Brief Interventions for Cannabis Use Disorders: The Check-Up Model



My name is Meg Bruner and I’m from the Northwest ATTC and I’m sitting in as your host today for Bia Carlini, who’s out of town. I’m excited to present to you today’s webinar: brief interventions for cannabis use disorders: the checkup model presented by Dr. Denise Walker. Before I introduce Dr. Walker I just wanted to quickly mention that our slides from and a recording of this webinar will both be available on our website by tomorrow. You’ll also be getting an email later today with a link to a survey about how we did and if you submit that survey you’ll receive a $5 gift card for either Starbucks or Amazon this time to thank you for your feedback. So thank you advance for your feedback as well! Okay so let’s get started. Denise Walker is a research associate professor — oops hold on slides not working there we go — Denise Walker is a research associate professor at the University of Washington, director of the Innovative Programs Research Group, and a licensed clinical psychologist.A main area of Dr. Walker’s research expertise is on the development and evaluation of interventions for marijuana disorders for both adults and adolescents. She’s been involved in the development and evaluation of the Teen Marijuana Check-Up, a school-based intervention to elicit self referral by adolescents who are heavy cannabis users. Another focus of her work is on adapting the checkup model for other high-risk populations including active-duty military with an alcohol disorder, active-duty military with untreated PTSD, and domestic violence perpetrators. Dr. Walker is gonna talk to us today about the checkup model for cannabis use disorder brief intervention.So I’m gonna transfer the slides over to you, just one second. Thank you, wow thank you for inviting me today. I’m really excited to talk with you about some of the research that we’ve been conducting, although I’m really hoping that the talk will be more clinically focused on brief interventions for cannabis use disorders that we’ve developed and sort of the types of conversations that we have with folks who are struggling with marijuana problems. I’ll use the term “marijuana” because I’m just more I’m just more used to using that, so through I’ll just use that term, it’s pretty much synonymous with “cannabis.” And just to let you know where we’re headed today, I’m gonna just briefly talk about why I believe brief interventions are really important for marijuana disorders. I’m gonna review a specific model called the checkup model for attracting voluntary participation into a brief intervention from folks, and then, again, I wanted to have a good section of this talk clinically-oriented, and I’ll just grab a two session motivational enhancement therapy intervention that we’ve developed for the teen marijuana checkup.So let’s get started. Um so you might know that folks who present to a substance abuse treatment facility are sort of rare and exotic gems, sort of like unicorn Pegasus, maybe a little bit more like Sasquatch or a four-leaf clover, because we do know that they actually exist. But for the most part we know that people who are struggling with a substance use disorder do not present for treatment, that 11% of the almost 20 million adults in the United States 18 and over who had a substance use problem did not actually access treatment or receive treatment. The numbers are a little bit better for marijuana disorders: 17% of Americans in 2013, of which that was the most current date I could get, receive treatment for a marijuana disorder but still not great right. So there’s 83% of our majority of folks who are struggling with marijuana are not accessing care. So why don’t people seek treatment, um, it could be that they are not interested in accepting a label, particularly if it’s a derogatory one. We know that stigma is still an issue with all sorts of drugs of abuse. There’s also a ton of practical barriers that get in the way for folks: finding a provider, figuring out how much it will cost and being able to pay for that, child care, how long is treatment, do they have transportation, there’s just a number of really practical things that get in the way of people accessing care.But I think one of the biggest ones, ooh, I’m sorry this slide is a little bit messed up, but basically I think one of the biggest barriers to accessing care is that most people, 95% that big huge blue piece of the pie, don’t actually perceive the need for treatment, so it’s — we know that ambivalence is a big issue with substance abuse and you can see it here that most people who are experiencing a substance use disorder don’t perceive them as having, being a good match for whatever they’re perceiving as treatment. And then by nature treatment facilities tend to be a poor fit for those who are ambivalent about their use or haven’t made a decision to change. So in addition, there may also be some concerns that non abstinence goals would actually be accepted if that’s what they chose to work on. So all of this suggests the need to develop and market interventions that reach more people and that also increase their motivation to change, and for the folks who are having a hard time making those changes on their own, interventions should also encourage treatment entry when it’s appropriate.We know that there are a number of different types of early interventions but most of them tend to operate in opportunistic settings, so, for example, SBIRT, or screening brief intervention and referral to treatment, is offered in a primary care setting, or these other types of, other types of opportunistic settings where there might be higher rates of marijuana disorders or substance use disorders within… sorry I didn’t move that slide and it look like it’s …Meg I’m having a hard time now. I got a slide — um yeah it says you lost control. Let me jump out again and go back in again, hold on a second, that’s