Twelve years after Washington and Colorado became the first states to legalize recreational marijuana, it’s safe to say that weed is here to stay. report using cannabis in the last month, and believe marijuana products are safe.����

When it comes to the safety of long-term marijuana use among the general population, the jury’s still out. But there are some groups for whom cannabis poses a serious health risk. Among the most vulnerable are young adults with psychosis, who tend to use cannabis at extremely high rates, and whose symptoms can be exacerbated by long-term marijuana use. A team of 91̽�� researchers is focused on this particular group.��

To effectively treat these patients’ symptoms and improve long-term outcomes, it’s critical for providers to help young adults as quickly as possible after their first psychotic episode. But that’s proven tricky. Current best practices aren’t always effective for young adults with psychosis, who tend to use cannabis for different reasons than their peers and who may feel different effects.��

That leaves mental health care providers with a difficult problem: How can they best discern why their patients use cannabis, and what’s the best way to help them stop?����

91̽��researchers and from the School of Social Work, and , an associate professor in department of psychiatry and behavioral sciences in the 91̽��School of Medicine, studied and then developed a novel treatment method. A pilot study of 12 people showed the method to be effective, though final results have yet to be published. 91̽��News sat down with the research team to discuss their intervention and why it’s so important to help young people in this group cut down their use.��

Cannabis use is increasing across the board, but the numbers are staggeringly high among young adults with psychosis – you cite statistics estimating that 60-80% have used cannabis at some point in their lifetime. What makes a person experiencing psychosis so much more likely to use cannabis?����

Denise Walker: Many people were probably using cannabis before the onset of their psychosis symptoms, because there is strong research evidence that cannabis increases the risk for developing psychosis-related disorders. For those who do develop a psychosis-related disorder like schizophrenia, continued cannabis use impedes the recovery process and makes outcomes worse. There is still a lot more to learn about the cause and effect of these relationships, but cannabis does seem to have a unique relationship with psychosis.��

Ryan Petros: In addition, there is some evidence to suggest that people with schizophrenia are more prone to feeling bored than people without schizophrenia. In general, a lot of people use cannabis because they like it, and they find the associated high to be fun. It may be that people with schizophrenia-spectrum disorders are more likely to use cannabis to have fun and feel good because they are more likely to feel bored and less likely to feel pleasure in everyday activities. But the fact of the matter is, we don’t really know. Another reason that people use cannabis, in general, is because it facilitates social interactions or provides a shared activity in social settings. Because people with schizophrenia-spectrum disorders have smaller social networks and fewer social engagements, it may be that they use cannabis to facilitate improved social interaction, but here again, we need more research to know with more certainty.��

At the heart of all this research is the different health risks of cannabis use for people with and without psychosis or other mental health challenges. What are those differences, and why is cannabis use among young adults with psychosis particularly concerning?��

RP: For people with a psychosis, cannabis use is associated with higher rates of dropping from treatment and decreased adherence to medication. It leads to increased symptoms of psychosis and higher rates of psychiatric rehospitalization. In the long –term, cannabis use increases the risk of poor psychosocial outcomes and diminished overall functioning.��

DW: Essentially, continued cannabis use makes it much harder for young adults with psychosis to take advantage of treatment, make strides in their recovery and, ultimately, get on with having the life they want.��

RP: Another major reason for concern is that not only is cannabis use on the rise, people also have progressively adopted more tolerant attitudes toward cannabis. Cannabis has recently overtaken alcohol as the drug most often used on a daily basis in the United States. While some people can use cannabis without a problem, it’s recommended that some others abstain from using at all.�� Over time, however, people have come to believe that cannabis use has health benefits, and they are less likely to perceive risks of use. This may result in a particularly challenging set of circumstances for helping someone with psychosis to learn about the real risks that cannabis use has for their health and wellness and to make the choice to reduce or abstain from use.��

DW: I agree. Perceptions surrounding cannabis are often polarized – it is often viewed as either “good” or “bad,” when in reality, it’s somewhere in the middle. There can be benefits for some to use cannabis and real risks of harm for others. These mixed messages, or at least the lack of acknowledgement of harms, contribute to continued hardship for those experiencing psychosis and their families.��

What methods are currently recommended to help people reduce their cannabis use, and why might those not be as effective for young adults with psychosis?����

