All right, welcome to paper session number four. This is the last meeting of our conference, and I'm excited to welcome five paper presenters. First up, we're going to have Adeolu Oladujoye talking about cannabis use and medication noncompliance and bipolar disorder and nationwide inpatient sample database analysis. Next we're going to have Abigail Richeson, a survey of providers perceptions and comfort with medical cannabis in central Arkansas. Next up, we're going to have Jessica Vandenin talking about moral injury in the context of substance use disorders and narrative review. The fourth presenter is going to be Bernard Sarmiento, speaking about cannabis use and mental health in Florida college students. And last but not least, we're going to have Chris Hammond talking about changes in tobacco and cannabis use and their impact on ADHD symptoms in adolescents receiving combination ADHD and cannabis use disorder treatment. I am Ellen Edens, and I'm the moderator for this session. If you have any questions, please put them in the Q&A. We are going to be doing Q&A at the very end, the last 10 minutes. So whatever question you have, if it's for Adeolu, then please just put his name in to make sure that I know that the question is to be directed to him and the same is true for all the following presenters and everybody will have exactly 10 minutes, as I've already mentioned. And so without further ado, if there's nothing else, I'm going to turn it over to you, Adeolu. Thank you for having me. And just as said, the topic here is cannabis use and medication noncompliance in bipolar disorder patients. It's from the Nationwide Inpatient Sample Database Analysis. And in this presentation, I have no disclosures. The educational objective here is to determine the prevalence of cannabis use disorder on medication compliance rates in patients with bipolar disorder. The second objective here is to determine the factors associated with cannabis use disorder on medication noncompliance in patients with bipolar disorder. So generally speaking, we know this, that medication noncompliance is still a big problem with patients, our encounter with patients, especially patients with chronic conditions. And bipolar compared to other psychiatric illness carries a higher relapse rate and mostly due to treatment noncompliance. So for cannabis use disorder, it's suggested that there's an increased number of those noncompliant with their medications because of cannabis use disorder. Studies have shown that there's a significant association of cannabis use disorder and bipolar disorders. The reason why we carried out this study basically was because we've seen that there are just few comprehensive analysis out there that looks at the effect of medication noncompliance in patients with cannabis use and bipolar at the same time. So what we did here was to look at a database, a large database, a US-based database, and we did a retrospective study looking at adult patients from age 18 and above, looking at the data from 2010 to 2014, and looking at patients with bipolar. And we had two groups of those who had cannabis use and those who didn't have this disorder. And then we kind of like looked at the primary outcome of medication noncompliance, and we did a logistic regression to see the comparisons between these two groups. And as you can see this table, you see our results here, kind of a fair distribution of the mean was like 41 years overall. We had in the non-cannabis use, 42, and then the cannabis use, 33. The age here was fairly distributed. The sex females were like, well, 56% overall more than males. And then we had the race distribution and then comorbid substance use as well. And then on the next slide, we see here that we tried to look at their income, their insurance, and kind of like see the distribution across board, both in those who were using cannabis and those who didn't. And also with hospital teaching, hospital status, whether it's rural or urban non-teaching or urban teaching hospital. And in our results, we found that generally speaking, the age group wise, 40 to 64, carried After multivariate regression, we found that they carried a higher odds of medication non-compliance in the cannabis use disorder group. And the same thing goes for some of the other things. We found out like the black race had twice higher risk of being medication non-compliant. And we look at some of the other things like those who had a higher income had the same thing. And we looked at the distribution based on whether they were hospital located in a rural area or urban and the urban were on the higher side. And that was kind of like a general take, kind of like surveying and seeing what's the general picture here. These different factors actually stood out to us and made us feel there's a need to do some more work when it comes to medication non-compliance with cannabis use in patients with bipolar. So in our study, we concluded that there's some association here with cannabis use is associated with medication non-compliance in patients with bipolar. And we feel it's imperative and very important that we look into implementing strategies to reduce cannabis use in bipolar disorder patients with these concerns. And we feel that this will play a role in improving those with medication compliance since like I mentioned earlier on that it's a big issue to tackle. But I think one of the things we can do is tackling cannabis use. And we feel further research is necessary to determine the most effective interventions for increasing medication compliance