Talking about Marijuana
in Primary Care
Teresa Foo, MD, MPH
Colorado Department of Public Health and Environment
Carolyn Swenson, MSPH, MSN, FNP
Peer Assistance Services
November 2014
Peer Assistance Services, Inc.
2014
Peer Assistance Services, Inc.
Dedicated to quality, accessible prevention and
intervention services in workplaces and
communities, focusing on substance use and
related issues.
Incorporated in 1984
Peer Assistance Services, Inc.
2014
Acknowledgements
SBIRT Colorado is an initiative of the Governor, funded
by the Substance Abuse and Mental Health Services
Administration, administered by the Colorado
Department of Human Services, Office of Behavioral
Health and managed by Peer Assistance Services, Inc.
Peer Assistance Services, Inc.
2014
Objectives
1. Describe current efforts in Colorado to define the
health effects of marijuana and educate health
professionals and the general public.
2. Introduce the supplemental guidance on marijuana
developed by the SBIRT Colorado initiative.
3. Explore screening and brief counseling about
marijuana in adolescent and adult patients.
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2014
Background: Methods of Use
• Smoking
• Edibles
– New DOR regulations: standardized serving of
10mg active THC, no products >100mg
• Vaping (vaporizer pens)
• Dabbing
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2014
Background: Colorado Laws
• Adults 21 and older can possess as much as 1 ounce of
marijuana and grow up to six plants for personal use.
• It's illegal to give or sell retail marijuana to anyone under 21.
• It’s illegal to possess or use of retail marijuana on school
properties.
• It’s illegal to use marijuana in outdoor or indoor public spaces
 Some local governments have different laws, so be aware of
any differences in your area
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2014
Other Colorado Laws
• Department of Revenue Regulations
– Limits advertising, restrictions on packaging (child
resistant, warnings on packages)
• Driving
– Open container law
– Colorado drivers with 5 nanograms of active THC/mL in
whole blood are considered to be driving impaired
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2014
CDPHE: Marijuana and Public Health
Senate Bill 13-283
a. "Monitor changes in drug use patterns, broken down
by county and race and ethnicity, and the emerging
science and medical information relevant to the
health effects associated with marijuana use.”
b. "The Department shall appoint a panel of health care
professionals with expertise in cannabinoid
physiology to monitor the relevant information.
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CDPHE Monitoring Activities
Target Population
Problem
Monitoring
Young Children
Accidental Poisoning
Pilot surveillance project
Colorado Hospital Association (CHA) Data
Rocky Mountain Poison and Drug Center Calls
Child Health Survey(CHS) - risk factors
Youth
Increased Use/Abuse
Healthy Kids Colorado Survey (aka YRBS)
Poisoning, Overdose, Abuse
Colorado Hospitalization Data
Rocky Mountain Poison and Drug Center Calls
Accidents/Trauma
Colorado Hospitalization Data
Colorado Trauma Registry
Increased Use/Abuse
Behavioral Risk Factor Surveillance System (BRFSS)
Tobacco Attitudes and Behaviors Survey (TABS)
Poisoning, Overdose, Abuse
Colorado Hospitalization Data
Rocky Mountain Poison and Drug Center Calls
Accidents/Trauma
Colorado Hospitalization Data & Colorado Trauma Registry
Pilot Surveillance (Ski-Related Injuries)
Contaminated Products
Foodborne Illness Surveillance related to Edibles
Rocky Mountain Poison and Drug Center Calls
Birth Defects,
Developmental Disabilities
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Services,
Inc.(PRAMS)
2014
Pregnancy Risk Assessment
Monitoring
System
Active Surveillance (Birth Defects Registry)
Adults
Pregnant/
Breastfeeding
Retail Marijuana Public Health
Advisory Committee
• Review the scientific literature currently available on
health effects of marijuana.