strange, okay, so click on the slides again, yeah yes. Sorry about that. Okay, so earlier inventions tend to operate in opportunistic settings so they’re offered to people when they’re sort of screened for high-risk behavior such as in primary care or emergency settings or juvenile justice systems.There’s also earlier interventions that focus on working through a concerned family member to motivate a substance user into treatment, such as the intervention or community reinforcement and family training. The checkup model is really unique in that it’s one of the only models that directly appeals to the substance abuser themselves and is really intended to try to create, to decrease this gap between the number of people who are experiencing problems related to their behavior and the number of people who are engaged in treatment. And so the checkup model appeals specifically to the substance user and tries to elicit that self referral into an intervention-type experience, so it’s really focusing on individuals who are contemplating the effects of risky behavior but are not self initiating change or seeking treatment per se, and it’s designed to really increase their commitment to change, and it includes three things: an advertisement strategy that advertises the program to people, an assessment of the behavior and the risk factors that are associated with it, and an intervention, which for us usually means a variant of motivational enhancement therapy.So the checkup model again is really about decreasing all of the barriers that are possible to engage someone who might have questions or concerns about their use, but are not necessarily seeing themselves as treatment worthy, and it’s specifically targeting them so it attracts those who aren’t otherwise seeking treatment and the ways that which, in which it decreases barriers are: it is advertised as an opportunity to talk; it’s not called or labeled as “treatment;” it’s presented in a really non-judgmental, individualized way; it’s a personalized session that’s all about them.Of course these services are confidential but many of our checkups have also been offered anonymously so that people experiencing really stigmatizing behaviors such as domestic violence perpetrators can actually enroll in an anonymous wa. And then of course it includes the intervention. Motivational enhancement therapy, you might know, is a variant of motivational interviewing and the major difference between motivational interviewing and motivational enhancement therapy is that motivational enhancement therapy includes the provision of personalized feedback. So MET is used within the checkup model. The length of the sessions or the length of the treatment can be between one session and four sessions. Typically the delivery is in person or over the phone, but there are computerized and web-based versions of checkups as well. And the main counseling style that it dominates the entire intervention inside of motivational interviewing, so really using a style that is person-centered, non-judgmental, collaborative compassionate, uses a lot of strategies to evoke the clients own perspectives and own ideas about the problem, using open-ended questions and reflections, it includes the person — a personalized feedback report that’s based on the assessment that the person completes prior to the intervention.And personalized feedback reports often include things like normative data and summaries of the pattern of behavior that’s being targeted, consequences, risk factors for developing a problem, and we also include personal goals as well. The main principles behind a motivational enhancement therapy and the checkup is really to facilitate that candid exploration of someone’s substance use behavior or other high-risk behavior, and so the conversation oftentimes includes the discussion of the cost and benefits of the behavior and the impact of that behavior on their personal goals and their relationships, things that are important to them. There have been a number of checkup applications that, we’ve actually done most of these in our lab, but the drinkers checkup was the original checkup conducted, developed and conducted by Bill Miller at the University of New Mexico, and now there’s a few different iterations of that drinkers checkup available. We’ve done the work on all of the other checkups, and I’ll be talking a little bit about the marijuana checkup and the teen check up today but we’ve applied this to active duty military with substance use issues, domestic violence perpetrators, HIV risk behavior, and we’re conducting a trial now that has developed an intervention of, intervention for soldiers who are experiencing PTSD but not accessing care.So just to give you a little bit of a sense of the research on the adult marijuana check up, this is the first checkup model that was conducted in our lab and applied to, obviously, adults using marijuana and a problematic way. It was done by my colleagues Bob Stephens and Roger Roffman, and I’d like to show you some of the advertisements for this particular study because I think it gives you a good sense of what the checkout model is really all about. So as you can see the advertisement starts with a question, questions about your pot use, the marijuana check up, it’s for adults who have questions, it’s not a treatment program, it’s free and confidential. Another question: your marijuana use got you thinking? The marijuana checkup. That we address concerns and questions, no pressure to change, free and confidential. So right off the bat the advertisements are trying to differentiate this service from treatment, and it’s also trying to break down barriers that may get in the way of people accessing a conversation about their marijuana use, emphasizing that there’s no pressure to change, that it’s for people who have questions or concerns, it’s free, it’s confidential.The marijuana checkup study with the adults did indeed attract self