and good evening to everybody else. I'm very pleased to be here today with my colleagues, Dr. David Atkinson and Dr. Srini Gokarakonda, who are addiction psychiatrists like myself. And we'll be talking about the connection about COVID, cannabis and nicotine, and thinking about how we discuss this and inform our patients around this. I am an addiction psychiatrist, the Complex Pain and Addiction Service at the Vancouver General Hospital in Vancouver, Canada. And I will let Dr. Atkinson and Dr. Gokarakonda introduce themselves as well. Hi, reaching for the unmute button, I'm Dave Atkinson and I'm a Medical Director of Teen Recovery Program in Adolescent Addiction and Mental Health Service at Dallas Children's in Texas. And I'm at UT Southwestern as an Associate Professor. Good afternoon, my name is Srini Gokarakonda. I'm an Assistant Professor at the University of Arkansas for Medical Sciences. I'm a child psychiatrist and also do addictions. I work at the Residential Rehab. Glad to be here today to talk about COVID, cannabis and nicotine. Okay, great, so we can go to the next slide. So I just wanted to start with a little bit of a roadmap for the presentation today. We'll start off with some poll questions that I invite individuals in the audience to respond to. We're hoping to have a little bit of a discussion and a Q&A around the topics that we go over today. And hopefully the poll questions can stimulate either some thoughtful discussion or some additional questions as we then transition into a discussion about the basic science of COVID-19 and particularly thinking about the usage of tobacco and cannabis and how it relates to this. Then we'll transition into a discussion around the interplay between cannabis and tobacco use and present some real world data. And then we will have a discussion around informing of potential risks and really thinking about this from a motivational interviewing perspective. Next slide. So this brings us to our poll questions. So I'm going to just briefly summarize the poll questions and invite everybody in the audience to think about their own awareness as the first question about the interaction between nicotine, cannabis use and COVID-19. And so the options that we have put together for you today is no, there is no interaction that is known. The second option is to say, yes, I am aware of some vague interactions and nicotine use and cannabis should actually be encouraged to reduce the risk of COVID-19 infection. Next answer is that, yes, I'm aware of some vague interactions and nicotine and cannabis use may have negative impacts of COVID-19 risk. And the last option is to say, yes, I've explored the literature on my own and this has been a particular concern of mine. We can advance, oh, we can take a moment here. Okay. Okay, and let's go ahead to the next slide. And so this is the next poll question that we have is wondering about whether this has been a topic of discussion around these connections with patients and the options are yes and no. And if you would like to, you can either put a comment in the chat around why or why not. These have been topics of discussions, although these can also be opportunities for silent reflection or for topics of discussion towards the end of the presentation. I didn't see the second poll question pop up. Oh, there we go. So if we can go to the next slide, while people are answering the second question, we can think a little bit about the strategies that individuals have utilized to engage patients in this discussion, and the options that we've provided is following the patient's lead and not talking about these connections, using harm reduction recommendations, employing shame and guilt as strategies to affect change, thinking about providing information about statistics and risk, or have you been using motivational interviewing principles? And while we're answering that question, we can move to the next slide and think a little bit about our last poll question, which is just wondering around what patient responses have been at the times that individuals have been providing education about this topic. And the options include I've not spoken to my patients about this. Some of my patients view COVID as a hoax and so have not been able to be engaged in a discussion about risks of substance use. Some patients may be dismissive and may minimize the associated risks. Some patients may be aware of a risk, but have some ambivalence around making particular changes. Some patients may agree that nicotine usage may confer some risk, but are not convinced about the risk of cannabis usage in particular. And some patients may share these concerns with their providers and have been actively trying to make positive changes. And as we're answering that question, we can go to the next slide. And just think a little bit about what our own individual attitudes or perspectives about this topic is. And as we're answering our last poll question, I will hand over the control of the slides to Dr. Atkinson, who will talk about the basic sciences of COVID-19 infection and the associations of cannabis usage and nicotine. And then I will return to my slides after our other two presenters. So here I am, I'm going to try to share my screen. And it looks like this may work. And I'm going to do it. All right. Thanks, y'all, for coming out today. This is a nice topic. It's very timely. And talking about COVID-19 substance use, I'm going to talk about the basic sciences. No conflicts of interest to disclose. Understanding objectives. We're going to talk about the basic science of the SARS-CoV-2 infection. We're going to review the science of smoking and the effects that might pertain to SARS-CoV-2. And then we will review the effects of THC on the immune system. Not all of them, but okay. So first of all, you know, with SARS-CoV-2, I'm going to try to, okay, SARS-CoV-2 is what's called a SARBECA virus. It's a lineage B beta coronavirus. And that is important because basically SARS got its name because it is the same family of viruses that caused severe acute respiratory syndrome and that original SARS disease that had a 10% mortality rate due to this, you know, acute respiratory distress syndrome that, you know, was such a scary thing that came out in 2002 or 2003. Luckily, SARS-CoV-2 is not as fatal as SARS-CoV, but it shares a lot of similar properties. One of them is that it enters the host cells by attaching to ACE2. That's angiotensin converting enzyme. And then there's another important protein involved, which is a protease, basically something that cuts a protein, and TMPRSS2, transmembrane serine protease number two, will clip the virus, you know, at that, at the S1, S2 site. And that facilitates the binding and entry of the virus into the cell. And casepsin is also another enzyme that is expressed in similar tissues that another protease that can cut the virus and help it enter the cell. The pathogenicity and transmissibility is greatly enhanced inside the cell because the SARS-CoV-2 virus has something called a furin cleavage site. That furin cleavage site is a bunch of basic amino acids that all come together. There's a PRRAR sequence, so that's proline, arginine, arginine, alanine, arginine, three of those arginines are basic at the S1, S2 junction in the ancestral strain, and, you know, cutting there is what seems to be the key to its transmissibility. It can also be cut at the S2 site to create a fusion peptide and transmit with cell to cell transmission. So I will show you a little bit of what that looks like. There's the SARS-CoV-2 virus binding on the H2 protein, it's clipped, it's able to enter the cell. But what's really interesting is that this enzyme furin will cut the protein, the spike protein again of SARS, and that pre-processing of the protein makes it more infectious when it goes to the cytoplasm, but also there's this S2 prime unit actually enables SARS-CoV to transmit from cell to cell, kind of like the membranes of the cells fused together doing something called syncytia, you know, cells coming together. And that is how SARS-CoV-2 can evade the immune response. So and this is one of the things that actually, you know, causes a problem in the Delta variant. The Delta variant has been more infectious because it has an RRRAR site instead of a PRRAR site. And what you can tell here is that, you know, if this needs ACE2 to enter the cell, if you have more ACE2 receptors, then that's the increase the probability that the virus can enter the body. If you increase the expression of TMP or SS2 or cathepsin, that means that you're going to have more abilities to cut that virus in the appropriate location and the same with furin, you're going to have more of the proteins expressed that the virus manipulates to gain control of the cell. And we want to look at how smoking or anything else affects the levels of those proteins. So the contributors to host vulnerability, you know, as I mentioned, the increases in the