influence our attitudes about youth using marijuana. I will say that having two teenage kids influences me. Please pause for just a moment to consider what experiences in your life might influence you. What was your impression of the risks with marijuana when you were 15 or 24? How were they different from your impression of the risks now? What factors have influenced them along the way? I hope that some of your reflections in this exercise can help inform the rest of the conversation today.Jenni Lane:All right. Like adults, young people often have nuanced values around marijuana and other substance use. I'm going to play a brief video clip of a 17-year-old who shares his thoughts about the growing acceptance of regular marijuana use among his peers. This is going to be the first of a few different video clips of young people. Oop. Sorry. Sometimes that control doesn't always work.MC:The drugs that I see most in my school are mainly weed and a little bit of alcohol, and it's become a lot more accepted. I'm not sure if it's for better or for worse. All I know is when someone's drinking every day or just very addicted to alcohol, that's a problem. People speak up and they'll say something, try and get them help. With weed, it's kind of the other way around. It worries me a bit that I know a lot of people who smoke daily. Not a lot of people see a problem with that. They might get weird glances or some people that judge them about it, but the overwhelming majority doesn't have much to say about that.Jenni Lane:Okay. Thanks for that young person to kind of start us off by acknowledging how complex this is and how uncertain he was about... Is it for better or for worse? Now we're going to take a look at the landscape of where we are in the U.S. in terms of legalization. This map is from January of this year. The data will likely be changing in the coming months as legalization of recreational marijuana is expected to be on the ballot in more than 10 additional states. This map shows that medical marijuana is legal in 33 states, and recreational is legal in 11.Jenni Lane:I also want to note that there's been recent legislation to decriminalize marijuana-related offenses in a number of states, which may not affect how we counsel, but may influence some of the issues discussed in the bias activity that we just did, and it came up in some of the chats too, such as reducing stigma or impacting the ways that our systems disproportionately prosecute black, indigenous, and people of color for marijuana-related offenses.Jenni Lane:What are the pros and cons of recreational legalization? It came up a little bit earlier too. An obvious advantage is, and that we talked about, is an ability to increase research and to sort out actual medical benefits from the snake oil kinds of claims that we've been hearing. Also, if legalization leads to destigmatization, if, we might see some of the advantages that we've been talking about, like countering the effects of shame when it comes to disclosure or openness to treatment. We also need to consider the possibility that destigmatization might make marijuana use more appealing, lower the perception of harm, and possibly increase adolescent use and, thus, harmful impacts.Jenni Lane:Even though a number of states have legalized it for a period of years now, there's still not ironclad data that legalization increases adolescent use. We're going to get to that in a minute. What else can you think of in terms of possible pros and cons? We'll take just a moment for a couple chats. Any pros and cons that haven't been mentioned that you feel like need to be acknowledged about legalization, either that are a possible benefit or a possible drawback? Addiction, simply put. someone just put the word addiction and that that is the concern that if somebody has more access, that it's more likely that they're going to be disordered use. Decreased incarceration. Decreased incarceration for... Certainly, too, that, as mentioned, decreased incarceration that can have lifelong effects on someone and also disproportionately affect communities of color.Jenni Lane:Cons: Messaging around neural opponent processing is not happening and poorly understood. We are having this increase in access through legalization and for other reasons, too, increase in access. Along with that increase in access, there's not a companion education component for young people. They're not learning about the possible negative impacts on their brain, and processing, and development. Less likely to be a gateway to other substances because it is not purchased by a drug dealer. Removing the drug dealer element out of this, and if people are getting it through legal channels, less likely to be a gateway.Jenni Lane:I've seen an increase in adults... I'm reading the chats here, just to clarify. "In adults who feel more comfortable supplying youth, especially if they can buy from a dispensary. Legalization normalizes it for youth, and they may think it's safe." That's actually something that the data bears out, that young people cite the fact that it's legal as evidence that it's safe from their perspective, I should clarify. Regulation decreases criminal activity and violence.Jenni Lane:Pros: It is not lethal. Increased testing and regulation leads to a safer product. The product itself is more likely to be safe when it's more highly regulated. Impact on lung health when smoked, I'm guessing, is a con. Although it is interesting, I've heard also the argument, and from young people as well, that when there are more forms and it doesn't have to be smoked, but there are forms