referral from folks who were abusing and dependent on marijuana. Iit was a randomized clinical trial that included 188 adults and, of course, the overarching emphasis was to reduce marijuana use in ambivalent users. And what this study found was that, first of all, participants could be attracted into this service that were not treatment seeking, so they likely would not have sought treatment if the checkup intervention wasn’t available, and that the participants looked very similar in their marijuana use, their diagnosis, the problems related to their use, as folks who presented in our treatment studies. So they looked very much like a clinical population with a few exceptions. So the amount of problems that they experienced with regard to marijuana were fewer than the treatment seeking population, and they also met fewer dependence criteria, and of course, which makes sense, they were also lower in stages of change. The study did attract a lot of people, though, who had diagnoses for marijuana problems, so 89% of the sample met abuse criteria and 64% were dependent on marijuana. And what they found was a one session MET intervention reduced the days of marijuana use relative to the control conditions at early follow-up, so at second week follow-up, the differences weren’t evident between conditions at the six-month follow-up, but they were marginally significant at the 12 month follow-up. So there was hope that the intervention helped people change, especially in the short term and there was evidence that there were some lasting effects a year out.We thought, well if this works fine for adults what about for kids where barriers to treatment seeking are even greater? And so we developed a teen marijuana checkup. And with this, we really had to think through the application of the advertisement and the barriers that might exist for kids using marijuana problematically. So one of the things to make it easier again for people to participate in an intervention like this is that we thought we should go to where we thought kids were, so we brought the checkout model into the schools, they could participate in the checkup and the MET intervention within school, within the school day. The sessions were individual again, so nobody else needed to know that they were in the checkup at the school.A lot of the same components that were used in an advertisement for the adults were used here so it was emphasized that there was no pressure, no judgement, that it wasn’t treatment, it was a low burden, so it was a brief intervention, they were committing to 2 sessions, not 12 weeks of something, and we also thought that not requiring parental consent would be a huge advantage to helping people say yes to engaging in the checkout. The recruitment approaches needed to be modified because we didn’t think that newspaper or radio advertisements were quite gonna get the same response as an adult population, so we did a number of different things that were focused on the school. The main recruitment an advertisement strategy was we developed a classroom presentation that reviewed the myths and facts of marijuana and included the kids in a conversation about that, and at the end of that presentation, we described the teen marijuana checkup and its availability at their school. At the end of the presentation, everyone was given a piece of paper to jot down some notes about what they liked or didn’t like about the presentation, and all the kids were told that if they were interested in hearing more or participating in the teen marijuana checkout that they just write their name on this sheet of paper.Everybody folded up their papers and sent them to the front of the classroom, where that was a really easy anonymous way for them to signal to us that they were interested in participating in the checkup. We also did information tables at lunch and recess. We got referrals from school staff, kids would self-refer based on posters or flyers that they saw on campus, and then a lot of our participants refer their friends, so we got a number of participants in the teen marijuana checkup studies based on word of mouth. At this point we are in our fifth clinical trial for the teen marijuana checkup, that we’ve completed 4 clinical trials, three of which were randomized controlled trials, and overall these studies recruited over 700 teens across the 4 trials, to volunteer to participate in this marijuana intervention.So there was a lot of really good evidence that it can attract self referral from kids who were using heavily marijuana and the sample that we attracted was indeed heavy-using. They looked very, very similar if not more severe than the treatment populations that are described in the literature for marijuana in comparison to like the marijuana abuse and dependence diagnosis, but also with regard to clinical severity, internalizing and externalizing symptoms. And 89% of the samples tended to not have any experience with substance use treatment prior to their engagement with us. And what we found over the course of these trials is that a two session motivational enhancement therapy reduced marijuana use more than an educational control or a delayed control condition. When we offered abstinence based treatment, those participation rates seem to be pretty low, but again a two session intervention had a significant effect on reducing their marijuana use and related problems. So the next part of the talk today, I was just hoping to give you a sense of what is actually included in these intervention sessions, and I’m hoping that even if you’re not doing a check-up model specifically that some of the ways that we talk about marijuana might apply to you and your clients within a treatment setting.So the teen marijuana checkup, again, I’m going to use the teen marijuana checkup as the dominant example and show you what the personalized feedback report looks like and also the first session, I know, can look like, but