proteases, also the increase in ACE2, and also if you have a decrease in the immune function of the host, that all can conspire, all those factors can come together to make that host more vulnerable to infection. So early on the pandemic, CHI et al, you know, took existing studies of the expression of TMP or SS2 of furin, of ACE2, and it looked at what smoking did to those specific proteins. And furin expression was increased, ACE2 expression was increased as well. The effect size here of an ACE2 expression was a 0.25, you know, 0.25 standard deviations, very low p-values, so it was a very clear-cut finding. And also, you know, what's interesting here is this is in people who've ever smoked versus people who've been lifelong non-smokers. So you have a wide range of tobacco exposure in those ever-smokers, whereas the non-smokers are, you know, they're all at zero. But there's a big difference than somebody who smoked, like my mom did, two cigarettes for a week for two years, you know, versus, you know, somebody who's like three packs a day, like other members of my family. Furin expression was increased, TMP or SS2 was increased, and the effect sizes weren't very large, but again, this is just amalgamating together those, a lot of these people who have been ever-smokers versus non-smokers was a big contributor to a lot of the effect size, but it, you know, that may underestimate what the real effect of smoking is. It is unknown whether or not smoked THC produces these effects. We don't know if THC causes upregulation of TMP or SS2 and furin, you know, there just isn't enough data. Smokers also were specifically found to have increased alveolar macrophage ACE2 concentration and casepsin, that other enzyme that I mentioned, that protease was also increased in smokers. So take-home message here is that you have a lot of different proteins that are critical for SARS-CoV-2 transmission and infection that are being increased by cigarette use. And Kelicitis et al. this year showed, yeah, there was a tenfold increase of ACE2 expressing cells in tobacco cigarette smokers, five-fold increase in expression of TMP or SS2. The mean fluorescence intensity of the enzyme furin, you know, looking at just, you know, its activity with that fluorescent biomarker, you know, the furin activity was increased in smokers, as well as ADAM17, which, you know, it's a little more complicated, I'm not going to get into that, but this is a very good paper that came out this year. So does this lead to real-world pathology? Well, we know that respiratory infections are strongly associated with smoking pre-pandemic. Archavi in 2004 did a study on that, and we also know that there is strong indication that COVID-19 is associated with smoking. There was data from COVID patients in Wuhan that revealed a 14-fold increased risk of COVID-19 progression, and also the history of smoking compared to nonsmokers, and that could be the increased ACE2 expression. Smoking increases a lot of chemicals that could be irritants, and that could be some of the pathophysiology. It also impairs mucociliary clearance, and in one study, you know, it showed that it carried an odds ratio of 1.96 for severe COVID-19 infection versus nonsmoking, and a 1.79 odds ratio for a more critical condition. So there are some studies that have shown not—well, I'm sorry, there are some studies that did not demonstrate an effect of smoking, but if you're having a very elderly population, you know, a lot of them may have stopped smoking years ago because, you know, they're elderly, and I suspect that was one of the confounding factors in this study from the Veneto region of Italy. Other Italian pensioners might not be able to afford cigarettes, et cetera. So this brings up this next question, because what's all the rage these days is not good old tobacco, good old combustible tobacco, but vaping nicotine. You know, is vaping associated with COVID? And Srini will talk about some of the data about that coming up later, but the first thing I want to get out there is that E-Valley can be confused with COVID. There are differences with E-Valley. E-Valley is a central lobular pathology, and the COVID pneumonia is usually present in the lower lobes. E-Valley has lipid-laden macrophages that are universally present. E-Valley always has those. But if you do have COVID symptoms and, you know, a young person in the presence of a negative COVID test, you really should start thinking about whether or not this is E-Valley, you know, that's one of the things to start asking on the history. You know, the similarities are striking enough that there's a little conspiracy theory going around the internet that, you know, COVID-19 was in America earlier, and it was just what we were calling E-Valley was really COVID-19. But there's tons of reasons why that is not true, so don't worry about it. But it just, it kind of goes to show just how overlapping the pathologies are. You get brown glass appearance, lungs, et cetera. Respiratory infections in general have been tied to vaping. And there's a lot of questions whether vaping really could increase risk of COVID. Now, e-cigarettes, in a recent study, did show that they caused an increased level of urine expression. And TMPRSS2 also showed an increase in the mean aminofluorescence. It was a trend. It wasn't quite physically significant, but it had a 0.077, so it's getting close. So we know that e-cigarettes can do some of the similar things to combustible tobacco, which isn't entirely surprising. So I wanted to just shift gears over to the cannabis side of things, you know, talk about cannabis, inflammation, and the viral response. So the immune system is a double-edged sword. You know, you have something called the acute respiratory distress syndrome, sorry, psychiatrist here, acute respiratory distress syndrome, ARDS, and that's where the immune system effectively reduces, well, I'm sorry, and that is where, you know, you have a cytokine storm that causes an immune mediated pathology that is very often fatal, both in the original SARS and in SARS-CoV-2. The immune system is very important, not only in this pathological and fatal process of SARS-CoV-2, but also in defending yourself against getting the infection in the first place, right? So the double-edged sword is this, is that down-regulating the immune system could have benefits in late-stage infection. You know, this hasn't really been demonstrated in humans. And then there's this balance between the decreasing the overreactive immune system versus decreasing the innate host immunity and other host immunities and a potential reduction in the severity of ARDS is kind of a difficult balance. But, you know, one of the things you see is that with THC use, you know, the first thing that's going to happen to you is you get infected. So if you're using marijuana, you've increased your risk of getting, theoretically, because of the immune suppression, increased your risk of getting the infection. But then once you have the infection going and you're at risk for ARDS, then, you know, it's possible that this immunomodulator might help protect you. So, you know, and this is one of the things that immunosuppression has these negative things, like if you slow down the interferon response in the body, you're going to reduce the organism's natural immune response to SARS-CoV-2. You're going to become more infection vulnerable. And on the other side, of course, is the cytokine storm that causes ARDS. And, you know, you have to kind of balance that. So the interferon response, it was named, you know, interferon because it aims to interfere with the viral processes in the human body. Type 1 interferons, like interferon alpha and interferon beta, trigger an initial immune response that prepares the body in general for, you know, inflammatory response. And in specific cells with these interferon alpha receptors, when they receive a signal from interferon, they go into a different mode and they fail to support viral replication. So when you activate interferon, you slow the virus's ability to replicate within those cells that have been signaled. One of the key players in this is something called nuclear factor kappa light chain enhancer of activated B cells, which we all call NF kappa B. And it's a critical first step in this cascade. And it also is a major player in ARDS and has been a target of intervention. This is from Rucconiello's virology textbook, and you see the initial response in the body and the inflammatory role against viruses is that, you know, you would have interleukin 1, interleukin 6, TNF alpha, tumor and corrosive vector alpha, all of that kind of going around the body. And that is going to produce a lot of the symptoms of a viral infection, fever, fatigue, lethargy. And this is important because that's how the individual knows that they're sick. If you have some kind of treatment that decreases the interferon response, if you have something that's not going to