that are safer for the lungs that potentially... We're thinking about it in terms of harm reduction or on a continuum that it could be safer.Jenni Lane:Okay. I'm seeing lots of really good comments in here. I realized that I've got a lot of slides, so I'm going to move along. I really appreciate your feedback here too. We are going to take a look at this issue of access that we were just talking about. Certainly, one thing, this increases access. This 15-year-old here says, "It's a lot easier to get weed. Alcohol... You have to know people with fake IDs. You have to know upperclassmen. I think it's just a lot easier to use and get away with now."Jenni Lane:Youth also have access to much more information along with access to the marijuana. Access to the information is often shared by dispensaries and other organizations that are within a rapidly growing industry. Clearly, they're trying to sell it and they're... We have the information super highway as a means for people to access the information, right?Jenni Lane:I recommend just checking out the website, Leafly, because it really gives you a picture of the kind of information that's available to anyone. It's a national resource for people to help them find dispensaries, learn about products, and generally promote marijuana use. Just nice to know what's out there, and what young people are seeing and reading about. I'm going to share another quick video here of a high school junior who shares an additional perspective about access. She also raises a point about how access might influence why youth might use.RR:As teenagers, I think it's really easy to fall into the habit of using substances as a way to cope, whether it's with a mental health issue, or trauma, or grief. A lot of times, it's more accessible than the treatment services that would be more beneficial, like therapy. It's more socially acceptable to drink away your problems than to actually get the care and the treatment that you need. I think it's important for providers to recognize that and go about addressing substance abuse in a way that's not shaming people who are using, but rather, helping them to find better ways to cope.Jenni Lane:There are a few things that she said in this video here that I just really appreciate: certainly, the point about the accessibility and the ways that sometimes a young person is going to use substances or marijuana, specifically for therapy, or for seeking it for therapeutic purposes, or to deal with mental health issues. My question for you is about how providers... Thinking about it from a provider lens, how might providers miss a cue in screening or just in education about mental health issues when a patient mentions their substance use? I think sometimes, and I've heard this from young people, that when they mention that they use substances or that they've tried substances, that the provider zeroes in on that and that they feel that they miss the chance to talk about some of their mental health issues. Just food for thought, something to reflect on.Jenni Lane:I want to look a little closer at some of the social appeal for some young people and read a few quotes. I'm going to start with this one. "We're not just doing drugs. I'm sure there are kids that are just doing drugs, but between me and my friends, it's not like, 'Oh, let's go get high. I need weed.' It's just like, 'Hey man, you want to smoke this weekend? Okay, let's get a good sack, and just kick back, and burn.'" Let's unpack this a little. It sounds like this young person wants to distinguish between youth who are just doing drugs and youth who are using drugs as a valuable part of socializing.Jenni Lane:Considering the incredibly strong social aspect of this developmental phase, this underscores the connection between substance use and the desire to socially connect. Here are a couple of other quotes that really reinforce this. "It's an easy way to socialize or get people loosened up. Some of my friends who tend to be shy at parties become that guy that everyone wants to talk to. It's an easy way of socializing."Jenni Lane:"I mean, once you start hanging out with people and start smoking with them on a regular basis, you end up just chilling with them because they're smoking, and they're only chilling with you because you're smoking. If you don't smoke, they're going to go find someone else to smoke with." "In my social group, the cool thing is knowing how to use it, I guess. Knowing how to roll, knowing how to pack, which is rolling weed up into a smokable paper, or packing, filling a bowl with weed."Jenni Lane:This last quote speaks to the social capital that can be involved in weed culture. I think the most simplified adultist view that we've heard is that teens think that the social pressure looks like, "Come on. Do it. You'll be cool." I've heard many youth through the years reject that this kind of pressure, that this kind of pressure exists. I remember telling my own mother decades ago, "It's not like that," right? Perhaps a more nuanced and accurate version of this is that there can be social rewards to connecting through substance use, which makes so much sense developmentally, especially when we think of adolescence as having enhanced FOMO, right? You know that acronym, fear of missing out? The fear of missing out is huge because the need for social connection with peers is so high and developmentally appropriate.Jenni Lane:The forms of marijuana use have expanded drastically over the past 10 years. As weed culture has grown to reflect a rapidly growing industry with new products emerging constantly, the language to describe