remember that it includes an assessment which, with regard to the teen marijuana checkup, is a pretty brief computerized assessment where the kid answers questions about their marijuana use and related problems. And then it also includes two intervention sessions conducted by a counselor. The first session is pure motivational interviewing and the second session includes the provision of the personalized feedback report. So session 1: the whole idea is really to engage the kid or the client in a conversation about their marijuana use dominated by the youth of those motivational interviewing skills. So we’re engaging, we’re invoking from the kid their perspective, their experiences of marijuana so far, how it fits into their life, how they’ve been affected, and so again you’re using, you’re setting an environment that is non-judgmental, non confrontational, very affirming, that really focuses on the use of open-ended questions and reflections, to get the kid talking about their experience and to also decrease any defenses that they might have around being concerned about someone telling them what to do or giving them information that might be in contrast to how they’re feeling about their use.Some of the ways we start out a session are just asking them, you know, what got you interested in talking to us about your marijuana use and following that up with a lot of reflections, but then also just getting kind of into the meat of their own story. “Today I’d like to learn from you in your own words what your experiences have been like using marijuana. We know that it’s different for different people and I’m really curious about how it fits into your life.” So again that type of an open-ended question is really an invitation for them to share with us what’s going on with them and for you to reflect what you’re hearing and to help continue to deepen that exploration of how their use may be affecting their life. Other questions that we ask are “I’m curious how you started about using started using marijuana and what’s changed since you started.” So oftentimes people have different relationships and are engaged in different activities prior to marijuana use than they are when they’re using regularly.”Has that been — what, you know, what’s that been like for you? Tell me about some of the things that you get from using or what are some of the positive things?” So pretty early on, once you get a sense of how marijuana fits into their life, what it’s like in their typical day, what sorts of things are they getting from it, then you can kind of go into a pros and cons exercise starting with the pros again to decrease defensive notes, and, but definitely asking about the other side and being really curious about that. “What aspects of marijuana don’t you like? If you had a magic wand and could erase the negative parts of it, what would you erase?” Throughout the conversation, you’re thinking and keeping your eye, your ears really sensitively tuned for hearing that change talk in whatever form it could come from your client.So just as a reminder, change talk is really any statement that a client says that is in favor of change. And we think about it — when I’m training my counselors they talk about it in a bunch of different categories — but any desire to change or quit their use of marijuana, any statements that speak to their ability to do that, any reasons they have for quitting. So “I really like using marijuana, but I don’t like it if it in turn interferes with my soccer or my grades” — those are, that’s change talk.So you can directively look for change talk in those conversations that you’re having and also thinking about: how can you develop any discrepancies that they might be voicing that show a difference between their ideal self, what they want to be, who they want to be, and what they’re doing with regard to their marijuana use? So for an example, “You’ve mentioned that school is really important to you and you’re a good student and that you are really disappointed with your grades last semester. I’m curious about what you think about that and what role marijuana may have played in that?” Also just being aware, definitely be thinking about reflecting that ambivalence. So it is natural before someone makes a commitment to change a problematic behavior that they feel two ways about that, and with kids and marijuana use, they definitely do. There are oftentimes things that they really like about their use and will miss about their use if they make a change.So being able to be attuned to that and reflect it. An example is: “You enjoy the effect weed has on you, of making you feel more comfortable, not as anxious in social settings, and at the same time you’ve noticed feeling more like you need weed these days, and that doesn’t feel great to you. So tell me more about that.” So again you’re reflecting the ambivalence and then invoking more of it by asking for more details. Within session one, you’re also keeping their ears tuned in for what is really important to the client, what are the their core values and how are those or how are they not affected by their marijuana use. So look for opportunities to connect what the client values with their marijuana use.Oftentimes we’ll hear kids say, “I feel so guilty when I lie to my parents.” So a nice reflection to that might be, “You want to be an honest person and pot is getting in the way of that.” We oftentimes hear about kids wanting to set a good example for their siblings and really emphasizing that, “Your family is important to, your brother is important to you. How does the marijuana fit into you being a good example for your little brother?” Other really standard motivational interviewing techniques that we can rely on in session one are kind of like that “looking back” exercise: “So what’s changed since you started using regularly?What did you use to do that you’re not doing anymore? Who did you use to hang out with that you’re not hanging