allow the interleukins to cause these harms, the individual doesn't know they're sick and could perhaps transmit the virus more. They could walk around as, you know, a viral infection is building in their body and place themselves more at risk. So, and this is one of the things that, you know, the other side of this is the cytokines, you know, have this important role of producing acute phase proteins like fibrinogens, C-reactive proteins, serum amyloid protein, all those things that you can measure in an infection to show there's this process is going on. And they will also, colony stimulating factor will go to colony stimulating factor will go to the bone marrow and crank up hematopoiesis and allow the mobilization of lymphocytes. Now, if you look at cytokine storm, you see that, wow, there's a lot of the same players in here. You know, there's NF kappa B is an important player in cytokine storm. There's also IL-6 and IL-1. These different cytokines that we've talked about, they both play a role in this preparing of the body and in the, when they are actually overwhelmed and they can trigger the ARDS response. So, cannabis has been shown to contribute to immunosuppression, including an increased risk of lower respiratory tract infections. There's a couple of studies that demonstrated this. There is some difference between how cannabis is smoked and how tobacco is smoked. Cannabis is typically held in the lungs longer and there's a deeper breathing, deeper inhalation, deeper drags that happen when people are using THC. Cannabis has been shown to reduce cytokines in the body and inhibit the antiviral interferon response. Enrique's 2018 demonstrated that. And there are also a very similar thing to what is seen in smokers is deficient alveolar macrophage responses. But in this case, I think that cannabis has a stronger ability to suppress the alveolar macrophages than tobacco does. And that's probably due to some of the immunomodulating characteristics that I'll briefly talk about. There is some data, of course, that THC and CBD can cause a reduction in the pro-inflammatory cytokines. CBD can cause that decrease by itself. The two of them combined can cause it. Basically, in that combined treatment, you saw a reduction in TNF-alpha, interleukin-1, interleukin-6, and the gamma interferons, which are, I think, more active in the gut. So there is a response that we can see in the human body. And long-term, delta-9-THC, regular use, like many of our patients, they are going to have an inhibited pro-inflammatory response in the minor salivary glands of simian immunodeficiency virus-infected rhesus macaques. Another study by Cozella demonstrated that there were reductions in IL-1, interferon-beta-IL-6, and NS-kappa-B. And they proposed actually a CB2 receptor-mediated mechanism. And also, possibly, the PPAR-gamma receptor is involved in immunomodulation. And that's one receptor that we are starting to appreciate how PPAR-alpha and gamma might be targets of THC and other cannabinoids. So here's the basic science that shows that, guess what? If you give a CB2 receptor agonist, yeah, you decrease a lot of the expression of NF-kappa-B. That's in this graph on the left. And the lipopolysaccharide model of inflammation is well suppressed by HU308. On the other hand, the CB2 receptor antagonist, AM630, actually made matters even worse than the control. So it actually enhances the pathology. And you put them together, you get something that looks a lot like a control. So it's interesting. I love it when science works that way, the way we'd all hope it did all the time. But there's a reason why we do the experiments. And this is where, when I say we need to do experiments, we don't have a lot of data on SARS-CoV-2 and THC use. We don't have a lot of real-world data, but we have maybe a little bit, kind of eye-opening. One of the things that is very important about the immune response is toll-like receptor. And toll-like receptor 3 is an important signaling pathway for a lot of vaccines. This isn't really, this isn't based on the study of the Pfizer and Moderna vaccines. But in a novel subunit vaccine against SARS-CoV-2, it found that the TLR3 agonist will increase the effectiveness. And there is some data that lower peripheral TLR3 expression is possibly associated with unfavorable outcome in severe COVID-19. And if cannabis is disrupting TLR3, then that does raise the question of whether it could cause, they could make the individual more predisposed to severe outcomes. And at the same time, as I mentioned before, there sometimes is a real benefit to suppressing the immune response. So there was one industry-sponsored study in Canada that was very interesting. It was trying to look at strains that might have anti-inflammatory activities. And it was testing multiple different cultivars of cannabis, testing high CBD strains. And they found that like three of the strains really did show a reduction of IL-6 and TNF-alpha. But it was really hard to differentiate any pattern to this. Like some were high THC, some were low THC, some high CBD, some high cannabinol, some low cannabinol. There was no real rhyme or reason to it. They did find through analysis that beta-cariophyllene did possibly correlate with this reduction in inflammation from the real world, or not, I shouldn't say real world and human, but through animal model tests. And this is one of the difficulties is that because we don't have data on this, people are relying on what little they know. And what little they know often gets pushed to them by people who might have an agenda. And so some of the people within industry have been promoting very much this idea of marijuana is a treatment for COVID. It's going to make everything better. Cannabinoid modulation is a very real possibility of treatment of COVID-19 and other viral infections. We don't really know how to do it yet. And I think it is very important to let patients know that this system is theoretically going to be valuable in modulating the body's response and the body's overly inflammatory response to viral infection that would cause ARDS, but also could predispose them to more infections. So we have some possible correlations. And this is one of the things that I think we want to keep our mind open to this and we want more data out there. And as Srini will present on is that there is some stuff we know from the real world, but right now, the way I would leave this is that the basic science asks a lot of intriguing questions and doesn't give very many satisfying answers. So I wish that I had like more concrete scientific direction to give you on THC, cannabidiol, and SARS-CoV-2, but I don't. I think that with nicotine and tobacco, it really does look like all the indicators are pointing in the wrong direction as far as severity. And we just need to keep our eye on the literature and also advocate for these studies to be done. Can you see my slides? Yes, it looks great. Looks right? Yes. Okay, thank you. So thank you, Dr. Atkinson. I think, you know, you summarized the pathogenicity of COVID and how cytokines and interferons will play in infection, COVID infection. And you touched upon some of the studies, recent studies that talked about infection with COVID and cannabis use. So my presentation, I'll be talking more about some real world data that we had recently seen published in the last few months. So we'll be talking about that. Before I go into any of my presentation, I have no disclosures, no financial disclosures, no conflict of interest to disclose. And as I said, we'll be talking more about the evidence-based studies on substance abuse and COVID disease prevalence and transmission in people using cannabis and nicotine. So since we have been in the middle of pandemic for the last two years and, you know, it's not slowing down in time with so many deaths and new infections and still going on, we have to understand the possible mechanisms of, you know, disease transmission, how it affects, you know, how it affects individuals with substance use, how it affects individuals with mental health. We need to understand that and more research is needed. Even though there are a lot of studies that were published in the last two years since COVID emerged, there are a lot of studies that are systemic reviews or, you know, but there's no data until recently that was published. So we'll talk about that in a minute. So we see that there is cannabis and cannabis use disorder lifetime. Cannabis use disorder is 7.3% in the population. The lifetime prevalence was 32.5%. And so there are a lot of correlates for non-medical cannabis use, which includes younger age, male gender, unmarried people, lower income, residing in a state where there are medical marijuana laws. So non-medical cannabis use has been associated with psychiatric, more psychiatric disorders and substance use disorders. Okay. Sorry to interrupt, but Srini, I don't see your slides advancing. I still see them on