these different forms has also expanded and changed rapidly. There's always been slang for marijuana. We've moved way beyond grass, and weed, and reefer into a much wider array of forms, and then the accompanying vocabulary with all those forms.Jenni Lane:The quote on this slide is from a young person I interviewed who distinguishes between homemade edibles and dispensary edibles and weed, which may have been sourced from a dispensary, but purchased from a dealer, a.k.a., a plug. This might look like someone with a medical card who legally purchases products from a dispensary and then sells it to others, like youth, without a card. Someone mentioned that in the chat. We definitely see a fair amount of that where I am in Michigan, where recreational marijuana has been legalized for over a year now.Jenni Lane:Edibles or foods and candy that contain THC, which is the chemical component that makes someone feel high, are increasing in popularity. The concentration of THC can vary widely within edibles. It can take longer for someone to feel high if they take a bite of a cookie, or a brownie, or something. If it takes a while, it means it's easier for someone to ingest too much, especially if they're taking something that's not a single serving, right? If they're taking a bite of something, they wait a minute, and they don't feel anything, it's a lot easier for them to have too much. The result of this can be extreme confusion, anxiety, paranoia, panic, fast heart rate, delusions or hallucinations, an increased blood pressure, and hyperemesis.Jenni Lane:While we're talking about forms, let's talk about vaping marijuana. Similar to how people can inhale nicotine through an electronic vaporizer, or a pen, or a device, like a Juul, THC and/or CBD can also be inhaled using a vaporizer pen. In this quote that I'm going to share in just a second, a 15-year-old tells about dab pens and explains why they are discrete. "Dab pens are easier to use because you just screw a little cartridge onto a battery. You hold a button down. You hit it, and it doesn't smell as much, or the slang term is, 'It's not as loud.' It's a lot more effective, so one hit off of the dab pen compared to one hit off regular weed is a lot more powerful because the THC in a dab pen cartridge is a lot more concentrated."Jenni Lane:"You can really do it anywhere, anytime. You could hit a dab pen downtown, any city. If there's no cops by, really, I mean, no one's going to care. It just looks like a nicotine vape. I mean, if you're smoking a blunt downtown, which is a rolled joint with flower, often mixed with tobacco, it's different. Everyone smells it. The smell gets on everyone. Someone calls the police. Everyone gets pissed off."Jenni Lane:This quote sounds almost like a commercial with a young person giving some of the possible reasons why we've seen a huge increase in youth vaping THC. A side note: This kid says that vape pens are a lot more concentrated, which can be true, but the levels of potency can vary a lot. Some can just contain CBD or cannabidiol without any THC. That's an important thing to know about that.Jenni Lane:Okay. Somebody just asked a question about how long the webinar is. It does end at 2:00, Central Time, so 3:00 Eastern Time is what I'm on. We've got about 15 minutes left. Then I'll want to have some time for Q&A at the end. I want to interject here with this image from the National Institute on Drug Abuse's 2019 Monitoring the Future survey. This is about the prevalence of vaping THC. The percent of teens that reported past month, marijuana vaping, between 2018 and 2019, rose from 2.6 to 3.9% of 8th graders, 7.0 to 12.6% of 10th graders, and from 7.5 to 14% of 12th graders. This increase in past month, marijuana vaping, is the second largest single-year increase ever measured in the 45-year history of the MTF survey. It was only surpassed by the increase in nicotine vaping between 2017 and 2018.Jenni Lane:I'm going to come back to a couple more slides on prevalence shortly. Youth are still using what we think of simply as marijuana. Since there are so many other forms now, this needs its own term to distinguish it from other forms. Sometimes people just still call this, weed, to refer to the dried plant that's smoked. Sometimes it's called, flower or bud, to make that difference even clearer.Jenni Lane:Dabs or dab rigs are a really concentrated way to get an effect from THC. They look a little like a water bong, but instead of burning flower, they burn these small highly-concentrated pieces of wax or resin. The resin needs to be heated at a higher temperature than a lighter. Part of a dab system or a rig includes a small blow torch. Tinctures can have varying potency of THC. You can imagine that they allow for even more discrete use.Jenni Lane:Returning to the data from Monitoring the Future study, this graph illustrates the percentage of teens reporting daily use. In 2019, we saw a statistically significant increase in daily marijuana use in 8th graders and sophomores, who saw rates go from 0.7 to 1.3% and 3.4% to 4.8%, respectively. That means that in that one-year period, we saw rates of daily use doubled in 8th graders. This graph represents teens reporting past month's use, comparing cigarettes and marijuana. For the first time, the MTF survey also included questions on vaping nicotine and vaping marijuana, which you'll see on the far right with the sharp increases that we discussed earlier.Jenni Lane:I want to point out a couple of things here. First, this shows how we've seen cigarette use, which is the dark green line, on a steady decline. Not a surprise