out with more anymore? What do you like about those changes, what do not like so much about those changes?” And also kind of the contrast, “Envisioning the future, if things stayed the same and you continue to use marijuana every day, where are you gonna be in a year or two years or five years?” Another example of that might be, “Right now you feel comfortable with your marijuana use but what the warning signs be that you might want to make a change? What would your marijuana use look like if you decided, look, I got a, I’m gonna do something about this, or I need to, I need to quit, or I need to make a change.” So helping them think through proactively before it even happens what some of their limits are around their marijuana use or what it they want their limits to be.Self efficacy is also a huge area to be thinking about and trying to help reinforce that sense of self-efficacy within our clients, and marijuana clients are no different. So you can do that in a number of ways: through the use of evocative questions and really thinking about past experiences with quitting or taking a break from marijuana, “So how’s it gone when you tried to quit in the past? What was that like? Has there ever been a time when you’ve taken a break? How did that go? What skills did you use?” those kinds of things. “You’re clear that when you’re a mom, you don’t want to smoke. I know that’s a lot, you know, pretty far in the future, but how will that change happen when it needs to? How will you make that happen?” Using affirmations also can be a nice way to enhance self-efficacy.Thinking about, if they’ve talked about past experiences where they have taken a break from marijuana and were successful with that, really being able to emphasize the skills that went in that. “You have a lot of experience with what works and doesn’t when you’ve tried changing in the past.” Or “You’ve really been thoughtful about how you want to limit your use.” Anything that you see as a strength in that person can be used in a reflective affirmation.Also just the idea of thinking through what kinds of social support they have or would likely need to generate to make a change in their use happen. “So who will you look for when you make this change? How will they respond and how will it help?” So again session one is really about how providing an environment where the kid or the client is not defensive about their use but is really free to think clearly and thoughtfully and deeply about their marijuana use and think about it from all sorts of different perspectives and all sorts of different topics in their life, relationships, values, goals, how it fits into their day-to-day, what they like about it, what they don’t like about it. And getting a really clear picture of what it’s like for them. All the while, emphasizing that change talk, affirming, enhancing self-efficacy, or when they do, or if they do, decide to make a change.The second session continues on to use all of those motivational interviewing skills that we’ve already discussed, continues to build that rapport, provides some type of reflection on what you learn from them last session, and maybe summarizes some of the things that they are, some of the reasons that they’re using, but also some of the places where it’s been a bit of a rub, and they may be motivated to be thinking about changing. And then you can introduce the personalized feedback report. The personalized feedback report is created automatically through a system based on their assessment results. So there’s a computerized, there’s actually a web-based assessment that kids can use, and then it will automatically generate a personalized feedback report. You’ll notice that there’s no name on the personalized feedback report, so that it’s just another confidential way to keep their privacy, the kids are identified by a random number. And again all the answers are personalized based on the participants responses.So oftentimes I’ll introduce the personalized feedback report as in kind of this way, I’ll say, you know, “Last session I learned a lot about your use. I learned about what you get out of it, what you don’t, some of the places where you’re less satisfied with your marijuana use. The personalized feedback report is really generated based on all of those assessment questions that you completed on my computer, and it’s really designed to just help us kind of dig a little bit deeper and look at marijuana use from perspectives or ways that oftentimes just don’t come up in a normal conversation.” One of the first pages that we talk about reviews sort of, again, their pattern of use. And we report how old they reported they were when they first tried marijuana and then we provide that first piece of normative feedback.So this page, I might say, introduce it as, you know, “This really summarizes what you told us about your use pattern. And some people are really interested in knowing how their use compares to other people their age. You said that you first tried using marijuana when you were 12 years old and when you compare that to national data in the United States, only 1.4 percent of 12 year olds have ever smoked marijuana. So, what do you make of that?” And again whenever you’re going through a personalized feedback report, the personalized feedback report is a tool, it’s not the thing that has to be focused on, but it should be a tool to help you, again, really deepen that conversation and their perspective and their awareness of their use.So use it in that way and it’s not just about giving information, it’s really more about getting information and getting their perspective and their reactions to the information. So I want to know what the kid is thinking about themselves being only 1.4% of American 12 year olds having used marijuana at that age. I want to know what they think about that, how they’re processing that all of that. We also talked about when they started smoking regularly, which we define