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.��

A new article published by researchers from University of Puget Sound and 91̽�� reports that, based on analysis of public wastewater samples in at least one Western Washington population center, cannabis use both increased and substantially shifted from the illicit market since retail sales began in 2014.

Led by chemist Dan Burgard, the research team analyzed wastewater samples collected from 2013-2016 from two treatment plants that service a community of two hundred thousand��in Western Washington.

“We set out to perform a wastewater-based analysis that explored the impact of newly legalized retail cannabis sales on its use, and to determine if this approach could estimate the size of the legal market place,” says Burgard, who chairs the chemistry department at Puget Sound.

The researchers estimate that THC-COOH (the metabolite of psychoactive THC in cannabis created within the human body) found in wastewater has increased by 9% per quarter, on average, from December 2013 to December 2016. During this time, cannabis sales increased at nearly 70% per quarter, on average, for stores operating from August 2014 to December 2016.

“Given that wastewater represents a total population measure, these findings suggest that many established users switched very quickly from the illegal to the legal market,” says Burgard. “This is the strongest statement possible regarding displacement of the illegal market.”

Caleb Banta-Green, interim director and principal research scientist at 91̽��’s Alcohol and Drug Abuse Institute, is a co-author of the article and was a key researcher on the project.

“This project was designed to aid the understanding of how the sales of adult recreational cannabis impact its total consumption within a population,” says Banta-Green. “We believe this will be a valuable tool for local, state, national and international policy makers as they assess and consider Washington’s recreational cannabis law.”

In the past six years nine U.S. states (Colorado, Washington, Alaska, Oregon, Nevada, California, Maine, Massachusetts, Vermont, Michigan, and the District of Columbia), as well as the countries of Uruguay and recently Canada, have legalized the adult use of recreational cannabis.

“Existing measures, particularly surveys are subject to important biases and limitations, including potential changes in self-report as social norms change as well as very limited information on the amount of THC actually consumed,” Banta-Green notes. “Wastewater based estimates help address these limitations.”

The researchers note that their findings suggest that legalization is, in part, achieving one of its primary objectives which was to eliminate black market sales.

Funded in part by a grant from the National Institute on Drug Abuse, the research process included testing samples from 387 days spread over three years. The team utilized a new method that enables a complementary and potentially more timely and objective assessment of illicit drug consumption compared to existing measures.

Raw wastewater samples representing a full day are collected at a treatment plant and analyzed for drugs and their metabolites at extremely low concentrations (part per billion or part per trillion levels).�� These data can be used to track drug consumption trends, both legal and illegal, but not individual users. In some instances, the concentration of the metabolites can be used to “back calculate” to the actual number of doses of drug used in a particular area.

When this research project was announced in 2015 and throughout its duration it has earned national and international press from media like , , , and .

The report, titled “Using Wastewater-Based Analysis to Monitor the Effects of Legalized Retail Sales on Cannabis Consumption in Washington State, USA,” was published in , a journal published by the Society for the Study of Addiction.

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For more information, contact Banta-Green at calebbg@uw.edu.

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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.

A 91̽�� team of researchers sought to address those questions in the context of evolving marijuana policies in the United States. Their , published online Dec. 21 in the journal Alcoholism: Clinical & Experimental Research, highlight the difficulties of gauging the impact of a formerly illicit drug as it moves into the mainstream.

Recreational marijuana use is now legal in four states and medical marijuana in 23 states. Research on legalization policies has focused largely on how they impact marijuana access and use. But the 91̽��team wanted to know how legalization affects the use of alcohol, by far the nation’s drug.

The majority of adults in the U.S. imbibe to varying degrees, and alcohol abuse is the third leading preventable cause of death nationwide. Drinking accounts for almost one-third of driving fatalities annually, and excessive alcohol use cost in 2006 alone.

“We chose to focus on alcohol because even relatively small changes in alcohol consumption could have profound implications for public health, safety and related costs,” said lead author , a researcher in the UW’s .

The researchers sought to determine whether legalizing marijuana led to it becoming a substitute for alcohol or tended to increase consumption of both substances. If it was the former, they reasoned, that could greatly reduce the costs of healthcare, traffic accidents and lower workplace productivity related to excessive drinking.

But if legalized marijuana resulted in increased use of both drugs, costs to society could increase dramatically, particularly since those who use both substances tend to use them . Those who use both substances simultaneously are twice as likely to drive drunk and face social troubles such as drunken brawls and relationship problems, a recent found.

Drawing on previous studies, the researchers hypothesized that legalization of marijuana could result in either substitution or complementary effects. Marijuana and alcohol both provide users with similar “reward and sedation” effects, the researchers noted, which could prompt users to substitute one for the other. But blood levels of THC, the chemical responsible for most of marijuana’s pleasurable psychological effects, increase with simultaneous alcohol use — so the quest for a better high might lead people to use both substances.