to most people. In 2019, 5.7% of teens reported smoking cigarettes in the past month compared to 22.3% of teens reported using marijuana. About one quarter of teens reported vaping nicotine in the past month, which bears a mention. Though we've been talking about the increases in vaping marijuana and the increases in those reporting daily use of it, the overall rates of youth reporting last month, marijuana use, have remained relatively steady over the past 10 to 20 years. We have reason to be concerned about teens using marijuana. At the same time, it's really important to acknowledge that overall use has not seen a marked increase.Jenni Lane:How long will this hold? Each year for the past few years, I think we've been sensing and now starting to find in the evidence that general acceptance is increasing, and we expect that this will show up in the prevalence numbers. The graph on the last slide that we just saw represented past month use for all three age groups. When we look at the actual numbers in most of the categories, we see small increases that aren't statistically significant yet.Jenni Lane:I don't want to sound alarmist because this data doesn't support that. It's interesting. I find it kind of hard to square that the sort of general use is not really rising significantly, to square that with the normalization that seems to be happening among the youth and even the adults that I interact with and know.Jenni Lane:I'm going to share a few more quotes that illustrate youth perceptions of harm. "Marijuana isn't too, too harmful. They say it's a gateway drug, but I don't believe it's a gateway drug if you have the right mindset. I've done ecstasy once, but I've been smoking pot for a couple years now and nothing seemed to change."Jenni Lane:"I think the main argument that I usually have with people about weed is, not if it's addictive, if it's a gateway drug. I was always told that it wasn't and that everyone I met has smoked weed. They haven't started smoking cigarettes, haven't started doing any other drugs."Jenni Lane:"I realize it's not necessarily healthy for you to smoke, but when people smoke, they're not going outside trying to start fights with people. They're not driving insanely drunk. When I get high, I just want to sit there and have a good time. I want to laugh. I don't want to fight. I don't want to go rob somebody, or steal from my mom, or anything. It doesn't make me want to be a bad person."Jenni Lane:Then let's listen to this clip of youth talking about the comparison of the risks of alcohol and marijuana, which illustrates some of the conceptions and misconceptions about marijuana's effects.Speaker 1:Drinking and smoking are completely different because when you smoke, you're completely aware. You remember what you did when you're high and you know what you're doing when you're high, but when you're drinking, you... People do and say stupid stuff when they're drunk.Speaker 2:Yes, I agree with that. Like she said, people don't remember stuff. Hypothetically speaking, you could smoke 12 months or whatever, and you will still think before you act. If you drink so many shots, it's going to be a time where you remember the last thing you said, and you remember nothing after that but waking up.Speaker 1:Exactly.Speaker 2:Right. I don't understand. Yes, you still intoxicated if you smoke marijuana.Speaker 1:You remember-Speaker 2:It's not. It's not the same as alcohol because alcohol is literally taking you out of your body.Speaker 1:Alcohol can kill you. Alcohol poisoning.Jenni Lane:Hmm. Yes, there was a lot in there, right, and certainly some misconceptions about the potential harm. Okay. I'm going to move on to our clinical conversations. Let's shift gears. As I mentioned in the beginning, this is not a training on MI or SBIRT. We'll be looking at some of the core principles from these approaches and I think that through the lens of adolescent perspectives in a patient-centered way, to understand why SBIRT, and motivational interviewing, and strengths-based approaches might be most effective. I really want us to keep at the forefront what we mean when we're talking about patient-centered care with adolescents and why that is so relevant here.Jenni Lane:One thing that comes to mind for me is the platinum rule. Have you heard about this? It's the idea that instead of the golden rule, which says to treat others as you would want to be treated, the platinum rule asks us to treat others as they want to be treated. By centering youth voice and values and really listening to what they're asking for, we can be truly youth-centered and patient-centered. It happens that this fits perfectly well with motivational interviewing principles and strengths-based approaches. I also want to clarify that this doesn't mean that we are never sharing our concern or that we're not informing them about potential harms, but it means that we need to shift our messaging and our communication style if we want to help youth make positive change. I'm going to touch on just some of the key principles in the next slides. Again, rather than do a deep dive, I'll connect the approaches to what youth value and what they're asking for.Jenni Lane:SBIRT provides a structure that's ideal for brief visits, often where you have multiple other issues competing for limited time. Screening can either be comprehensive, like with HEADSS, or SSHADESS or RAPS, which is another comprehensive risk screening tool, or can focus on substance use, like CRAFFT. Using an MI framework for the intervention part is a really nice pairing. For referrals, it's important that you have