as 3 or more days per week, and we go into normative data that’s more up-to-date. So I’ll introduce this section oftentimes as, you know, “People oftentimes really think it’s interesting to know how their use compares with other kids their age and in their area, so this normative feedback shows you where you are in comparison to other students your age in King County, and what you reported was that you used 15 days out of the last 30 days of marijuana, and when you compare that to other kids your age in King County, we see that 82% of kids have not used marijuana in the last 30 days.And the piece of the pie that you might be more close to, that 10 or more days of use in the past 30, only 5% of kids in the Seattle area are using at that level. What do you make of that? And again, really engaging from them, inviting them to engage with the material and react to it and think it through. And all the while you’re reflecting and particularly looking for change talk. We also have a section that specifically focuses on school, so I want to know, you know, how often they’re using before school how, often they’re using while at school, because that can generate a question a host of questions and a topic of conversation about how marijuana fits in with their education, with their schoolwork, with their responsibilities at school.We also ask them how much they spend, so how much literally are they investing in marijuana per month, and then we take that monthly estimate and multiply it by 12 to get a yearly estimate, and then the personalized feedback report puts that into how many of certain items that kids often buy they could buy with that yearly money. So here this kid is using $40 a month that translates into about $480 a year which translates into buying around 370 iTunes, 7 pairs of Nikes. So again using that information to get their reaction, “What do you think about that amount? What kinds of things are you saving for? What kinds of things are you hoping to buy in the near future? What else could you spend that money on?” When we developed the personalized feedback report, it was based on the DSM-IV system, so there are two pages: one page goes other abuse symptoms, and one page over dependence symptoms.We don’t call them that, we call it “marijuana use can lead to consequences,” because we try to avoid labeling, but here’s basically the abuse symptoms page, and anything that has a triangle by it, that kind of the warning triangle sign, is one of the symptoms that the kid specifically endorsed. So using this page to really hear about any consequences that they have experienced as a result of their marijuana use is really important. So being able to review that, you know, “Sometimes people have consequences related to their use of marijuana. Some of the things that you reported are, you know, it, marijuana kept you from meeting your responsibilities at home, at school, and at work. I’d love to hear from you what that looked like. Tell me a time when marijuana use got in the way of your work.” And so throughout this page, you’re giving them feedback but you’re really getting, it’s an opportunity to hear more details, more specific examples about consequences that they’ve experienced related to their marijuana use. This is the dependence page, and we give them a little bit more candid feedback. We don’t, again, use this, the label of marijuana dependence or marijuana disorder, but we talked about these consequences as red flags for marijuana use becoming a habit.Anything that they have endorsed in their assessment has a red flag next to it, and so again, I’ll be really curious to hear from them, “Oh you know you spend a lot of time either getting marijuana, using marijuana, feeling the effects of marijuana, or waiting for it to wear off. Tell me about that? How does that fit into your life? What’s that been like for you? Give me example.” And so again getting a kid to talk about and really process what kinds of consequences they’ve had as a result of their marijuana use and what they think about. We do give them specific feedback about how many red flags they’ve had and their risk for developing a habit on marijuana. We ask about alcohol and other drugs and have them talk about how marijuana may fit into or not their use of other substances. And then this is specifically an exercise that you do with the kid during the session. So there’s nothing pre-populated based on the assessment but it’s an exercise that you complete with them in the session, and there’s a page for it in the PFR . So we say, you know, “Being a teen is hard. We like to kind of take some time to identify people who are important to you and who you can count on for support. If you could just take a few minutes to write down the names of three or five people who you turn to when you need some help or who you can depend on or trust.” So they do that and then you ask them these other questions: so does this person know you smoked marijuana, yes or no, and then how does that person or how would they feel if you knew if they knew about your marijuana use? So this is an opportunity to really dig in deep about the people that are important to them and how marijuana use fits in or is in contrast to their relationship with those people.The goals is the last section of the personalized feedback report, and they have identified goals within the assessment that they are working on in the near future. And so the goals are pre-populated, but the exercise that you complete with the kid or with the client is, “How does your marijuana use affect that goal, the achieving of that goal? And how might reducing marijuana use affect your ability to meet that goal?” And so again, rating those, but then having that conversation, using lots of reflective listening and lots of open-ended questions, to have them tell you how marijuana use really does fit in with or not with the goals that they have for themselves. So you know I went through a lot