among patients with bipolar disorder. And I think that's the end of my presentation. Thank you. And here are my references. Thank you so much, Adeolu. So you finished in plenty of time, but why don't we move on and we will get back to questions at the end. So next up, we have Abigail Richeson asking or presenting on a survey of providers' perceptions and comfort with medical cannabis in Central Arkansas. I'm an addiction psychiatry fellow with Vanderbilt, and I will try to be as quick as the last presentation. So again, I'll be talking about a survey of providers' perceptions and comforts with medical cannabis in Central Arkansas. And last where I did my residency was at UIMS in Little Rock, Arkansas. And so I have no conflicts of interest. And here are my acknowledgments. And to give a little bit of background. So currently, there are 37 states that have approved a cannabis for medical use, as well as 18 states that have approved cannabis for recreational use. Previous studies have shown that clinicians do feel ill prepared to recommend medical cannabis. And in 2016, there was a study that showed that less than 10% of medical schools have documented content on medical cannabis, and about over 80% of residents and fellows reported having no educational medical cannabis. In Arkansas, we had our medical marijuana event passed in November of 2016, with the first dispensary opening in May of 2019. So pretty recently, we have a little over 60,000 medical cannabis cards that have been sent out, as well as less than 200 physicians writing for these cards and about 31 dispensaries up and operating. So the aims of this, just from providing care to patients, as well as talking with other residents, it seemed that a lot of the residents felt very ill prepared to speak to their patients about it. And I myself had a lot of patients coming to me asking me questions about it. And if they can't get information from us, who knows where else they're going to get their information from. So I wanted to see, asides from psychiatry and residents, how did everybody else kind of feel with medical cannabis. So the aims are to examine clinicians knowledge, perceptions and comforts when discussing cannabis, both medically and recreationally, as well as evaluate for any discrepancies in care or comfort based on provider characteristics, and identify interest in education regarding cannabis. So participants, they had to be employed at the University of Arkansas Medical School. So again, that's in Little Rock, Arkansas, have to be an MD, DO, PA, or APRN, and have to be able to understand and complete a survey in English. They were excluded if they had incomplete survey responses, if they weren't involved in direct patient care, or under 18, which nobody was. Looking at the design of the survey. So this was an online anonymous self-administrative survey. It was sent through Survey Monkey that was distributed to all providers across all specialties over at UAMS. And the final assessment included four components, so demographics, age, sex, race, ethnicity, years in training, as well as specialty, their perception. So risks, benefits, safety with cannabis, screening practices, how often they ask about it, if they recommend medical cannabis for any other patients, or get toxicologies, as well as comfort. So how comfortable do they feel discussing or certifying somebody, how knowledgeable are they, and interested in learning more about it? Answer choices ranged between yes, no, open answered questions, select all that apply, and rating on a five-point Likert scale. Looking at our participants. So we had 290 responses, of them 114 were attendings, 122 were residents, 49 were APRNs, and six were in the other, so PA, essentially. I think we had one clinical psychologist. And then looking over on the right side of the screen, you can see that most of the participants were in primary care, so that included internal medicine, family medicine, as well as dermatology and internal medicine specialties, with an N of 112. And then the surgery group had 55 or 19% of the responses. Again, that was surgery, urology, so on with that. Pediatrics was at 10%, neurobehavioral, so those in psychiatry or neurology was at 17%, internal medicine was at 5%, and then other was 10%. That was a lot of PMRS, as well as radiology and interventional radiology. So looking at a few of the questions, I wanted to show a few, just to kind of show what the responses were. So this was looking at difference between specialty, and the question was, medical cannabis is acceptable as an alternative medicine. And you can either choose one, disagree, two, somewhat disagree, three, neither disagree nor agree, four, somewhat agree, or five, agree. And as you can see here on the bottom, you have the different groups, and looking at neurobehavioral compared to the other groups, there was a significant difference with P being less than 0.001, with neurobehavioral believing that medical cannabis is not acceptable as an alternative medicine, with most people scoring in the more disagree section compared to the other specialties. The next question was, I feel comfortable discussing cannabis. And as you can see here, those in the neurobehavioral group scored higher with an average of about 4.2, saying that they did feel more comfortable discussing cannabis, and this was significantly different from the other specialties as well. The last question looking at the difference between specialties was, I feel comfortable treating addiction, and this is something that I expected to see, the neurobehavioral