an updated list of youth-friendly services in your community.Jenni Lane:Some considerations around screening that are really specific to adolescents... It's important to standardize screening, to remove stigma, and to avoid having patients feel singled out. I do this with all my patients or everyone fills this out. Oh, educating families and teens about the purpose and limits of confidentiality is a really helpful thing too, knowing what their rights and their limitations are with minors. Written information in exam rooms or letters to families explaining state mandates and clinic practices around confidentiality can be very helpful. Helpful to have clinic staff familiar with those confidentiality consent laws. Then AHI, where I work, at the Adolescent Health Initiative, I have a link at the end of the slides, has some short training modules for clinics called SPARKS with simple sheets explaining specific state laws.Jenni Lane:For the next few slides, we're going to focus on overall approaches to screening. One way to frame the strengths of adolescents' thought process is by understanding the role that risk-taking can play in adolescent development. This model that we're looking at comes from a 2017 review in developmental cognitive neuroscience describing how taking risks is a way for adolescents to better understand the world around them. Looking at the graph on the right, you can see how different types of risk change throughout adolescence. Known risks where you know the probabilities of your choices, like if you're asked to choose between getting $2 for sure or getting $4 versus nothing, keep declining throughout childhood and adolescence. This is that black line.Jenni Lane:Insensitive risks describe risky actions taken without thinking, kind of a sort of impulsivity. It's not seen in all youth. This is the red line. Ambiguous risk happens when the number, nature, and probabilities of the outcomes are less known, which help to encourage adolescents to explore new environments and to accumulate new experiences to gain wisdom. That might include something like trying a new drug or becoming sexually active.Jenni Lane:Another way to see the relationship between risk and wisdom is to plot it on a hypothetical graph like this, where essentially, the red exploration curve corresponds to risk, especially ambiguous risk, which rises and falls, and helps wisdom or knowledge that's gained from experience to increase dramatically during early adulthood. As we age, our cognitive control declines, which means also that we tend to make more decisions based on gist or feelings of risk, like going with your gut, rather than by rational thinking. Adults are also much more risk-averse or loss-averse than adolescents, which is a quality that can actually hamper effective decision-making in adulthood.Jenni Lane:The same inclination to take ambiguous risks and try a new drug or experiment with sex can be involved in other risk-taking that we generally think of as positive. I'm glad when my teenage kids are interested in taking risks, like doing a poetry slam or trying a new sport. I think of it as putting themselves out there. It feels really different to me when they take risks like vaping or smoking weed, and for good reason, but it's helpful for me to remember that it's developmentally appropriate, even if not healthy. The trick as a parent and often as a provider is to help young people channel their risk-taking and novelty-seeking into positive activities. I also think about the impact of COVID here and how much it has limited the types of activities that many young people can participate in, especially with youth-serving organizations being closed or only doing virtual programming, sports not happening in the same way. Just those outlets are just no longer there.Jenni Lane:This table here shows kind of a more traditional way of seeing something through a deficit-based lens and the comparison to taking a strengths-based approach. Just taking a look at some of these, like the idea of hanging out with the wrong crowd as a deficit-based way of looking at sort of a young person's experiences instead of identifying some positives, the supportive relationships they have with adults and peers and building on those is an example. Just for reflection, thinking about... What specific strengths do you like to recognize and build on? What clinical advantages do you see with using a strengths-based approach?Jenni Lane:In the interest of time, because I know we're really coming close to the end here, just some ideas for clinical advantages is that it can really help build positive communication skills with family and other supportive relationships. Protective factors significantly influence clinical outcomes of substance use disorders in teens. It supports growing ownership over health as adolescents transition to adult care.Jenni Lane:I mentioned this isn't an MI training. I just want to highlight a couple of things in the definition of motivational interviewing and encourage people to either do a booster course or get some training if you haven't already. The pieces that I want to tie into what we've been talking about, I put in italics here. It's designed to strengthen personal motivation and, let's see, for commitment to a specific goal by eliciting and exploring the person's own reasons for change, and within an atmosphere of acceptance and compassion, and a person-centered counseling style for addressing the common problem of ambivalence about change.Jenni Lane:All of these are helpful for people of any age. It's particularly helpful to think about how well suited