DW: The gold standard treatment includes a combination of motivational enhancement therapy (MET), cognitive behavioral therapy (CBT), and contingency management. Contingency management is often not available in the community, and studies show that MET plus CBT perform almost as well. Because it is normal for motivation to wax and wane for someone contemplating changing their cannabis use, MET addresses the issue of motivation early on. CBT teaches skills to avoid drug use, cope with social situations and negative moods, and solve problems without the use of cannabis. Family therapy is another option with strong support.����

The big problem is that we don’t know if these treatments are effective for young adults with psychosis.�� MET is the most studied intervention in cannabis treatment, alone and in combination; however, it has not been tested with young adults with psychosis.�� With a few optimizations, we believe that it could perform even better than with the general population, and we have begun to test it with young adults with psychosis.��

Your team has developed an intervention for young adults with psychosis that incorporates MET. Can you describe what that intervention looks like, and why it might be more effective for this population?����

DW: MET is a person-centered, nonjudgmental approach that facilitates an honest and candid discussion about cannabis use. The techniques are intended to draw out the individuals’ personal reasons for making a change and to grow their motivation to do so. Individualized feedback is created based on a client’s responses to an assessment of their cannabis use and related experiences and summarizes information about their cannabis use patterns, how their cannabis use compares with others, and their risk factors for developing a cannabis use disorder. It also provides an opportunity for clients to think about their personal goals and how their cannabis use promotes or detracts from their ability to attain those goals.����

When we asked young adults with psychosis what they wanted in a cannabis intervention, they were clear that they wanted an individualized and nonjudgmental approach. They also said they wanted accurate and science-based information about the relationship between cannabis and psychosis. MET ticks those boxes. With a few adaptations, it is an ideal format for providing objective information, while also inviting the young adult to talk it through and consider what the information means to them personally.��

Currently, providers are giving the message to patients that cannabis is harmful for those with psychosis, which is a great start.�� But most providers don’t feel confident discussing why cannabis is harmful and what the research has found.�� My sense is that patients often take that message and defend against it with their own personal experiences of what they like about cannabis. MET offers an invitation to receive and discuss objective evidence, consider their own experiences of how cannabis affects their symptoms and what they want for their future, and do so in a supportive environment that allows for looking at their use from a variety of perspectives.������

You ran a pilot program to understand how the new intervention works. What did you learn in that pilot study?����

DW: We adapted the MET intervention to include personalized feedback on the interaction between cannabis and psychosis and included some graphics and ideas about ways to reduce those risks in addition to abstinence. Twelve young adults experiencing psychosis who used cannabis regularly enrolled in the study and were offered the intervention.��Most of the participants were not interested in changing their use of cannabis at the outset of the study, and by the end, several chose to reduce their cannabis use.��

Overall, the feedback was very positive. Participants overwhelmingly said they would recommend the intervention and would retain the psychosis specific pieces of the conversation. They appreciated the data that was included and the opportunity to discuss what it meant for them. They also said they enjoyed talking about how cannabis fits into their larger life and goals for the future. Overall, the feedback suggests this intervention has promise and should be studied in a larger trial.��

Maria Monroe-DeVita: My long-term goal would be to offer this new intervention either in addition to, or integrated within, the evidence-based package of services known to work best for individuals experiencing first episode psychosis.��

is a research professor in the 91̽��School of Social Work, is an associate professor in the 91̽��School of Social Work, and is an associate professor of psychiatry and behavioral sciences in the 91̽��School of Medicine.����

For more information or to reach the researchers, contact Alden Woods at acwoods@uw.edu.��

As the war in Afghanistan enters its 17^th year – it’s often labeled America’s longest war – an estimated have post-traumatic stress disorder.

But PTSD symptoms of anxiety, sleeplessness and anger aren’t, of course, relegated to those who served in the Middle East, or even in combat. Veterans have a than the general population, among which an estimated 7 percent will experience symptoms at some point during their lives. Research has shown, too, that service members have a than those without military experience.

Yet many service members don’t seek help, because they think it’s unlikely to work, they fear damage to their career, or they simply don’t know where to turn.

Now the 91̽�� is launching a study to identify soldiers experiencing post-traumatic stress symptoms and to determine whether free, confidential, over-the-phone counseling can help them navigate resources and spur them to seek further support.

is recruiting active-duty personnel to participate in the study, which involves three counseling sessions over two months, as well as four follow-up assessments within the first six months, all by phone.