of that pretty quickly but just to summarize some of the points that I was trying to make today: it really is important to think about creating models that capture that far majority of folks who are not accessing care but are using heavily and problematically.We need to be focused on developing those alternatives and promoting self-referral to these types of interventions. The checkout model is a viable method for reaching clinical populations who aren’t seeking treatment, and we’ve seen this applied in our own lab to multiple different populations with multiple different risk behaviors. It does attract voluntary participation, particularly from marijuana users, and it has an impact on behavior change, so it promotes reductions in use, it promotes the reduction of associated problems. The effects are small to moderate, that is absolutely true, and that is true of the treatment literature as well. So even longer doses of full-on treatment with treatment seekers, the effects tend to be small to moderate. We also have successful adaptations for the checkups for the phone, the web, but these interventions are not widely available. So I think it’s really up to us as clinicians but also policymakers to really figure out how we can create more of these opportunities for people. And then just two seconds, I know I’m kind of out of time and I want to give you opportunity for questions but two seconds just to say I know we’ve covered a lot really within the checkup model but that motivational enhancement therapy is what I really presented throughout this, and that regardless of who you’re working with, motivational enhancement therapy is the most widely studied intervention for marijuana disorders across the board for adults, for adolescents, for non- treatment seekers, for treatment seekers.So I’m hoping that there are things that you can use in your daily practice regardless of if you’re implementing the checkup or not, the principles and the interventions around motivational enhancement therapy look the same if you’re doing the checkup, if you’re doing it as a pretreatment intervention, if you’re doing it as a standalone brief treatment, which it has been evaluated as, or if you’re doing gold standard marijuana treatment, which is a combination of motivational enhancement therapy, CBT, and contingency management. We’ve also looked at motivational enhancement and applied it in aftercare for marijuana disorders. I just want to acknowledge my colleagues who I’ve done a lot of this work with, and also alert you to our website, the Teen Marijuana Check-Up Resources. You can find, you can basically have access to the assessment the web-based assessment and PFR creation tool for free by accessing that website. And you can contact us if you have any questions. Okay great thank you so much Dr.Walker. I’m gonna take control back. So before we do questions I just want to remind everyone that you’ll be getting a link in an email today asking you to complete a survey and for those of you that attended this live, we’ll be incentivizing those surveys this time with a $5 gift cards. Slides and a recording of the webinar will both be up on our website by tomorrow at the latest, and I’ll send a link in that email today as well.Okay so if you have questions please type them in the chat box, and we have a couple already. So Dr. Walker, one question is: I’m curious if you have any ideas about how to secure funding to provide these services to the community, like what might be a good way to pitch this to county school districts etc.? Wow, that’s a great question. So the current TMCU trial right now is really focused on dissemination, implementation and I think that the checkup has the potential to be to be implemented like in a statewide hotline or helpline. You might know, I don’t know what state you’re from, but in Washington the original intent of the legalization initiative included reserving money for prevention and treatment and this — creating some type of a hotline and advertisement strategy that could be rolled out across the state and delivered over the phone would be a great use of those funds. It hasn’t been realized yet, and a lot of those funds have been recaptured by the legislature, but um that might be one idea for trying to implement this at a really big level.Okay another question: what was the process of getting the teen checkup project cleared for use without parental consent? Yes that’s a great question. So I don’t know what state you’re in, but Washington State kids can consent to their own treatment, mental healthcare treatment, at 13 or above and they can do that without parental consent. So we argued that the teen marijuana checkup was basically in that same thing, that by participating in the research they were consenting to their own intervention of sorts, and that that would be required or would be allowed by law in Washington State. Another question: in my rural area I can see controversy if the report says the teen is low risk for problem use, for example, giving permission to use. Is this a problem with acceptability? Yeah, that’s a good question too. So we only included kids in our study that were using a little more than weekend use, so basically nine or more days out of the past thirty.So um I actually don’t think that there was a low risk category everybody at least scored moderate because by nature if you’re using as an adolescent, you’re at risk for developing a marijuana problem as an adult, you’re at greater risk, excuse me, so we would probably never give that message, that someone was at low risk for developing a problem. I don’t even think that’s a category within the person’s feedback report. It’s either moderate or high. Interesting. Okay, could this be used in addition to ongoing mental health therapy we are doing with our clients? Didn’t know if this works best for clinicians who are primarily working with teens on their substance use only.Yeah well I think that’s