– Developed a literature review process including rating
quality of each study
– Translate science into public health messages
– Recommend public health related policies and surveillance
activities
– Identify and prioritize gaps in science related to public
health
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Literature Review Topics
Pregnancy/Breastfeeding
Neurological, Cognitive and Mental Health (Adults)
Adolescents and Young Adults
• Dose and Drug Interactions
• Extra-pulmonary Effects and Injuries
• Respiratory Effects and Lung Cancer
https://www.colorado.gov/pacific/cdphe/retailmarijuana-public-health-advisory-committee
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Public Health Statements:
Pregnancy/Breastfeeding
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There is no known safe amount of marijuana during pregnancy.
THC can pass from mother to the unborn child through the placenta.
The unborn child is exposed to THC used by the mother.
Maternal use of marijuana during pregnancy is associated with
negative effects on exposed children that may not appear until
adolescence.
• The most negatively affected are academic ability, cognitive function and attention.
• There are negative effects of marijuana use during pregnancy
regardless of when it is used during pregnancy.
• THC can also be passed from the mother’s breast milk, potentially
affecting the baby.
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2014
Prevention Campaign
• Initial media campaign to educate the public on safe,
legal, responsible use
• Launch date: January 2015
• Ongoing campaign will include targeted messaging
for high-risk populations (youth, pregnant women
etc)
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Clinical Guidelines
• 2-3 page documents with evidence based information
on talking to patients about marijuana (screening,
recommendations and referrals)
• Incorporate messaging and evidence approved by the Retail
Marijuana Public Health Advisory Committee
• Initial Topics:
• Pregnancy/Breastfeeding
• Pediatric Exposure Prevention
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Pregnancy/Breastfeeding Guidelines
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Screening recommendations
Talking points
Medical marijuana
Current laws
Mandatory reporters
Secondhand smoke
Breastfeeding
Parenting and safety
Common myths/FAQs
Resources for health care providers and patients
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2014
Guideline Timeline
• Pilot testing of pregnancy/breastfeeding draft
guidance in early January 2015
• Development of pediatric exposure prevention
guidelines in early 2015
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Safe Environment
• Restricting access to children
– Packaging
– Safe storage
– From Jan - May 2014, unintentional exposures were
increased at Children’s Hospital1
• Increases also seen with legalization of medical marijuana2
• Smoke free environment
1. http://www.denverpost.com/news/ci_25807342/childrens-hospital-sees-surge-kidsaccidentally-eating-marijuana
2. Wang GS et al. Pediatric Exposures in a Medical Marijuana State. JAMA Pediatrics.
2013:167(7);630-633
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Mandatory Reporters
• Adult use of marijuana (>21 years) is legal in
Colorado, just like alcohol, however it is important to
make sure parents are aware of responsible use of
legal substances.
• If you as a health care provider have a suspicion of
abuse or neglect (i.e. that the health or welfare of a
child is threatened), it is your duty as a mandatory
reporter to report child abuse or neglect.
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Adolescents
• The important role of the parent in prevention
– Include marijuana in discussions about alcohol,
tobacco
– speaknowcolorado.org
• Specific health risks
– See Adolescent and Young Adults Findings
Summary
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2014
Other Health Considerations
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Older adults
Mental Health
Acute psychotic symptoms
Cannabinoid Hyperemesis Syndrome
Surgery
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Substance use disorders
are preventable.
Earlier initiation of any substance use
is associated with greater lifetime risk
for a substance use disorder
Earlier intervention
improves outcomes.
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Prevention Begins Early
“A child who reaches his or her 21st birthday
without using drugs, tobacco or alcohol is
‘virtually certain’ never to slip into those habits.”
-Joseph A. Califano Jr.
How to Raise a Drug-Free Kid
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The evidence:
Screening and brief intervention for drugs
• United States Preventive Services Task Force
(USPSTF): “I” statement
– Insufficient evidence
• Recent research published in JAMA (August
2014) found that SBI for drug use did not
reduce days of use of marijuana, illicit or
prescription drug misuse.