the first slide. I'm not sure if others are having the same issue or not. Could one of the triple AP staff comment if they're seeing something? Yeah, I'm noticing that as well. Okay. So can you guys see it now? Yes. Okay. Thank you. Thank you, Martha. So I think we talked about that already. So we're talking about this epidemiology slide. We just talked about that. So we'll just advance to ... You see it now? Advancing. Okay. So this is the data from the Monitoring the Future study. So the past year marijuana use did not change. And since 2019 and 20, we still have almost the same amount of marijuana use in the 10th and 12th graders. Also on the daily marijuana use, I can see the similar data, maybe a little less than 2019 in 8th graders and 10th graders. And there's a slightly increase in marijuana use in the 12th graders. And as far as nicotine vaping, the data is still the same from 2019 and 20. The trends are the same except for a little decrease in the 12th graders on nicotine vaping past year. As we see the daily nicotine vaping, we see a decline in 2020 compared with 2019 in 12th graders. So there's still a lot of vaping of marijuana and also nicotine going on with adolescents. So that is very concerning, especially during the times of COVID, because we know that from Dr. Atkinson's presentation that a substance abuse can increase the susceptibility of COVID. And again, this is past year marijuana use of vaping in 8th, 10th and 12th graders. It's still high, but it is trending down compared with 2019. Maybe it's the availability due to pandemic, the availability of marijuana and the accessibility of marijuana is reduced due to pandemic. Maybe that's the reason that we are seeing that. Again, this is daily marijuana use versus past year marijuana use in the adolescents. This is again, nicotine vaping, which is holding study for the 8th and 10th and 12th graders in 2020. There is some decrease in vaping, but still we see a lot of 8.6% of 12th graders still vaping. And the popularity of vaping has gone up. Recently, if you see the high school students using tobacco product versus e-cigarettes has significantly picked up since 2017, 2018 and steadily going on. So this is a study that looked at US middle and high school students reported use of e-cigarettes. So in 2020, there are about 3.6 million students that used e-cigarettes. And then 80% of the current e-vaping or e-cigarette users, they prefer flavored cigarettes. And then the disposable cigarettes came into play recently. And that has been significantly increasing since they arrived in last year. So it went from, if you look at the e-cigarettes used in middle school from 3% to 15%. And then from high school students, it went from 2.4% to 26% last year. So that's a significant increase of e-cigarette use comparing with the previous years. And this is just a basic knowledge about cannabis. And since Dr. Atkinson talked about the pathogenicity and all that, I'm just going to skip some of these slides, but just for completion sake, I'm just using these slides. So the two main components of marijuana is like psychoactive components, THC, tetrahydrocannabinol, and then the other cannabidiol, which is CBD. They're almost same in the structure, except for the hydroxy molecule and the cannabidol that we see here on the right side. And as we saw this in the previous presentation, I'm not going to touch much on this receptor system, the CB1 and CB2 endocannabinol receptor systems. That's where this marijuana works. And this is an important slide considering the availability of marijuana these days, and then how potent that is compared with the THC and CBD ratio. In 1994, the THC to CBD ratio was 14% 14 times higher. Now in 2014, it was 79 times higher. And I don't have the recent data on this, but I think it's going down a little bit, but it's still at over 70%. And we've seen this in Dr. Atkinson's presentation about how marijuana affects immune systems and how it works on proteases and ACE inhibitors. This is again, some of those studies that looked at marijuana and respiratory infections in patients. So there is a 14 times increased risk of COVID-19 in individuals with history of smoking compared to non-smokers. This is a study by Liu in 2020. And there is another study that looked at the respiratory ARDS in patients with COVID-19. There is another study that looked at the respiratory ARDS in patients with COVID-19. And regarding the e-cigarette or vaping-induced associated lung injury, there are several deaths in 2020. There are 68 deaths that were reported in 29 states that are aged between 17 to 75 years. There were total about 3,000 cases, 2,800 cases that were reported. So out of these cases, about 2,600 were hospitalized. And out of those, 66% were males. And out of those people, the 82% of patients that were admitted for EVALI were using marijuana-containing products. And then 57% of them reported using nicotine-containing products. So the good thing is the trend is going down. The use of these products is going down. The incidence of EVALI is going down. But since we still are in the COVID era, I think anything can be possible. And the infections can go up. And this is a study that examined the potential of cannabis and how it is correlated, like cannabis use disorder and cannabis use, with the mental health issues, like especially ADHD, major depression, and schizophrenia. They looked at about 22 different various psychiatric and health manifestations and looked at how cannabis is affecting that. So let me show you this thing. So here we have the diamond shape. This is the cannabis use disorder. and then the circle is cannabis use. And if you look at the correlation with ADHD, it's ADHD is highly correlated with cannabis use. And the people that have cannabis use disorder have increased risk of ADHD. And then same here with the alcohol use disorder, and then also major depression. So there is a significant correlation with that. And then, so this is a study that looked at liability of cannabis use disorder and COVID-19 hospitalizations. How does cannabis increases the risk of hospitalizations? So basically there are several factors that play, behavioral and lifestyle factors, living in a crowded neighborhood, living in a homeless shelter can also increase the risk of hospitalizations with COVID infections. So there is a genetic vulnerability to hospitalization after COVID-19 infection. If they were using combustible psychoactive substances like marijuana, right? And there is association between cannabis use disorder and COVID-19, when they accounted for marijuana tobacco and smoking, if they ever smoke regularly, if they smoke cigarettes for days, if they're actually were smokers and then stopped smoking. And when they actually initiated smoking and when they stopped smoking. And there's also a lot of other factors that looked at. So there is a significant correlation or association with cannabis use disorder and COVID-19. And then if somebody is using cannabis regularly, there is an increased chance of hospitalization due to COVID-19 respiratory infections or complications. Like we talked to earlier, it could be because of upregulation of ACE2 inhibitors or receptors, cytokines, and then also proteases on this inflammatory pathways. So this is a study that was done at Stanford looking at adolescents who are smokers. And they looked at both nicotine and also cannabis. So COVID-19 diagnosis was five times more likely among ever users of e-cigarettes. And then if you combine that with cannabis users, it is seven times more likely they have a diagnosis of COVID. And then if they have both cannabis use and tobacco use or e-cigarette use in the last 30 days, they're 6.8 times more likely to have a COVID diagnosis. So as far as like testing goes, testing was nine times more likely among those past 30 day and dual users of cannabis and nicotine, which is compared to like only 2.6 times for patients. I mean, for people that are using e-cigarettes only. So your risks are significantly increased with both marijuana use and e-cigarette use. And the symptoms were 4.7 times more likely among past 30 day and dual users. There are more symptoms compared to just one, either cigarette use or marijuana use. So it was so prevalent in California that they have to add smoking and vaping of nicotine and cannabis to the COVID triage protocol because of more frequent cannabis use and e-cigarette use. So this was added in the protocol for the screening protocol in this hospital. So this is a study that was released, I think in October. This looked at the COVID-19 risk and outcomes in patients with substance use disorders. And they looked at the electronic health records of several states. And they looked at 360 hospitals across the US from 1999 until 2020. So they included opioid use disorder, tobacco use disorder, alcohol use, and cannabis and cocaine use. And then about... So out of all those patients that they looked at, 12,000 