group did score higher with an average of 4.36, so a lot of people saying somewhat agree or agree, and this was significantly higher from the other specialties with a P of less than 0.001. Next, I wanted to look at the difference between residents and attendings. So the first question I want to talk about is, medical providers should be offering cannabis for management. And as you can see here, the attendings have a more negative view, scoring lower, so a lot of them disagreeing more compared to residents, saying that medical providers should not be offering cannabis for management, and you can see the P value of less than 0.007. Next question, medical cannabis has significant interactions with medical therapies. Again, you can see that attendings have a more negative view of cannabis with this, so a lot of them agreeing that medical cannabis does have significant interactions with medical therapies with a P value of 0.03. And then the last question I'd like to talk about looking at the difference between attendings and residents was, I feel comfortable discussing cannabis with attendings reporting that they do feel more comfortable with more saying that they somewhat agree or agree with this and a P value of 0.008. One of the last questions I asked was, are you interested in learning more about cannabis? And as you can see here, a majority said yes, with an N of 225, which was 77% of respondents compared to 23% or an N of 66, saying that they were not interested in learning more about cannabis with a P value of 0.003. So in conclusion, depending on the specialty and level of training, perceptions and comfort regarding medical cannabis may differ. Attendings and providers in the neurobehavioral group were more likely to have negative views towards cannabis and feel more comfortable discussing cannabis and treating addiction, and over three-fourths of the participants expressed interest to learn more about cannabis, indicating the demand for didactics regarding risk and benefits with medical cannabis. And here are my references. Thanks so much, Abby. So we are right on time or ahead of time, actually. So this is great. Again, to the audience, if you do have questions, put it into the chat. We'll do questions and answer at the end. Make sure you put the question, the name of the person presenting next to the question. So next up is Jessica Vanden End, talking about moral injury in the context of substance use disorders, a narrative review. Good afternoon. I'm really happy to be here. My name is Jessica, and I work as a chaplain at the Connecticut VA. I'm really grateful for the contributions and guidance of some of my co-authors, Drs. Irene Harris, Dr. Brian Furline, and the brilliant Dr. Ellen Edens, who's here on the call. And we have nothing to disclose or any conflicts of interest. So in the next couple of minutes, really quickly, I just want to give you a brief working definition of moral injury as it's been understood in a combat or wartime experience for veterans. And then I want to review literature looking at moral injury occurring in the context of substance use disorder and offer a model for continuing to investigate and think about treating this later kind of moral injury. So moral injury, well, we can start by saying that philosophers, writers, and theologians have been thinking about the moral impact of trauma and war for centuries, right? But in the modern, the contemporary sense, the conception of moral injury as a clinical presentation requiring intervention was first introduced in 2009 by Litz. And they were looking at veterans who had been in a combat or a war situation, and they were looking at how those vets were exposed to events or experiences that conflicted with their personal moral values or expectations. And so they're hypothesizing that there's sort of a rupture, again, between these two conflicting forces. So there's the survival needs in a high stakes situation, and there's their own code or ethics. So in the bottom of the slide, I have some examples of events that might cause moral injury. And they also, they noted that moral injury can exhibit clinically as existential, psychological, emotional, spiritual distress. So some of the symptoms they noted were shame, guilt, lack of forgiveness for self or others, and sort of a loss of meaning making and value. Like this rupture kind of just causes a lot of these meaning making systems to lose coherence or even shatter altogether. Generally it's understood, well, I should say moral injury is emerging and being studied and debated. It's generally understood to be often co-occurring with PTSD, but we're starting to think of it as a separate phenomenon and as separate treatment interventions. And the VA has been obviously given their population on the forefront of this research and doing a lot of really good work with veterans. In recent years, and now I mean like literally the last couple of years, we've started to think about how moral injury can arise in other high stakes situation. And again, it's the same phenomenon. It's when there's sort of this collision between a situation that has intense pressure or survival needs and one's existing code of values. So I'm not going to go through all of these, but for example, in the last couple of years, people have started to talk about how healthcare providers may have their own set of moral standards related to, for example, that they should be able, that family members should be able to be present with people who are sick in the hospital or who are dying in the hospital. And in the past