The researchers reviewed more than 750 studies on marijuana and alcohol use and focused on 15 that specifically addressed the links between marijuana policies and drinking. They looked at how decriminalized marijuana, medical marijuana and recreational marijuana impacted alcohol use.

The findings of those studies fluctuated widely, depending on the demographic and the type and frequency of alcohol and marijuana use. One study, for example, found that states where marijuana is decriminalized had more emergency room visits related to marijuana and fewer visits linked to alcohol and other drugs. Some studies found that high school seniors in states where pot was decriminalized tended to drink less, while other research found that college students who used pot also drank more.

Findings around medical marijuana also varied. One study reported that states with medical marijuana dispensaries had higher rates of both marijuana and alcohol use, as well as higher admissions into alcohol treatment facilities. But while states with medical marijuana had fewer alcohol-related fatalities overall, those with dispensaries saw more of those deaths.

Other research found that while legalized medical marijuana wasn’t associated with any increases in underage drinking, it was linked with more binge drinking and simultaneous use of pot and alcohol among adults.

The issue is particularly complicated in Washington state, which legalized recreational marijuana use in 2012 after privatizing liquor sales the previous year. As a result, the uptick in alcohol sales made it difficult to isolate the impacts of legalized marijuana on drinking from the change in alcohol policy.

The researchers concluded that there’s evidence of marijuana and alcohol being both substitutes and complements. Given the rapidly evolving landscape of marijuana policy, they say further study will be important to understand how changes in marijuana laws impact the use of alcohol and other drugs.

In particular, Guttmannová said, future studies should address specific dimensions of marijuana policies, timing of policy change and implementation, and different aspects of marijuana and alcohol use, such as age of users and whether they are episodic or regular consumers.

“This is a complicated issue and requires a nuanced approach,” she said. “We were hoping to have more clear-cut answers at the end of our research. But you know what? This is the science of human behavior, and it’s messy, and that’s OK.”

Co-authors at the 91̽��Center for the Study of Health and Risk Behaviors are Associate Director , professor of psychiatry , assistant professor of psychiatry , and research assistant professor . Other co-authors are 91̽��School of Social Work lecturer and investigator and Social Development Research Group investigator .

The research was funded by the National Institute on Alcohol Abuse and Alcoholism and the National Institute on Drug Abuse.

91̽�� , published recently in Substance Use & Misuse, found that only 57 percent of Washington parents surveyed knew the legal age for recreational marijuana use and just 63 percent knew that homegrown marijuana is illegal under the law.

And while 71 percent of 10^th-graders correctly identified the legal age, fewer than half (49 percent) knew how much marijuana can legally be possessed.

The findings underscore the need for better educational outreach about the law, said co-author , professor of social work and director of the at the 91̽��’s School of Social Work.

“As new states are taking on legalized marijuana, we need to have public information campaigns to make sure people have the information they need,” he said.

The study surveyed 115 low-income families of teens attending Tacoma middle schools, who were part of an ongoing prevention study. Data was initially collected before Washington approved recreational marijuana, and then two years later during the summer of 2013.

The study found that while 70 percent of parents said they talked about marijuana laws with their children, those conversations were infrequent. That is troubling, Haggerty said, since 10^th grade is a critical time for family discussions about drug use.

“We know that parent expectations, even as late as senior year in high school, have an impact on kids’ college-age marijuana use,” he said. “If kids are thinking in 10^th grade that the legal age for marijuana is 18, they could potentially be more likely to use it later.”

The study also found that the Washington law made little difference in the teens’ attitudes about marijuana use or the likelihood of them smoking pot.

“We were most surprised to see how little parents and teens know about fundamental aspects of the new law, such as the legal age limit,” said corresponding author W. Alex Mason, director of research at the Boys Town National Research Institute.

In 2012, Washington and Colorado became the first U.S. states to legalize recreational marijuana use, and Alaska, Oregon and Washington, D.C. passed marijuana legalization measures last November. The legal age for marijuana use in Washington is 21. Adults can possess up to one ounce, and homegrown pot is prohibited.

The study comes at a time when educators, parents and others are trying to determine what young people need to know about marijuana use and what messages might most effectively steer them away from it.

The Washington State Department of Health launched a $400,000 statewide campaign in June that featured on radio and digital media encouraging parents to talk to their kids about the risks of using marijuana. The UW’s Alcohol & Drug Abuse Institute has also launched an education which is expected to eventually be supported by marijuana tax revenues.

Washington’s law mandates that a portion of revenues from marijuana sales be used for public education, drug abuse treatment and research, and that the state consult with the 91̽��annually to decide which programs to fund. The department of health plans to launch a broader education campaign when marijuana revenues become available later this year.

“This study convincingly points out that people don’t have good information about the new law,” Haggerty said.

Other co-authors are Koren Hanson and Charles Fleming at the 91̽��and Jay L. Ringle at Boys Town Research Institute. The work was funded by the National Institute on Drug Abuse.