“There are a lot of barriers to seeking care in the military,” said , a research associate professor in the 91̽��School of Social Work. “Soldiers are worried about it going on their record, losing their security clearance, or risking a promotion. But with PTSD, like substance abuse, if you seek treatment earlier, you can get your life back sooner.”

In recent years, Walker led a similar 91̽��study involving soldiers, known as the , which used a phone-counseling intervention to address excessive alcohol use. Participants in that study cut their drinking in half by the end of six months – an example of a “self-change,” in which a person can take action to adjust his or her own behavior.

“In this trial, the target is different. The ultimate outcome is for people to seek additional resources and to resolve their ambivalence about doing that. If they could just stop having PTSD, they would have done so,” explained Walker, who is leading the study with , a 91̽��professor of psychiatry and behavioral sciences.

“This is an opportunity for them to talk about the symptoms related to the traumatic event, how that experience has gotten in their way, or is getting in the way of relationships, work and school, in an effort to help them weigh the pros and cons of seeking help,” Walker said.

Soldiers receive up to $200 for their participation. The study is funded by the U.S. Department of Defense.

To participate, call 1-866-866-0137, email ucheckup@uw.edu or visit . For more information, contact Walker at ddwalker@uw.edu or 206-543-7511, or Kaysen at dkaysen@uw.edu or 206-221-4657.

Almost half of active-duty military members in the United States — 47 percent — were binge-drinkers in 2008, up from 35 percent a decade earlier. Rates of heavy drinking also rose during that period, according to a 2012 by the Institute of Medicine. But many in the military avoid seeking help for alcohol abuse, fearing disciplinary action or other repercussions, and few soldiers are referred for evaluation or treatment.

“If you’re in the military and you seek substance abuse treatment, your commanding officer is notified and it goes on your medical record and your military record. That’s a huge barrier,” said , director of the at the 91̽�� School of Social Work.

Not surprisingly, there is little research on what type of treatment is most effective for active-duty military members. To shed new insight on that question and remove obstacles to seeking treatment, Walker and a team of researchers tested a telephone-based intervention geared specifically to military members struggling with alcohol abuse — with promising results.

The , published online Oct. 13 in October in the , found that participants in the telephone intervention significantly reduced their drinking over time, had lower rates of alcohol dependence and were more likely to seek treatment.

The trial involved 242 military members at Joint Base Lewis-McChord in western Washington, who were recruited through advertisements and informational booths at military events. All met the criteria for alcohol use disorder, though none were enrolled in treatment programs.

Participants had an initial interview by phone to assess their daily and monthly alcohol consumption. They were also asked a series of questions about the consequences of their drinking — for example, whether it had impacted their physical training or interfered with their ability to fulfill their duties.

Then participants were randomized to a treatment or control group. The control group received educational information about alcohol and other drug use, while the treatment group got a one-hour personalized intervention session over the phone that used “motivational interviewing,” a goal-oriented approach intended to help people make positive behavioral changes.

“The intervention really connects their behavior with their values and goals and wants for themselves,” Walker said. “It’s a safe place to talk confidentially and freely with someone on the other end who is compassionate and non-judgmental.”

The counselors also asked participants about their alcohol consumption versus that of their peers, to gauge whether excessive drinking was in part spurred by normative perceptions about alcohol use in the military.

“The army has a culture of drinking, so there’s a heightened sense among soldiers that their peers are drinking more than they actually are,” said , project director for the study and a 91̽��doctoral student in social work.

“When those perceptions are corrected, it can have a strong effect, as heavy-drinking soldiers often reduce their intake to more typical levels.”

Follow-up interviews were conducted three and six months after the sessions and showed significant decreases in both drinking rates and alcohol dependence. Intervention group participants went from drinking 32 drinks weekly on average to 14 drinks weekly after six months, and their rates of alcohol dependence dropped from 83 to 22 percent. Alcohol dependence also decreased in the control group, from 83 to 35 percent.

“Those are pretty dramatic reductions in drinking, particularly for one session with a counselor,” Walker said. “That was really encouraging.”

Participants increasingly sought treatment over time; by the six-month follow-up, nearly one-third of soldiers in both groups had made some move toward seeking treatment, such as discussing substance abuse concerns with an army chaplain or making an appointment for treatment intake. While the intervention led to more dramatic decreases in drinking, providing educational information may be enough to prompt some to take a first step toward making a change, the researchers said.