year, that has conflicted with some of the demands due to safety, due to the pandemic. And so is there, what's happening with this conflict? And again, this sort of collision of different needs and codes. So I'm going back to those clinical presentations that I talked about. In my work as a chaplain, I saw a lot of those sort of things occurring in my work with vets with substance use disorders. And I was really curious to see if anyone had thought about moral injury related to the context of having a substance use disorder. So that prompted me to do a literature review. I did find some literature and some research connecting the two. However, most of the research that I found related to sort of seeing if a moral injury sustained during combat linked to kind of later substance use. It didn't really look at the moral injury arising in the substance use context. There were a couple things that I found, very few little really. One was a quantitative study, which had to do with sort of taking some of these scales that the military had been used to think about, or that had been used with veterans to think about moral injury in the military context and trying to translate that to the civilian context. They did find that some of the highest level, that there was a lot of perpetration related to stress in a general civilian context related to using their words, causing harm while using alcohol or drugs. And then a couple of other qualitative studies with very small ends, as you see that, but that are actually start that illustrate that there is, you know, some accounts of moral injury in the different populations that they're studied. So obviously, more research is needed. And I really do believe that the lack of research at present has less to do with relevance and more to do with just that this is a really emerging and interesting concept, but it's very new. And so very interesting to sort of think about this and study it further. So we put together a conceptual model looking at how this might occur in the substance of the substance use disorder. Now I'm talking to an audience that I'm sure doesn't need explanation of like the dopamine hypothesis of STDs. But my interest here is the way that this primitive reward system reinforces activities meant for survival and for procreation. In fact, one can argue that this reward system is in place to ensure that if there's a situation in which one has to choose between upholding high moral standards and possibly having their livelihood or person threatened or even die, or the other option to break moral character to survive, this system inclines us to choose the later. So in other words, when addictive substances hijack the system, this exact system designed to ensure that we break moral character to ensure survival is now ensuring that we break moral character to compulsively seek the substance we are addicted to. So again, it's the same idea of this inherent conflict between survival needs or experience survival needs and the person's moral values, and potentially the same result of moral injury. On my chart here, you can also note that we postulated that because SUD use creates even a riskier and vulnerable environment, there's actually increased actual survival needs, which then can further create and allow for more moral injury. And we were wondering also whether social stigma may also exasperate this injury. But again, the thought is that the moral injury resulting from these pathways would be expected to have many of the same components of moral injury resulting from a combat situation. And again, this sort of pans out with a lot of the clinicians I talk to and in my work also, in that we see some of these clinical presentations, right? The guilt, the remorse, grief, shame, lack of self-forgiveness. So we've known this for a long time within SUD treatment, but I wonder if moral injury can give us a better picture of the etymology. So again, lots of opportunities to think about this and explore this. I'm really curious to learn more about what some of the similarities and differences of moral injury experience and clinical presentation might be between combat and the SUD experience. Have a lot of thoughts on how they might be different, but also maybe similarities too. And secondly, how might moral injury be a barrier to treatment? So if someone, how can we support someone in their recovery process and how can we support them through the process of grappling with moral injury so that it doesn't become something that becomes too intimidating or too big or a reason for not entering the process. And then lastly, there are, like I said, the VA is starting to work on evidence-based treatments for moral injury related to combat. And might we be able to utilize some of these and try some of these out in our SUD care? And that is it for me. We are still ahead of schedule, which is great. So moving on to presenter number four, and please don't forget to put, type in your questions. So we have some discussion at the end. Without further ado, this is Bernard Sarmiento speaking about cannabis use and mental health in Florida college students. So my name is Bernard Sarmiento. I'm a third year medical student at the University of Central Florida College of Medicine. On my team, on my team is Matthew Abrams, another medical student at UCF and my research mentor, Dr. Ryan Hall, who might be here with us today. But what I'll be talking about within the next 10 minutes is cannabis use and mental health in Florida college students. And of course, I have no disclosures at this time, but what