• Patients with drug use may require multiple or
more intensive interventions.
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2014
The evidence:
Screening and brief intervention in adolescents
• USPSTF: “I” statement
– Insufficient evidence
• American Academy of Pediatrics:
Recommends SBI for alcohol, drugs and
tobacco.
• Adolescents may require more intensive
intervention, or multiple interventions to
effectively address substance use.
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Screening (S)
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Marijuana screening: Adults
“How many times in the past year
have you used marijuana?”
Positive score = 1 or more times
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Screening: Adolescents
• Who?
• All adolescents
• Starting at least by age 12
• Younger may be appropriate (start by asking if friends have
tried tobacco, alcohol, or drugs)
• How?
• CRAFFT screening tool for alcohol and drug use.
• For use with individuals under age 21
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Conversations about Marijuana
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2014
Common Beliefs and
(Mis)Perceptions
• It’s legal so it must be safe
• It’s ‘all natural’ so how could it harm me?
• It’s better than drinking too much alcohol or
smoking tobacco
• It’s not addictive
• It helps stress, anxiety, depression and many
other conditions
• It’s better than drinking and driving
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2014
Harm Reduction
• WHO? Adolescents; pregnant women; others
• GOAL: Keep the door open to ongoing open
communication.
• Start with a clear, strong, personalized message to
abstain when indicated.
• Then ask what they think:
– “What do you think about this?”
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Brief Negotiated Interview
1. Raise the subject
2. Provide feedback
3. Enhance motivation
4. Negotiate a plan and advise
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Step 1: Raise the Subject
“Would you mind taking a few minutes to talk
with me about your screening results?”
(ask permission to have the conversation)
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2014
Step 2: Provide Feedback
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Review reported substance use.
Compare reported alcohol use to moderate limits for adults.
Provide feedback on health or other potential effects of use.
Link substance use to purpose of your visit with the patient.
Offer educational resources.
• Don’t give too much information!
• Always elicit the person’s response to the feedback!
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Step 3: Enhance Motivation
Pre-Contemplation
Contemplation
Maintenance
Preparation
Action
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2014
Enhancing Motivation:
Explore the pros and cons
“What do you like about using marijuana?”
Followed by:
“What are some not so good things about your use of
marijuana?”
Then summarize both sides:
“So, on the one hand ____, and on the other hand, ____.”
Peer Assistance Services, Inc.
2014
Enhancing Motivation:
Assess Readiness or Importance
“On a scale of 0 -10 how ready are you to make a change
in your marijuana use?”
THEN RESPOND
“What made you choose that number?
OR
“What makes you a 5 and not a lower number?”
Peer Assistance Services, Inc.
2014
Enhancing Motivation:
Assess Confidence
“On a scale of 0 -10, how confident are you that you could
make a change if you decided to?”
THEN RESPOND
“What could help you feel more confident?”
OR
“What could help you move from a 5 to a higher number?”
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2014
Step 4: Negotiate and Advise
Elicit response:
“What are some of your thoughts about our discussion?”
Negotiate a goal:
“What are some steps you could take to make a change?”
Harm reduction is appropriate!
Assist in developing a plan:
“How will this be challenging for you?
Summarize:
“It sounds like your plan and next steps are ____.”
Thank them for having the conversation:
“I appreciate having this conversation with you today.”
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2014
Demonstration:
A brief conversation about marijuana
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Possible Cannabis Use Disorder:
CUDIT
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2014
A Few Good Questions
“How does your current pattern of marijuana use fit with
what matters most to you in your life?”
“How would you know if you were developing a problem?”
“Let’s say you did decide to quit or cut back, how would you
go about doing it?” “What’s the first step you would take?”
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2014
LinkingCare.org
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www.improvinghealthcolorado.org
Carolyn Swenson, MSPH, MSN, FNP
Manager, Training and Consultation, SBIRT Colorado
303-369-0039 x 227
Peer Assistance Services, Inc.
2014