a great question um one of my one, well my current project director on our current TMCU trial right now also has a private practice, and she was a counselor in one of our previous trials, so she conducted a lot of teen marijuana checkups. And in her private practice she sees a lot of young adults and teens for a variety of problems but oftentimes presenting for anxiety or relationship or you know other depression, other mental health concerns, and oftentimes it’s uncovered that marijuana use is a, is an issue for them as well. And so she regularly sort of will take a break and ask them if it’s okay to do a few sessions focused on their marijuana use to explore that area, and she’s had a lot of success with that. So I don’t see why it should be siloed to substance abuse professionals only, or for people who are only working on substance use, because I think we know that you actually are probably more likely to get substance abusers in other mental healthcare or that it definitely is an issue with people who are presenting in other ways other than their substance use, and I wouldn’t want them to have to go somewhere else to get that care that they need when it might decrease the chances that they could actually go and do that.Interesting okay so we have someone who is a member of an adult drug court team and they are saying that they have many participants who self medicate using marijuana for various reasons including pain management, stress and anxiety reduction, and transitional drug abuse. They ask, what comes to mind for effective techniques for us to use in this treatment and problem-solving court? Yeah anxiety and sleep are the two biggest things that we hear from our kids, and some of the ways that we will have those conversations are, you know, you’ve talked about how you use marijuana for your anxiety.Let’s, if it’s okay with you, let’s look at what the symptoms of anxiety are and then, you know, we might do that. So the symptoms of anxiety are irritability and anger and feeling key up and problems with sleep and general you know restlessness. Okay so now let’s look at the marijuana withdrawal symptoms — they’re basically the same. So do you know for sure that you’re using your marijuana to relieve your anxiety or are you relieving your withdrawal because marijuana works perfectly for relieving withdrawal, but it’s not always a perfect solution to anxiety.And so sometimes we’ll do sort of some of that discovery, so I did it in a really quick way not very, you know, that you would want to evoke from them and kind of talk clearly about contrasting the symptoms of anxiety with the symptoms of withdrawal, and trying to think through “how do you know that that’s what you’re doing and how do you know that it’s not the withdrawal that you’re actually trying to medicate yourself with?” And have candid discussions around that. And similar if things happen with sleep, right, so marijuana has been shown in research to help people get to sleep, so to fall asleep, but it interrupts with their REM cycles, and so the quality of their sleep tends to be poorer over time.Plus they’re developing a tolerance to that effect, that to be able to get to sleep by using marijuana, so you get into these like conundrums with marijuana and having a really kind of like transparent candid conversation with kids about, “okay so it might be helping you fall asleep but it may actually be decreasing the quality of your sleep and making you more tired generally over the course of the day and then you’re, the fact that you’re gonna need more and more marijuana to get yourself to fall asleep or have that effect is putting you at risk for developing a habit with marijuana.” So kind of having again just that conversation and candid way. Of course, with sleep too one of the withdrawal symptoms from marijuana is sleep problems and really weird dreams. So again marijuana has this funny relationship with both like anxiety and sleep where it really can perpetuate problems rather than solve them. Interesting, okay, one last question: this person is asking is it a bad idea to discuss legal consequences and facts regarding underage use of marijuana?Bad idea? I don’t know that I would say bad idea. I think that with any conversation around marijuana, it’s about the delivery.So legal consequences can be a huge motivator for kids to steer clear or moderate their use or use in more healthy, well for adults, more healthy ways, right? So the way that I address legal consequences is I’ll try to evoke from them, “What do you know about some illegal consequences of marijuana use? What do you think could happen? What are the legal ramifications of getting caught as a minor with marijuana in your system or with it as a possession?” And so I’ll want to know from them what they’ve heard and oftentimes it does feel like kids are becoming better informed about what some of those consequences are and then just talking about, so, “What would happen if that were, you know if you were the one that were, got caught with that? What would happen if you got you know a driving under the influence ticket because you had any marijuana in your system, you don’t even have to be high at the time.But what does that mean for you? What would that do to your football career or your chances of getting into the college of your choice, or how would that affect your relationship with your parents, that you’re really concerned about?” So it’s just more about again using it as another topic of conversation to explore so that you’ve really got a full understanding of how marijuana is affecting lots of different areas of your life and potentially your future, and doing it in a really non-judgmental, curious, evoking kind of a way.Great all right. That’s all our time for today. Thank you so much, Dr. Walker, that was really interesting. Thank you for having me. All right have a great day everybody! Thank you! .

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