Walker and Walton attribute the intervention’s success to its convenience and confidentiality. Participants could enroll without fear of their superiors finding out — recruitment materials made it clear that military command was not involved — and could schedule the phone calls at their convenience.

“Some did the session on their lunch breaks or in the garage while their family was in the house,” Walker said. “They didn’t have to walk into a building that says ‘army substance abuse program.’ It was private and a low-burden intervention.”

And though the military offers substance abuse programs, Walker said, many soldiers avoid seeking help and are not referred to treatment until their problems reach a crisis point.

“People who get into army substance abuse programs are often mandated to go or have gotten into trouble,” she said. “That leaves out a huge proportion of the population who are struggling and not doing well.”

That reality and the protracted conflicts in Iraq and Afghanistan, Walker said, have intensified the need for additional options to help soldiers grappling with substance abuse and other problems. Telephone-based counseling, she said, is a cost-effective way to encourage military members to seek help confidentially, without the barriers of more traditional approaches.

“This intervention has the potential to be used for soldiers and military personnel worldwide. It would really help fill the gap in service provision that is currently available to soldiers.”

Co-authors are Clayton Neighbors, professor of psychology at the University of Houston ; , a 91̽��professor of psychiatry and behavioral sciences; Lyungai Mbilinyi, research social scientist at RTI International; Jolee Darnell, program manager of the Army Substance Abuse Program; Lindsey Rodriguez, an assistant professor at the University of South Florida, St. Petersburg; and , professor emeritus at the 91̽��School of Social Work. The study was funded by the U.S. Department of Defense.

For more information or a copy of the study, contact Walker at ddwalker@uw.edu or 206-543-7511.

The , an organization in the 91̽��School of Social Work, is recruiting people 18 and older for a free marijuana and tobacco treatment trial. The study is aimed at adults who are regularly using both substances, want to quit marijuana and are willing to consider kicking the tobacco habit as well.

This group tends to struggle when it comes to quitting marijuana. Rates of tobacco use are high among regular cannabis users — between 40 and 90 percent, depending on the study and the population — and people who seek treatment for marijuana use who are also smokers tend to have poorer outcomes and higher relapse rates, principal investigator said.

“We have some indication that people coming into treatment using both tobacco and pot don’t do as well in treatment as folks who only use marijuana, so how do we better help them?” said Walker, director of the Innovative Programs Research Group. “If we also focus on tobacco smoking while they’re trying to quit using marijuana, will that improve outcomes?”

Trial participants will be randomly divided into two groups, one to receive treatment for tobacco concurrently with marijuana treatment for 12 weeks, and the other to be treated for marijuana first for 12 weeks, followed by another 12 weeks of tobacco treatment. Participants must come to an office in the University District twice weekly and have their urine tested for THC and other drugs.

Each marijuana-negative sample is rewarded with a Visa cash card, with the amount increasing for each consecutive marijuana-free sample. Participants who are successfully able to quit marijuana and provide negative samples can earn up to $435.

The trial uses a mix of and therapy. After an intake screening assessment with a researcher and a brief counseling session, the treatment is delivered primarily via computer. Participants complete weekly interactive sessions on a computer that are intended to increase motivation and teach skills to help meet their goals. The approach was developed by , a professor of psychiatry at Dartmouth College, who is conducting the trial in partnership with the UW.

Walker worked on a with Budney that tested the computerized treatment with an in-person version and found there was little difference in outcomes between the two approaches. Web-based treatments are less costly and more convenient, she said, and can provide access in settings where counselors may not be as available.

“It opens up a wide array of places where you can try to intervene with people — primary care settings, juvenile justice or other places where you can capture people in waiting rooms,” she said. “You can have them working on a computer, getting assessed and getting feedback, and if needed, getting referrals for additional treatment.”

The Innovative Programs Research Group, which focuses on providing early interventions for youth and adults struggling with behavioral issues, conducted a separate 2010 trial for people who wanted to quit marijuana and recruited more than 70 participants within weeks.

“Our phone was ringing off the hook,” said Lauren Matthews, project director for the current trial.

But that was before Washington and Colorado in 2012 became the first two states in the nation to legalize and regulate recreational marijuana use. Matthews said participants in the earlier trial seemed primarily motivated by the feeling that their pot use was out of control, rather than the drug’s illicit status.