patients were diagnosed with COVID-19. And then about 1,900 patients were diagnosed with substance use and COVID-19. So people with substance use that are more susceptible to COVID-19, like we talked earlier, especially with opioid use disorders, they are eight times more likely to have COVID-19 infection followed by tobacco use disorder. Patients with substance use who developed COVID-19 have significantly worse outcomes if they're admitted to hospital. There's increased significantly higher rates of hospitalizations and high rates of death if there are substance use. The same adverse outcomes if there are substance users and they have racial disparities, especially if they're African-Americans, they have significantly higher risk of developing COVID-19 than their white counterparts. And there is also increased risk of hospitalization and increased risk of death in African-Americans compared to whites. And they're more likely, people with SUD, they're more likely to come from a low socioeconomic background. They're incarcerated, homelessness, and also lack of access to healthcare also increases the risk of hospitalization, infections, hospitalizations, and death. So especially for patients or people with COVID, then during the COVID times, people that are substance users, they have reduced access to a lot of substances. So they are in a withdrawal and the withdrawals can be an emergency sometimes and it can also lead to death in some patients. So COVID has a potential to worsen the withdrawals in these patients. And then sometimes, we see a lot of fentanyl use now that can lead to overdose and death in people that have opioid use disorder diagnosis. So this is another study that looked at the increased risk of COVID-19 breakthrough in patients that are vaccinated, fully vaccinated for COVID and are substance users, right? So the breakthrough infections range from 6.8% for tobacco use disorder to 7.8% for cannabis use disorder. And after controlling for demographics like age, gender, and ethnicity, the highest risk breakthrough infections was seen in patients with cocaine use and cannabis use disorders with a hazard ratio of 2.2 for cocaine and then for cannabis, it's 1.92. And there's also, this is significant here, risk was higher in substance users that received Pfizer vaccine than the Moderna vaccine. I don't know, it's hazard ratio is 1.49. I don't know how they came with this, but they said that the risk was higher for Pfizer compared with Moderna. In the vaccinated people, substance users, the risk of hospitalization was higher with 22.5% for breakthrough infections and 1.6 only for non-breakthrough cohort. And so these data suggest that fully vaccinated individuals with substance use are at higher risk for breakthrough COVID-19 infections. And because they have a lot of, like we discussed socioeconomic determinants of health and other comorbid health issues that can lead to hospitalizations and deaths. And this study looked at patients with mental health disorders that are more susceptible to COVID-19 and death. This was also published in 2021, which is a recent publication. So they found that depression was seven times, patients with depression were sometimes more likely to become infected with COVID-19 than people without a mental health issue or disorder. And the risk is also increased with patients with schizophrenia as well. And also African-Americans had a higher odds of a COVID-19 infection than Caucasians. Again, those with mental health disorders. And the risk is also high for women with mental health disorders. And they are at a higher odds of having COVID-19 infection, two times more likely. Right? And patients with both recent diagnosis of mental health, mental disorder and COVID-19 had a death rate of 8.5%. That is pretty significant. When compared with 4.7% among COVID-19, patients with no mental health issues. And the hospitalization rates were also high compared to other patients with no mental health issues. So this is my study. I just added this study to see how the trends are in other countries. So basically this study looked at cannabis use overall in the population since the pandemic. So if there was an increase in cannabis use versus decrease in cannabis use. So overall there is an increase in cannabis use during the pandemic, especially when they looked at the central region of Canada there is an increase in cannabis use. In age groups, certain age groups from 18 to 29, there is an increase in cannabis use. And then people that had less education, college education or university education were increased use was seen. And then patients that were worried about personal finances, there is an increase in cannabis use. And this is also another study that looked at medical cannabis users. They actually changed how they use their medical cannabis. Were they vaping? Were they using, are they eating eatables? So 16% of the medical cannabis users changed their route of cannabis administration switching to non-smoking forms. That is a major change that was seen in medical cannabis users. So. So, how does, you know, substance use disorder and mental health issues affect susceptibility to COVID? Especially because this is a public health problem because of homelessness, you know, there is a chance of increased crowding in shelters, increased risk of respiratory infections due to that, and then a lack of resources can also increase risk of COVID infections. And also, they rely on food banks and community food centers for their day-to-day meals, which are unable to adhere to home confinement. So in conclusion, COVID-19 has rapidly changed a lot of restrictions in daily activities. Due to COVID-19, and persons with substance use disorder are at increased risk of COVID-19 infections and also withdrawals because of, you know, lack of access to substances. And because of restrictions due to COVID, there is a loss of traditional support, in-person support systems, and also patients who are attending like AA meetings, NA meetings, were not able to attend, so that is also escalating substance use. And also, a lot of research studies have been affected due to COVID because there is no participant intakes or research visits were canceled because of COVID-19. It's also affecting the substance abuse research. So safe housing and access to medical care and equitable reach of support systems is needed to curb this gap. And as far as the vaccines, those vaccines are highly effective, but effectiveness in individuals with SUD might be curtailed by immune system compromise and also a greater likelihood of exposures from the community due to new variants. Thank you. So if I can ask the AAAP staff to please pull up my slides and we can start at slide number eight. In the meantime, I want to thank Dave and Srini for their amazing presentations and presenting sort of the basic science around COVID and nicotine and cannabis usage and really thinking about the real-world data that is currently in existence. I think as they've presented, there's some conflicting information, there's some uncertain information, but I think that we are still able to discuss these topics with our patients. And my task today is to think a little bit about how we do that and what structure we use. When I work with my, and I should mention, I don't actually have any relevant disclosures or conflicts of interest. So when I work with my patients and I'm thinking about effecting change, I'm frequently using the self-determination theory, which is a theory of human motivation and personality that concerns people's inherent growth tendencies and their innate psychological needs and is concerned with motivation behind choices people make and thinking about the absence of external influence and interference in that. And so thinking about the degree to which human behavior is self-motivated and self-determined. And so there are three major components that go into the self-determination theory that I think are fairly consistent factors that we as addictions providers and psychiatrists in particular may be thinking about with our patients. And those concepts include the concept of autonomy, which is an individual's desire to be a causal agent of one's own life and act in harmony with the integrated self. And that doesn't mean that there's an independence from others, but constitutes a feeling of overall psychological liberty and freedom of internal will. And so this is the sense of being able to take direct action that will result in real change. And so what has been found is that when a person is autonomously motivated, their performance, their wellness, and engagement are heightened rather than if an individual is told what to do. The second principle is that of competence. So it's been found that individuals seek control of an outcome, they try to experience mastery. And so unexpected positive feedback on a task can actually increase intrinsic motivation to continue engaging in something. And so essentially, this