The portal content is flexible to allow for real-time tailoring to prevent/reduce misuse, addressing heterogeneity in motives and other risk factors . Use of the fully-crossed 4-group RCT design will help identify the optimal combination of interventions based on risk severity in terms of efficacy, cost-effectiveness, and reimbursement mechanisms. Our conceptual model, which guides the examination of moderators and mediators of efficacy, will provide unique information regarding mechanisms of behavior change and identify opioid-related risks to inform translation. The final product of these strategies involves an online toolkit adapted for our interventions to include one-stop shopping for screening, a health coach support guide, and training videos to increase scalability, with cost analyses guiding future implementation. In designing this trial, we carefully weighed the advantages and disadvantages of scientific protocol decisions and there are, of course, limitations in the current approach. First, the trial results may have limited generalizability to other ED settings since our study takes place in a single site . Further, conducting a trial during a historical public health event like COVID-19 has potential implications for generalizability to future populations. Additionally, to advance the science on opioid prevention in AYAs,cannabis vertical farming there was a requirement to harmonize measurement across HPC studies to address larger scientific questions about the progression of opioid misuse. This greater harmonization effort required modifications to measures, potentially impacting reliability and validity.
The use of an external portal platform as opposed to the health system’s EHR-integrated patient portal could be viewed as a limitation; however, because of the need to maintain confidentiality pertaining to research participation specifically we found it necessary to build a separate portal. Finally, we note that the use of health coaches of varying skill levels at the bachelor’s and master’s level could be a potential limitation because of the limited clinical experience of some of these staff. Nonetheless we note that our coaches met fidelity thresholds in our pilot and that a number of studies have used peers and lay health workers without extensive clinical experience to deliver MI meeting a number of fidelity thresholds.74–76 Further, as Miller and Rollnick41 recommend we use ongoing quality assurance and fidelity monitoring in this trial. Dual marijuana and alcohol use is especially prevalent, with 47% of marijuana users reporting simultaneous use of alcohol . Furthermore, individuals who have a cannabis use disorder are at increased likelihood for the development of an alcohol use disorder , and rates of substance use disorders and treatment admissions are highest among individuals that use marijuana or alcohol compared to other substances . Approximately 68% of individuals with current CUD and over 86% of those with a history of CUD meet criteria for an AUD . Cannabis dependence doubles the risk for long-term persistent alcohol consequences and dual marijuana and alcohol users consume higher levels of alcohol and experience more alcohol-related consequences than only drinkers . Despite these additional risks, 60% of college students do not perceive regular marijuana use to be harmful .The combination of low perceived risk, policy changes surrounding marijuana legalization, and the rise in marijuana use over the past 10 years heightens the importance of effective interventions for alcohol and marijuana use. In the adult substance use treatment literature, it is relatively well-established that alcohol use negatively impacts treatment of other substances . In contrast, literature examining the impact of marijuana use on the treatment of other substances is mixed. With the exception of a few studies that do not show marijuana use to negatively influence alcohol or smoking cessation outcomes , many studies have demonstrated that using marijuana before or during alcohol treatment is associated with higher levels of drinking at follow-up .
For example, among alcohol dependent individuals, those who used marijuana during alcohol treatment reported fewer days abstinent from alcohol one year following treatment than those who did not use marijuana . Thus, marijuana use seems to have a negative impact on alcohol treatment outcomes. A number of studies have also examined secondary changes in marijuana use following receipt of an alcohol-specific intervention. A recent integrative data analysis study indicated that alcohol BMIs may not facilitate changes in marijuana use among college students ; instead, regardless of treatment condition, college students who successfully reduced their drinking at short- and long-term follow-ups were more likely to be non-users of marijuana or reduce their marijuana use at follow-up. This complementary relationship between marijuana and alcohol use is also supported by research indicating that the risk factors for initiation and maintenance of problematic use are similar across substances . Together, these studies suggest that interventions for alcohol may lead to secondary changes in marijuana use. Consistent with this hypothesis, young adults who participated in an in-person BMIs for alcohol use in an emergency department setting reported greater decreases in marijuana use at the 6-month follow-up than those who received feedback only . Similarly, weekly marijuana users who were seeking treatment for cigarette smoking and completed a brief alcohol intervention within the context of the smoking cessation intervention, demonstrated reductions not only in heavy drinking and tobacco smoking but also in marijuana use . In the college setting, BMIs that target multiple substances have also been associated with reductions in poly-drug use . One explanation for the differential influence of alcohol interventions on marijuana use across these studies may be related to the populations examined. Thus far, alcohol interventions delivered to acute-risk populations have had an impact on marijuana use outcomes, while collectively, interventions delivered to ‘college students’ have not. However, college students are a heterogeneous population, and not all require the same level of intervention . To our knowledge, no one has examined the influence of an alcohol intervention on marijuana use when alcohol interventions are provided sequentially in the context of stepped care, in which individuals who do not respond to an initial,drying cannabis low-intensity level of treatment are provided a more intensive treatment .