I was interested in was looking at how cannabis use rates initially were affected by legalization efforts within the state of Florida and nationally. So the objectives for today's session would be to look at the growing mental health concerns facing college students, as well as to better assess the association between cannabis use and mental health status through three survey scales that were collected by the healthy mind study in the University of Michigan. And hopefully everyone can get a better insight into the epidemiology of anxiety and mood disorders and employ this in research endeavors or in clinical practice. So starting at the global level in 20, excuse me, 2019 was cannabis was used by over 200 million people with young adults having the highest prevalence. And cannabis in general is actually the third most used psychogenic compound behind alcohol and tobacco. In terms of cannabis use disorder specifically, an estimated 22 million people potentially, and this might be an underestimate, were affected with CUD in 2016 with a median age of onset within the range of 19 to 22 years old based on the literature and which is within our research demographic of college students. In the United States, of course, it's federally a schedule one substance. Federal government has let states decide on whether they want to implement medical use program. 37 states have medical use programs or recreational use as well. And 18 of these states plus DC have that. Interestingly enough, legal sales of marijuana is expected to increase by 2026. To $42 billion, which I found very interesting. And the National Institute on Drug Abuse actually found a significant increase in the cannabis use in US college students from 34% in 2014 to 2020, 34 to 44% by 2020, which is a significant increase that we hope to find within the healthy mind study data. This is a big chart, but the key takeaway from this is I wanted to show the medical use of marijuana act passing in 2017 by the Florida Senate. However, it wasn't really implemented until the following year in 2018. And our data from the healthy mind study covers starting from fall 2015 to the spring of 2020. In terms of medical cannabis and the medical use of marijuana act in 2017, it allowed for medical cannabis to be used in certain situations for certain qualifying conditions, such as cancer, epilepsy. And in the past year, Florida, there was a bill actually trying to limit or cut off the THC content in available medical cannabis, which failed. And as we know, THC plays an involvement in the potential development of a psychotic episode. So health effects of cannabis, of course, all of you probably are well grounded in this. Of course, negative consequences in terms of respiratory system, maternal use can have an effect on field growth and development, but specific to mental health in the literature, we see that daily chronic and heavy use is associated with the development of psychotic disorders, other drug and alcohol use disorders. And there was increased odds of developing major depression and generalized anxiety disorder in people with CUD. Now the data source we are using is the healthy mind study, which was launched in 2007 by the university of Michigan. So very comprehensive questionnaire sent out electronically, hundreds of questions, including questions on demographics, substance use, sexual assault, sleep. But what we're looking at are demographic substance use and the three scales that I'll show, which are the PHQ-9 depression scale, the GAD-7 anxiety scale, and the flourishing scale, which is a psychological wellbeing scale, asking participants to evaluate their self-perceived value in themselves and their self-esteem and their relationships in their life. We had overall over 300,000 responses from 300, close to 300 school reports on the national level. And within the state of Florida, we had 20,000 responses in this timeframe. And as mentioned, we'll be looking at demographics, cannabis use, which was asked in the way of have you used cannabis in the last 30 days? So as you can see, it doesn't differentiate between low dose or, you know, one-time users versus heavy chronic users of cannabis. And of course, the three scales. We used Excel Stata, calculated mean survey scores between cannabis, non-cannabis users, found the T-STAT-P values and to see if there was a significant difference. And the alpha level was 0.05. So nationally, what we found was significantly worse than scores, as we expected in cannabis using scores and cannabis using students, excuse me, versus non-cannabis using students across the five-year time period. Higher PHQ-9 scores, higher GAD-7 scores and lower positive wellbeing FS scores. We also found generally a worsening screening scores across all five years in all three scales, which I'll show after I talk about how we did not find a significant increase in US college students who reported using cannabis. Surprisingly, this was at the national level. And we also found that on the Florida level could be explained by a number of things. Potentially, we need more time to analyze use trends based on legislative policy changes. But significantly, we found higher depression or worse depression scores in cannabis users as marked by the green compared to non-cannabis users marked by the yellow and worsening over time of overall student scores. And this was found in the PHQ-9 depression score. We had this. We had worse anxiety scores amongst cannabis users and worse or lower flourishing scales scores, which means a lower FS score means a lower psychological