this is for adolescent's developmental need. The need for individuation is at its peak. This might look like, "I want to make my own decision, even if I know it's wrong." Motivational interviewing allows us to help young people make their own decisions with guidance and care.Jenni Lane:Here's a quick case that illustrates what the tone of motivational interviewing is. Mark's friend brought him into the ED disoriented. They said he'd used dabs, became really out of control, and got sick, and tried to drive home. Mark was monitored and given supportive care until coherent." Here's one response from a provider. "It looks like you have a serious problem with marijuana. You say you don't use that much, but you're smoking so often you're unable to get up for school and feeling depressed. Those are signs of a problem. You are using way too much to try to cope with your depression. Your mom thinks you have a problem too. You'd rather watch television, and smoke, and deny that you have a problem. Sure sounds like drug addiction to me. How about you?"Jenni Lane:There are a few parts of this that stand out as the most cringey for me, like the, "Sure sounds like drug addiction to me." In general, I can imagine a provider saying this. It feels somewhat plausible to me, and not every part of this is wrong, per se. Let's compare this to a motivational interviewing approach. "Here's what you've told me so far. I just want to make sure I'm understanding you. You've had a few warning signs of sometimes using too much marijuana that scared you a little. You were also surprised that using marijuana could maybe make it hard to get to class, and even your depression a little worse. When you wake up in the morning, you often feel pretty bad: feeling down, nervous, like you want to use marijuana again to get through the day. What else have you noticed?"Jenni Lane:Thinking about how these feel to Mark, kind of putting yourself in the patient's perspective, and then adding the developmental layers of not liking being told what to do... I mean, no one likes to be told to change, but everyone wants to feel empowered and especially, teens are more likely to do the things that they say they're going to do when they have the chance to say it. Okay. Going to move on.Jenni Lane:Partnership and autonomy are really key parts of a motivational interviewing approach. Practicing partnership requires sitting on your hands and avoiding the expert trap, which is presuming your expert knowledge will solve the patient's problems once it's shared. We have to really watch out for that, with young people in particular. Autonomy conveys to the patient, "What you decide is up to you." Respecting a patient's autonomy means offering unconditional positive regard. It doesn't mean you approve or disapprove of a behavior.Jenni Lane:I think affirmations are sort of one component of motivational interviewing. I thought I would share a slide with just a few examples of affirmations, which are sort of like a mini version. They're really part of being strengths-based and a way that you can practice that. Here are some: emphasizing a strength, noticing a positive action, a statement of appreciation, a compliment, an expression of hope, caring, or support.Jenni Lane:I am watching my clock. I know we've got just a minute left here at the end. I'm going to go ahead. I know that these slides are going to be shared. I have quite a few with youth quotes. I'm just going to move through those and hope that if you want to see them, you can access them later. Provider talking points about messages for teens, that it is important to be able to do some of that education that I mentioned earlier is really kind of lacking right now. It's going to take a while for our schools to catch up to being able to really accurately, and appropriately, effectively do prevention messaging around marijuana.Jenni Lane:Here's some of the points that can be made in counseling about the impact on the brain. Alters the developing brain... We have research to support this. Has a negative impact on memory, concentration, and learning. This is with significant use. One thing that I think a lot of young people feel is that it helps with depression, and that is not the case. It can actually exacerbate depression and anxiety. Also want to acknowledge if a young person believes that it is helping them, it's not enough for us to just quickly arm them with the facts and say, "Well, that's not true." We want to acknowledge that that is their perception.Jenni Lane:The point about it being illegal is a point that will have some impact for some people and that young people should never drive under the influence or drive with someone who is under the influence, and that smoke is toxic. I have a final video clip I want to share with you from a young person. It's very brief. She's talking about all substances, but I think that this is really relevant here. I want to end with this.NM:When I was in middle school, someone who is really important to me started using a lot of different drugs, like weed and Xanax. I think for me, watching somebody who is so close to me, how that was sort of deteriorating his life and his interactions-Jenni Lane:Sorry.NM:With me, that was really hard for me. I think it's almost kind of... It sort of scared me from getting involved in any substances. Part of it was just seeing how whenever he was using, it made him really, just aggressive. He'd steal things, or we couldn't sit down and enjoy each other's company. That was also really frustrating, just to see sometimes, his other friends, how they'd be able to use with