is simplified to the concept that when an individual feels equipped and competent in something, they're more likely to engage in actions to continue this. And relatedness relates to the concept and the will to interact with and be connected to others, which are also major drivers for change. If we go to the next slide, I think we can use these principles to guide our engagement with patients. And I'm not going to spend a lot of time talking about building the therapeutic alliance or individualized treatment, because I think that these are principles that are frequently talked about in addiction and substance use perspectives. But simply to make the linkage that this theory of human motivation of the self-determination theory actually relates very well to the type of strategies that we're using with patients. If we go to the next slide, what that means practically is thinking about building rapport, creating individual treatment plans, and establishing the process of self-advocacy, and also using brief interventional therapy to have developmentally appropriate competence building in multiple domains for patients, and being able to build on that relatedness, those principles of autonomy, and also competence in effecting change. Creating realistic goals and determining the appropriate settings for treatment with patients as we talk about their substance use, for example, their nicotine or cannabis usage, and also connect that with concerns about the affected risk on COVID-19. If we go to the next slide, this is a slide talking about motivational interviewing. I suspect that most on the presentation today are aware of motivational interviewing as a client-centered counseling style that was developed by clinical psychologists Milner and Rolnick that is a directive and guiding style for eliciting behavior change by helping clients explore and resolve ambivalence and around changing their personal behaviors. It builds on these concepts that I've just mentioned, and it's a very effective tool that we use in addiction treatment, but also is the strategy that we would encourage in this moment to really think about discussing change with patients around their substance use, their awareness of the connections around the substances that we've talked about in their COVID risk, and also vaccine hesitancy. Motivational interviewing has been extensively studied for substance use and has shown positive outcomes in substance use. One of the principles, if we move to the next slide, that I think is particularly important to use in this topic is called the elicit-provide-elicit framework. We can move to the next slide. This is one way that we can share information when working with our patients, and it may be more effective for fostering behavioral change because it lets the clinician identify and respond to factors that may make change challenging for patients, such as cultural values and personal habits. The corollary to that is that if we take our usual approach to focus only on an individual's knowledge deficit or knowledge gap, we may not be able to uncover the real reasons that patients make particular decisions. The way we use the elicit-provide-elicit framework is by talking with the patient about their existing knowledge. We try to determine their own interest in a particular topic, and we ask permission before sharing additional information. This allows us to understand the patient's reasons for change, which is evidence-based is the most likely course of exploration that is likely to lead to additional change. After that, we want to provide some additional information. We want to affirm the goals, the values, the priorities that the patient has told us, provide bite-size pieces of information that are understandable, relevant, and help support autonomy and decision-making and also that competence piece. Then from there, transition back into a phase of eliciting more information about the reactions and questions that an individual may have in response to that information that was provided. It also can allow for collaborative decision-making in terms of providing next steps. Next slide. The principles behind starting with an eliciting question from the patient and asking them of what they know or would like to know and asking permission to share information is to avoid starting off a conversation with an argument or a lecture. It expresses an openness to listen to the other person's point of view and their questions, and that shows the person that you're working with that you're genuinely, respectfully trying to understand their point of view. That allows the individual to be less likely to reflexively put up walls. It opens a space of dialogue, fosters connection, and mutual listening. This does require developing a genuine non-judgmental willingness to hear the other person's point of view and also to tolerate those differences of opinion and roll with resistance. When you are willing to listen to an individual, we may actually be surprised at how much more likely they are to listen to us. Once this connection and this line of communication has been established, there may be more willingness from the individual to actually listen to some of the information that you've learned about COVID-19 and cannabis, COVID-19 and nicotine usage, or also about vaccination. You're showing respect for the other person, giving them the opportunity by asking permission to share this information to consent or refuse, which again makes it more likely for them to listen to you. If they have provided that consent and that permission, this is the opportunity to transition into the provision of information and to give science and facts to an audience that is more likely to be receptive. Some questions that we can use to elicit information is by asking, what do you know about X, Y, or Z topic? Do you mind if I express my concerns? Can I share some information about this topic with you? Is it okay if I tell you about what we know? Next slide. When we think about providing information, we want to provide that in a neutral, non-judgmental fashion. Practically, there are some suggestions that we may want to avoid personalized language in this. Reframing from the use of I statements or I believe, or actually use statements in particular as we're talking about the evidence base, we want to talk about research or studies or what individuals and other groups have benefited from. These are some examples of language that we can use. Next slide. Once we have provided the information that we are looking to convey to the individual, we want to take a step back and once again, elicit the patient's interpretation. What meaning has the information that you have provided to them held? What additional questions do they have? How does this information that has been provided, how do they reconcile that with the information or their understanding that they entered the conversation into? That allows for developing more questions, provision of more information, or sharing that approach and that perspective, which can be very helpful and tailor and streamline the conversation in a particularly effective direction. From there, you can ask the question, where does this leave you? How can I help you or what would you like to do next? That allows for the development of this collaborative treatment plan that can be tailored to the individual that you're working with, but in a way that is in line with their goals, their priorities, and their values. It's going to be that much more likely for the individual to follow through, as opposed to these situations where we are indicating to patients what our own individual goals for them are. Next slide. So here are some practical tips for using the elicit-provide-elicit framework. I already mentioned using the neutral language and trying to avoid sentences starting with I or you. It can be helpful to use conditional words rather than concrete words, might, perhaps, consider versus should or must. And all of this encompasses the utilization of the spirit of motivational interviewing. So we want to make sure that we are recognizing where a patient may be ready to make change and providing relevant advice or information or guidance rather than overwhelming with too much information. If we go to the next slide, we look at an example of a particular framework that might be considered. We may start by asking the patient, what do you know about how smoking, cannabis, nicotine, your opioid use disorder, affects your risk of developing COVID-19? We want to provide the patient a nonjudgmental, compassionate environment to share their perspective on this. And then we can provide some further information if the patient has agreed to that. We may say what we know is that smoking tobacco is associated with the increased disease severity for those that contract COVID-19. Individuals with mental health conditions in certain minoritized populations may be at higher risk of developing COVID-19, having