wellbeing score. And in Florida, the results kind of mirrored what we found at the national level. In addition, we can talk about how there was also a rise in individuals who met the threshold to be considered moderate or severely depressed or anxious. We found those percentages increased over the five years as well. Demographically within the state of Florida, the interesting takeaway is the female response rate was higher than the male response rate. And this was our cannabis use within the state of Florida. Fluctuations initially could be explained by the fluctuations in the sample size. As you can see, it increased from 645 to close to 11,000 in five years. And these results mirrored what we found in the national level. Florida cannabis users had higher, worse PHQ-9 scores, higher, worse GAD-7 scores, and lower and worse FS scores. Of course, there are limitations. I'll quickly run through a cross-sectional study. It's kind of more difficult to assess for causal linkage. Of course, we understand self-report questionnaires can be a little tricky. Even when anonymous, people might limit or even exaggerate responses to mental health or substance use questions. And a key point is that there's no differentiation when asked in this question, have you used cannabis in the past 30 days? That doesn't tell us about dose or frequency, which could have increased based on legislative policy changes that we cannot see using this data. Of course, I talked about the sample sizes increasing, fluctuating, female response rate was higher compared to the national average. So what we found was, of course, I've mentioned higher depression anxiety scores in cannabis users, lower psychological wellbeing scores in cannabis users. And a very crucial part is we found a growing mental health kind of impact based on these worsening screening scores in all five years and all three scales amongst all college students nationally and in Florida. And as mentioned, we did not find use rate changes, but we might need more time in terms of that to look at that within the state of Florida and nationally. So of course, college students remain a high risk population group for depressive and anxiety disorders. Future research should be expanded to other states using this data set, such as Oregon, Washington, look at states with recent recreational cannabis legalization. And of course, recommendations, continue screening, finding strategies to increase utilization of mental health services within colleges, and continuing to monitor cannabis use trends as more states continue to legalize. I would like to thank my mentor, Dr. Ryan Hall, for her statistical guidance at UCF and other UCF College of Medicine faculty and staff, and also the Healthy Minds Network for providing such a comprehensive database for me to use. Thank you so much, Bernard. All right. We are going to keep moving forward. We will have plenty of time for questions, I hope. So the next presenter is Dr. Chris Hammond, and he will be presenting on changes in tobacco and cannabis use and their impact on ADHD symptoms in adolescents receiving combination ADHD and cannabis use disorder treatment. Just to speed through the introduction part again, so my presentation is going to focus on changes in tobacco and cannabis use, and examine their impact on ADHD symptoms and functional outcomes in adolescents receiving combination ADHD and cannabis use treatment. I sort of sped through my disclosures and sort of given a little bit of background on really the prevalence of co-occurring cannabis and tobacco use among young people. I think it's important to point out that tobacco and cannabis co-use may bi-directionally impact substance use, addiction severity, and treatment outcomes. That is, use of tobacco appears to impact treatment outcomes for individuals trying to stop using cannabis and vice versa. A major question in this space of co-occurring use is whether tobacco and cannabis act as complements versus substitutes. And when I say complements, that is when an individual uses them, do they use them concurrently and do they increase their use together? Or if they act as substitutes, when one goes down, the other potentially goes up. Few studies have really prospectively examined the relationship of changes in tobacco use, the relapse or remission of cannabis in adults or adolescents and mixed findings across studies have been shown to date. Further focusing on youth with ADHD, ADHD is one of the best known risk factors for addictive disorders in young people. And adolescents with ADHD commonly use and co-use tobacco and cannabis products. And little is known about how tobacco use influences ADHD and cannabis use treatment outcomes in young people with ADHD and cannabis use disorders. And so really the present study that I'm presenting today uses data from the NIDA clinical trial networks 0028 trial to characterize relationships between change in tobacco use and change in cannabis use and to determine the impact of changes in these substances on ADHD and functional outcomes in adolescents receiving a combination treatment of long-acting stimulant medication for ADHD plus group cognitive behavioral therapy for cannabis use disorder. This slide shows really the study design for the parent study from which our analysis is drawn. In terms of participants, the parent study recruited 302 young people with ADHD and non-tobacco substance use disorders and their demographic characteristics are shown there. The parent study used a double-blind placebo-controlled study design examining oral orosmethylphenidate