him. Then they'd show up to school, and they could go to class, and get a job, and go to college, but for him, that wasn't really a possibility. I think it's just been a constant reminder of how unfair and unpredictable substance use can be.Jenni Lane:I mentioned that I was going to close with that. I do have a couple slides left. I am going to stay on to answer questions. I appreciate going over a few minutes for anyone who has more questions and wants to stay on. I want to just acknowledge what's in the slides here, that the training resources about motivational interviewing and expert training, AHI's website. Then after here is the references page and then a closing slide, I'm going to put up there. for any of our free resources, posters... Everything is all free for download there. There's more training. There's one on adolescence and marijuana use there. Now I'll open it up for questions.NCTCFP:Thank you. We have a couple questions in our Q & A. The first one is, is there any research on whether the increasing potency of THC and wax/dabs, about 70 to 99% THC, is associated with the increased or decreased adverse negative events/harms?Jenni Lane:I have not seen anything in the literature about this. I also will say that I know we've got an audience here today with a lot of different areas of expertise and some who work in the field of substance use and prevention. If anyone has any information about anything in the literature, feel free to weigh in. I have not seen anything in the research. I mean, the research is scant. There is not a lot of literature out there about negative health outcomes, positive health outcomes for that matter, and medical benefit. There is some, but that's one of the repercussions we have of having had the restrictions on research for so long, that now there's just a big gap. I have not seen anything on that.Jenni Lane:I see another question. When it comes to language surrounding marijuana, do you feel the name matters? We find in Washington that using the name, cannabis, is considered more elite or even healthy, especially when it comes to shops, while marijuana is more reserved for the back-alley drug deal. It's interesting. I considered changing my references entirely anytime I use the term in here to cannabis, in part because I've read a couple of articles about the stigma that's associated with the term, marijuana, and the sort of history of the term, marijuana, used with either subtle or not so subtle racial undertones.Jenni Lane:You think about the term, cannabis, and a cannabis shop, you might imagine an Apple store or some of the higher-end uses that make it feel more socially acceptable and more elite, as this person mentioned. Yes. I think there are times that I have really tried to be mindful and just really use the term, cannabis. In this case, because marijuana is more commonly used and more of our young people were using the term, marijuana, is why I used it for this.Jenni Lane:Here is a question. What are your thoughts about tackling social norms as a way to combat youth marijuana use or drug use in general? For instance, similar to the data you showed, according to one of the recent national college health assessments, young people thought that only 9 or 10% of their peers had not smoked when reality, almost 60% of their peers reported not smoking. Youth often have a social perception that is skewed by popular media and can be corrected. The National Social Norm Center at Michigan State University has had success using this approach with drinking norms.Jenni Lane:I've also seen similar study about attitudes around sexual behavior and sort of the perception that more people are doing it or having sex, more of their peers are then are not, and that it may sort of increase the sense of pressure. I do think that tackling social norms is a way, is one of the multi-pronged kind of approaches that we need to take. I think I was really thinking, when I was working on these slides, about the trickiness of something that does not have one simple approach or way of sort of solving a problem of kind of what the young person said at the very end in the video of, we don't know who is going to have a harder time, or who's going to be more impacted, and become more habitual or disordered of a user than someone else who tries it recreationally and can be just fine. I do think that one of the approaches that we should be thinking about and talking about a lot is social norms and normalization.Jenni Lane:What are dabs? Somebody asked the question about dabs. Dabs... There was a brief slide early on, that they're small kind of concentrated balls of resin or wax that are heated up at a really high temperature with a blow torch and smoked. It looks kind of like a bong, like a water bong, but it's different. It's highly concentrated. Okay. My facilitator, Carissa, you've been so kind to help me facilitate here and for me to go over. I'm going to put your slide up now. Is there any other of kind of closing business that you have for our audience?NCTCFP:There is. Thank you so much. That was an excellent presentation. Unfortunately, it's all we have time for today. You will all see a survey upon exiting this webinar, so be sure to take that to receive your CE, which will come within three to four weeks. The recording with a transcript of this presentation will be available on within two weeks. We'll also send you the PDF of the slides and the survey link just in case it doesn't show up with a follow-up email. That's all. Thanks again. Take care, everybody. ................
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