a severe illness course, and research shows there may be higher rates of mortality. As we share this information, we're having a bidirectional conversation back and forth, and we may wrap up by saying, tell me what your thoughts about this are, how would you like to proceed next with this information? Next slide. And so we can use these principles both as around enacting change and listening for change talk around substance use, such as cannabis and COVID, but we can also apply these principles for individuals that are COVID-19 deniers or have a sense that this may be a hoax, and also for vaccine hesitancy. So the information that is available at this point in time suggests that people who are vaccine hesitant usually have mixed feelings around vaccine access, and so in the face of ambivalence, a lot of us may be tempted to list all the ways that lives will be better or safer if they get vaccinated. If we instead, and this could be applied to our personal or professional lives, instead utilize the elicit-provide-elicit framework, we can get the individual's thoughts on this and some of their own motivations for vaccination or what preventing illness might be. And so again, using the principles of exploratory open-ended questions, such as do you think there could be any advantages to being vaccinated or what do you think they might be, builds the individual's own internal motivation and allows for this change to happen because the ideas are coming from them rather than from you, and they know which principles are going to be most guiding and most important for them to change. And that can include goals of wanting to travel more, to protect a loved one, and we enter with assumptions based on our own experiences about the patient population or the individual that we're working with, and we don't know this for sure until we work with them. Another challenging but important topic in this is the importance of being patient, so realizing that a single conversation may not be enough to change somebody's mind, especially if there's a lot of reluctance or worry around and ambivalence around making change or worry about vaccination. And so this may be a process, as motivational interviewing is, that extends over the course of a few conversations to lead to change. And, you know, just going back to I feel like I can't highlight enough the importance of maintaining that stance of openness and respect to foster the growth of connection and trust. And so an individual may be more likely to revisit the topic with you in the future. We go to the next slide. This is just an example of the recommendation by the CDC to actually incorporate these principles and these ideas that come from motivational interviewing in how we talk about COVID-19 vaccination with friends and family and around vaccine hesitancy. And so if we go to the next slide, we, you know, I just want to share that this might sound nice and this may be a nice concept to utilize, but many of you may be thinking and wondering what the evidence base is. And this is a recent paper out of Canada that actually is being used for vaccine hesitancy, not just for COVID, but generally for individuals. And they have compiled the evidence base around the effectiveness of motivational interviewing to combat and address vaccine hesitancy. And as we can see there, the use of these formats have been incredibly helpful for, so there's been a 15% increased uptake in maternal intention to vaccinate their children. That's been associated with a 7% increase in infant vaccination coverage. Over a two-year period of time, there's a 10% increase in complete immunization status. Vaccine hesitancy scores individually are reduced by 40%. And what the literature shows is that for the groups that have been, the populations that have been studied, vaccine hesitant mothers have benefited the most with 97% in the study population reporting that they were satisfied with the motivational interviewing intervention using the elicit provide elicit format and would actually recommend it for ongoing topics of conversation. In the interest of time, I'm not showing the example that is available in this paper, but it's a table format that shows the traditional approach of engaging patients in discussion and change. It's based on education and counseling and the challenges that come up in that where the healthcare provider adopted the role of expert and used a directive intervention approach that was based on the writing reflex and information provision. And that intervention led to an opposition from the parent in comparison to the other side of the table, which used a motivational interviewing approach and allowed for the mother in a nonjudgmental way to express her concerns and ambivalence about the risks of vaccination and the healthcare provider to then give solicited information that could be accepted by the mother. And naturally this is a paper, so they're using best case situations, but whether the individual ends up accepting the recommended treatment or not, you still have a positive relationship that will allow for further visits and further discussions of this topic in the future. Next slide. So in Vancouver, which is where I practice, we have the downtown East side, which is sort of similar to the Tenderloin in San Francisco or Skid Row. There has been a huge push and a targeted COVID-19 vaccination program because this is a clinically and socially disenfranchised population with high rates of homelessness, substance use and severe mental illness. And so building on these strategies, we have motivational interviewing, meeting patients where they are at, both in terms of the stages of change, but also physically and utilizing peer recovery mentors. There has been a very successful vaccination program where almost 12,000 people from the downtown East side have received at least one vaccination dose and that's increasing now. 80% of the individuals receiving the vaccines and 20% were working in the community. These are staggering numbers because the downtown East side is estimated to have a population of about 10,000 individuals. So more than the actual resident census has received vaccination based on the effectiveness of these strategies. Next slide. And so lastly, I just wanna think a little bit as we are thinking about working with individuals who may have vaccine hesitancy or are ambivalent about the effect of their substance use, COVID-19 and the complex interrelationship between them, it can be really important to acknowledge our own feelings and our own experiences first. We can lean into the emotional experience that comes out of this to thinking about what we might be experiencing, do we feel like some of our core values may be at risk here and spending some time allowing our feelings to arise and name them. From there, we can practice self-kindness. So self-compassion can be particularly helpful here. And I encourage thinking about some of the strategies that Dr. Kristin Neff, who is a psychological researcher and self-compassion recommends. And one of those principles is think about treating yourself as you would treat a good friend. Additional guiding principles include seeking common ground, seeking to understand and to do no harm, first and foremost, once you have listened and understood. Offer that it's, listen to the patient, that if they tell you that they're not interested in further discussing this topic, to set it aside. And part of the situation may be not to inflame the situation further in that guiding principle of doing no harm. And sometimes the most powerful tool that we can use in these situations is to allow someone else to feel understood and to develop that therapeutic relationship. Lastly, is to think about relieving suffering and also relieving our own suffering. And so the citation that I've left on this is access to a CME that is found on the University of British Columbia's website around changing practices. And I will invite you to take the time in your own lives to take a look at this. With that, I'm hoping that our AAAP staff can pull up the poll questions and we'll have just a very couple of minutes to engage in a discussion and think about how we can do that. And I'm going to turn it over to you, and thank you so much for joining us today. I hope that you enjoyed the discussion and think about how this information is affecting yourselves clinically and your patients. Okay, where did that go? So for the first poll question, about 78% of you mentioned that there's an awareness of nicotine and cannabis use, that there may be some negative impacts on COVID-19. there was an interesting split with 50% of you talking about these connections with patients and 50% of you not. If we have a couple of moments, I'll be very interested to hear from the audience around why or why not. I just want to confirm that individuals are able to see the poll results. Okay, perfect. Okay, we can go to the next one. I'm very pleased to