The purpose of the current study was to examine marijuana use in the context of a stepped care intervention for alcohol use.We conducted a secondary analysis of data from a randomized clinical trial implementing stepped care with mandated college students . In this study, all participants received a brief advice session administered by a peer counselor. Participants who continued to drink in a risky manner six weeks following the BA session were randomly assigned to either BMI or AO conditions . Step 2 participants who completed the BMI as opposed to AO reported greater reductions in alcohol-related consequences at all follow-up assessments . We tested three hypotheses to examine whether interventions that reduce alcohol-related outcomes may also reduce marijuana use. First, because dual marijuana and alcohol users consume higher levels of alcohol use and experience more alcohol-related consequences , we hypothesized that marijuana users would report higher HED frequency, peak blood alcohol content , and alcohol related consequences in the 6 weeks following a BA session, after controlling for their pre-BA drinking behavior. Second, we hypothesized that heavy-drinking marijuana users who did not respond to the BA session and, therefore, were randomized to a Step 2 BMI or AO would report worse alcohol-related outcomes at 3-, 6-, and 9-month follow-ups than non-users. Third, we examined whether marijuana users changed their marijuana use frequency at any of the three assessment time points following the Step 2 BMI. Examination of marijuana use in this context will improve our understanding of whether marijuana use lessens the efficacy of alcohol interventions, even when delivered sequentially in stepped care. Furthermore, it will inform future intervention efforts aimed at reducing both alcohol and marijuana use.Participants indicated how many times they used marijuana in the past 30 days at baseline and at each follow-up assessment time point. Because marijuana use was highly zero-inflated , and due to our interest in whether being a marijuana user influenced intervention outcomes, dichotomous variables were created to group individuals into user versus non-user for use in analyses to compare these subgroups.The combination of low perceived risk, policy changes surrounding marijuana legalization, and the rise in marijuana use over the past 10 years heightens the importance of effective interventions for alcohol and marijuana use. In the adult substance use treatment literature, it is relatively well-established that alcohol use negatively impacts treatment of other substances . In contrast, literature examining the impact of marijuana use on the treatment of other substances is mixed. With the exception of a few studies that do not show marijuana use to negatively influence alcohol or smoking cessation outcomes , many studies have demonstrated that using marijuana before or during alcohol treatment is associated with higher levels of drinking at follow-up . For example, among alcohol dependent individuals, those who used marijuana during alcohol treatment reported fewer days abstinent from alcohol one year following treatment than those who did not use marijuana . Thus, marijuana use seems to have a negative impact on alcohol treatment outcomes.
A number of studies have also examined secondary changes in marijuana use following receipt of an alcohol-specific intervention. A recent integrative data analysis study indicated that alcohol BMIs may not facilitate changes in marijuana use among college students ; instead, regardless of treatment condition, college students who successfully reduced their drinking at short- and long-term follow-ups were more likely to be non-users of marijuana or reduce their marijuana use at follow-up. This complementary relationship between marijuana and alcohol use is also supported by research indicating that the risk factors for initiation and maintenance of problematic use are similar across substances . Together, these studies suggest that interventions for alcohol may lead to secondary changes in marijuana use. Consistent with this hypothesis, young adults who participated in an in-person BMIs for alcohol use in an emergency department setting reported greater decreases in marijuana use at the 6-month follow-up than those who received feedback only . Similarly, weekly marijuana users who were seeking treatment for cigarette smoking and completed a brief alcohol intervention within the context of the smoking cessation intervention, demonstrated reductions not only in heavy drinking and tobacco smoking but also in marijuana use . In the college setting, BMIs that target multiple substances have also been associated with reductions in poly-drug use . One explanation for the differential influence of alcohol interventions on marijuana use across these studies may be related to the populations examined. Thus far, alcohol interventions delivered to acute-risk populations have had an impact on marijuana use outcomes, while collectively, interventions delivered to ‘college students’ have not. However, college students are a heterogeneous population, and not all require the same level of intervention . To our knowledge, no one has examined the influence of an alcohol intervention on marijuana use when alcohol interventions are provided sequentially in the context of stepped care, in which individuals who do not respond to an initial, low-intensity level of treatment are provided a more intensive treatment . The purpose of the current study was to examine marijuana use in the context of a stepped care intervention for alcohol use.We conducted a secondary analysis of data from a randomized clinical trial implementing stepped care with mandated college students . In this study, all participants received a brief advice session administered by a peer counselor. Participants who continued to drink in a risky manner six weeks following the BA session were randomly assigned to either BMI or AO conditions . Step 2 participants who completed the BMI as opposed to AO reported greater reductions in alcohol-related consequences at all follow-up assessments . We tested three hypotheses to examine whether interventions that reduce alcohol-related outcomes may also reduce marijuana use. First, because dual marijuana and alcohol users consume higher levels of alcohol use and experience more alcohol-related consequences , we hypothesized that marijuana users would report higher HED frequency, peak blood alcohol content , and alcohol related consequences in the 6 weeks following a BA session, after controlling for their pre-BA drinking behavior. Second, we hypothesized that heavy-drinking marijuana users who did not respond to the BA session and, therefore, were randomized to a Step 2 BMI or AO would report worse alcohol-related outcomes at 3-, 6-, and 9-month follow-ups than non-users. Third, we examined whether marijuana users changed their marijuana use frequency at any of the three assessment time points following the Step 2 BMI.