As legalize marijuana, Walker said there is concern that cannabis is increasingly perceived as harmless. Some marijuana users are easily able to quit, she said, but others struggle and may experience withdrawal symptoms such as sleeplessness, irritability and loss of appetite. According to the , almost 4.2 million people in the U.S. abused or were dependent on marijuana in 2014, and studies suggest that 9 percent of users will become dependent at some point.

“There’s a segment of the population that has a really tough time quitting or cutting down, and even with treatment, quitting appears just as hard as with other substances including alcohol,” Walker said.

People interested in participating in the study, which is funded by the National Institute on Drug Abuse, can contact Matthews at uwmatts@uw.edu or 206-616-3235.

The will be published in the July 2014 issue of Addictive Behaviors, but is already online.

Synthetic marijuana, sometimes called “Spice,” is made with shredded plant material coated with chemicals that are designed to mimic THC, the psychoactive compound found naturally in marijuana. The U.S. Drug Enforcement Administration has listed several of synthetic marijuana’s main compounds as Schedule 1 substances, making them illegal. But producers of the drug keep synthesizing new compounds to try to get around those bans.

“Because the formulation is constantly changing, one batch could be innocuous while the next batch affects you totally differently and you land in the hospital with seizures,” said , project director for the 91̽��study and a research coordinator in social work. “So the health effects are very unpredictable.”

Those health effects have not been widely studied yet, but emergency rooms have reported seizures, nausea, vomiting, and cardiovascular and respiratory problems. Psychological effects of using synthetic marijuana can include anxiety, confusion, agitation, irritability, depression and memory issues.

The U.S. military has banned synthetic marijuana in all branches of the service.

Participants in the 91̽��study came from the Department of Defense-funded , a telephone-based intervention trial for Army personnel with untreated substance use issues who are ambivalent about making changes or engaging in treatment. All participants were stationed at Joint Base Lewis-McChord in Washington state at some point during the 2011-2014 recruitment period.

Nearly one-third said they had used illicit substances within the previous 90 days; 38 percent of those used synthetic marijuana, twice as many as had used regular marijuana.

Study participants told researchers they believed that use of synthetic marijuana was significantly higher in the military than in the civilian population. It was the only substance that soldiers believed they used more than civilians, which supports the idea that synthetic marijuana is particularly attractive to military personnel, the researchers said.

“What we think other people do tends to be important in prevention efforts and intervention efforts,” said , lead author of the study and a 91̽��research associate professor of social work. “If soldiers think it’s common for military personnel to use Spice, then they might think it’s OK to use it.”

Walker said soldiers tend to avoid treatment for substance abuse issues because seeking treatment automatically goes on their record.

“Who would sign up for that in the civilian population if your boss and your coworkers will immediately know?” Walker said.

The Warrior Check-Up is not considered treatment, and participation is strictly confidential.

Users of synthetic marijuana were younger and less educated than those who were dependent only on alcohol. They were more likely to be single and earned less money than those who were dependent on other drugs or alcohol. But there were no differences in ethnicity, race, deployment history or religion. Researchers also found that synthetic marijuana users were two-and-a-half times more likely to develop drug dependence than those who used other drugs (but not alcohol).

The majority of participants believed their use of synthetic marijuana resulted in failing to meet obligations, such as being late for work, doing their job poorly, or not handling home and child care responsibilities well.

One hazard of using synthetic marijuana was needing more and more to get the same effect, a hallmark of drug dependence. More than three-quarters of users reported using it for much longer than intended (i.e., planning to take just a few puffs after work, but then smoking it for hours).

Walker said there are many reasons why someone would become dependent on alcohol or drugs, but soldiers face added stressors.

“They live very stressful lives. Most of them are young, and they may be going to war or coming back from war,” she said. “Being in the Army is very demanding.”

The military recently announced that it has developed a urinalysis that can detect synthetic marijuana, but Walton said that test doesn’t necessarily have a very high success rate.

“Those drug tests aren’t identifying all the users out there,” he said. “And, unfortunately, because of the consequences of self-reporting to substance use treatment, positive drug tests are the primary reason soldiers enter treatment. The Warrior Check-Up hopes to change that by helping military personnel change their substance use before it negatively impacts their lives and careers.”

Co-authors are Adam Pierce, , and of the UW; and of the University of Houston. The study was funded by the Department of Defense.

# # #

For more information, contact Walker at ddwalker@uw.edu or 206-543-7511, or Walton at towalton@uw.edu or 206-543-7511.

Department of Defense grant: W81XWH-09-2-0135.