see that nobody indicated that they were using shame or guilt as strategies to affect change and that the majority of you are using harm reduction and motivational interviewing principles, which is exactly in line with the guiding recommendations. Next question. And what our patients are telling us is actually pretty consistent with what the evidence base shows that there are some concerns and they're trying to make changes. Some individuals may not be totally convinced and that's fair because this is a very confusing and conflicting topic and there may also be some ambivalence about making change. And with that, I'll open it up for discussion and feel free to unmute yourself if you'd like to make a comment or ask a question. We have maybe about five minutes for a discussion, unfortunately not very long. I want to know if anyone else had tried motivational interviewing for vaccine hesitancy. I think because vaccination is a bona fide, clear-cut health outcome, I think it's an okay thing to do motivational interviewing for that and I don't consider it a boundary cross, which it could be for some trying to modify some other things like someone's religious belief or whatever. Has anyone tried to do that for vaccination? Well, yeah, yeah, and I will say is, I think, when I've, I've been confronted these on a couple of cases, I think, you know, one of the things I was surprised about one of the guys I was talking to, he said, you know, it was against his conscience. And, you know, but through compassionate listening, I was able to get him to elicit, I was able to get him to talk more about that. And it seemed like his definition of conscience was his gut feeling. He had a bad gut feeling about the vaccination, it didn't violate any of his principles. So just by kind of like talking with him and getting that out, I think it went better. I had another friend, a 32 year old farmer, who didn't get vaccinated, I was preparing to rip him for being vaccine hesitant, you know, which is something as a friend, you might be able to do, but probably shouldn't. So you don't do with a patient. And he said, you know what happened to my friend, also a 32 year old farmer, he had very bad myocarditis. And so at that point, you know, you just put on the brakes. And, you know, you really kind of listen with compassion and express, you know, concern about his friend or other people taking care of his farm. And, you know, and we kind of did discuss this, like, yeah, this is a real thing that happens. It's rare. You know, it's probably safer to get vaccinated than if they still use the virus. He eventually, of course, not that long after, did get vaccinated. And I think it, it shows it's, it's, it's why kind of it's important to talk through a lot of the hesitancy that people have. And, you know, I think that can be a benefit. Any comments or questions from the audience about vaccine hesitancy, your own experiences? Why or why not? This hasn't come up as a topic clinically. I don't know if most of you use Epic, but in our clinical practice, whenever we open a patient chart, the first thing that shows up is COVID vaccine discussion with the patient. So did you talk to the patient about this? Our patient declined vaccination. What are the other reasons? So that's the first thing that pops up when you open an encounter. So that actually leads to conversations and whether it's a positive or negative, but at least, you know, you have to have that conversations on so that, you know, at least at some point, if they're not ready now, maybe they can be ready next visit or visit after that. I see that Tom has put up a thumbs up reaction to Srini's comments there. I'm Dr. Thomas Weingarten from Minnesota. I'm a medical director of a residential community treatment center. There's about a hundred beds. They're mostly people from jail. They're mostly homeless, mostly on MA, had multiple treatments. They're almost all anti-vaxxers and they come into this treatment center and they don't believe in COVID and they just explain to them that if we get an outbreak, we have to close. If they close, we have to kick you out. You kick you out, you end up either dead or in jail. So I don't care what you think about COVID, but if you think about staying alive, then it makes sense to help us make sure we're safe, that we don't close. In Minnesota, half the treatment centers closed because of COVID. And so it was a serious problem. We never did because we made them all wear masks, et cetera, et cetera. But the vaccine part of it, what happened was that you said very simply, if you get a vaccine, it was also possible to let us go to a workout facility. And all of a sudden there was real leverage that managed them. So motivational interviewing is a hundred percent of what you have to do, but always got to get leverage so that they see what they get out of it because that's the way they think. So I agree with everything that's been said in this program, but getting real leverage on real patients you take care of is really important. You got to know those patients to know what's leveraged for them. Thank you. Absolutely. Nice example, Tom, of figuring out what's important and what's driving a patient's decision-making and helping guide them to the information that connects their individual motivations or intrinsic reasons for change with the practical strategies for that. I'd seen that Christina had her hand up. Yes. Hello, everyone. So I am curious as a mental health counselor in a small community center agency in the Boston-Somerville area, I was thinking about like we don't have as, you know, like most of, I think a lot of you here might be physicians. So I can see if you're using Epic or as part of a consultation, you know, that makes sense. But for example, I work with parents, sometimes involved with the system, and I'm thinking, does it make sense? Like what will be the frame to have these conversations about COVID? You know, I'm coming here for, you know, parenting, you know, programming or other type of more of other nature. And we do talk about self-care. So I'm just thinking that is something that, you know, parents find very valuable. So maybe in that context, I don't know what you think about that. Of course, all the principles of MI that are totally usable. Thank you for that. Yeah, and sometimes I'll bounce off of if there's headlines, there's things in the news. But yeah, I think there's several different ways that you can work it in. And one of them is self-care. And, you know, we talked about general health. And I, you know, I believe that, yeah, I think it's important to plan to make sure it gets thrown into the topic somewhere sooner or later, just so you've presented it and given that patient the opportunity to accept or refuse. But I want to hear other people's ideas of how they work. Dave, I think you got muted partway through your answer. Well, yeah, hopefully, you know, I didn't lose too much. But, you know, because I do think it's important to actively bring this up. And, you know, do any of you all have ways that you have been able to work this into the discussion? Sometimes I've also done it on pros and cons of substance use, you know, really, as we're doing the MI session itself is adding that kind of thing into some of the other pros, cons, risks, benefits that they're talking about. You're muted again. I would also encourage you to take a look at that citation that I provided, because there's a really nice example of actually, it's a it's an example of talking with parents about vaccinations for their kids. And so I think that that might provide a framework for talking about this a little bit further. And I think that can provide some really practical suggestions as well. So I recently had a conversation with a mom who has a 14 year old autistic daughter. Mom doesn't believe in vaccination, but she wanted to give vaccine to her child because child goes to school and she doesn't wear a mask all the time. So after one month after the vaccination, I got a call saying that she is agitated and aggressive throwing stuff and I think it's because of the vaccine. So I have to have a conversation with her. She delayed her second dose of vaccine because of that. And then when she came back, I had to sit with her, talk to her about her baseline behaviors and then said, this is not related to the vaccine, but this is just an issue at school. Finally, she was convinced and then she was able to get the second dose for her daughter, but she didn't get the vaccine. With that, I think we are now at our time allotment for the workshop today. Thanks to our presenters, thanks to everybody that joined us today in the audience and thanks also to Kara and Randy at Triple AP for moderating our session today. Bye everyone.

COVID-19

cannabis

nicotine

smoking

vaping

substance use

adolescents

risk of COVID-19

mental health issues

substance use disorders

racial disparities

breakthrough infections

vaccine hesitancy