compared to placebo administered for 16 weeks for the co-treatment of ADHD and substance use disorder. Both groups, those in the orosmethylphenidate arm and in the placebo arm, received weekly manualized individual cognitive behavioral therapy. And I've included the primary and secondary outcomes listed there. This slide shows the demographic and clinical characteristics of the analytic sample that we examined in our secondary analysis. We chose to focus on youth with ADHD who had a cannabis use disorder diagnosis. This represented roughly 90% of the larger sample of the full parent study. And in terms of just basic demographics, the average age of these young people were 16 and a half, 80% were male and 59% were non-Hispanic white race. Ethnicity. Their average days of cannabis use in the past 28 days at baseline was 14 and their average days of tobacco use in the past 28 days at baseline was 16. This slide shows the variables of interest and the analytic approach that we used for this project. In terms of the substance use variable, we focused on days and amount of past 28 day tobacco use and cannabis use assessed via the timeline follow-back, examining those at baseline and at week 16, the end of treatment. For ADHD, we focused on the same primary outcome from the parent study, clinician administered ADHD rating scale from patient information, which was assessed weekly during the study. We used the children's global assessment scale scores as an index of global functioning. And our analysis, we applied regression and general estimating equation models to examine relationships of change in tobacco and change in cannabis use, ADHD and functional outcomes while co-varying for age, sex and baseline clinical variables. This slide here shows the primary efficacy outcomes from the parent study with ADHD outcomes shown on the left and substance use outcomes shown on the right. Across both youth that were randomized to oral somatophenidate and youth that were randomized to placebo, both groups showed significant and clinically relevant reductions in ADHD symptoms. And there were no differences between those two groups. And both groups also showed modest reductions in drug use, including marijuana use, again, with no differences between the groups. This slide focuses in on that subgroup of interest, youth with ADHD and a cannabis use disorder diagnosis, examining co-occurring tobacco use. Within this subgroup, tobacco use was common and over half of the young people reported near daily tobacco use at baseline. In terms of patterns of change during treatment, most participants showed a pattern of decreasing cannabis use and decreasing tobacco use with increasing or persistent cannabis use and tobacco use patterns being less common. Of note, more young people showed a reduction in cannabis use than showed a reduction in tobacco use, but really the main focus of the intervention was on cannabis and non-tobacco substance use. So that is likely a good explanation for that. Cannabis use and tobacco use were associated with each other and their change was associated with each other during treatment. Our regression analysis showed that during treatment change in tobacco use was positively associated with during treatment change in cannabis use at the level of the amount, grams of cannabis and cigarettes per day and at the level of days used in the past 28 days in these adolescents with ADHD and comorbid cannabis use disorders. Associations were also seen between changes in cannabis use and functional outcomes in the sample, but not with ADHD. So during treatment change in cannabis use and tobacco use were unrelated to ADHD treatment outcomes. While during treatment change in cannabis use was negatively correlated with global functioning, indicating that a reduction in cannabis use in these youth with ADHD and comorbid cannabis use disorder was associated with having better global functioning at the end of treatment. And so really in conclusion, sort of the three main take-homes or findings from this post-hoc analysis, our findings indicate that changes in tobacco and cannabis, that changes in tobacco and cannabis use tracked together during ADHD and cannabis use treatment with reductions in cannabis use contributing to post-treatment improvements in functioning for adolescents. These results provide preliminary evidence for a complimentary as opposed to a substitute relationship between cannabis and tobacco during ADHD and cannabis use disorder treatment. And really these preliminary findings really indicate that additional research is warranted to clarify the clinical implications of different patterns of change in tobacco and cannabis use, both in non-treatment seekers and in treatment seekers across the continuum of co-use and as well in young people with ADHD and also those without ADHD. And so I'll end there and this slide just shows my list of collaborators and colleagues and members of my lab that have contributed to the study. Thank you. Chris, thank you so much. And it turns out we are right on time. Everybody seemed to work together well so that we're done at 4.50. So we have 10 minutes for questions and I was thinking probably the best way to do this is we've had about seven Q and A's answered in the chat. And I'm wondering if Abby, you would go first and answer, just kind of summarize your question and that was given. I think you had one question. Yeah, I did. So the question asked if we differentiated between medical cannabis and cannabidiol. We did not, but that's actually something that's very interesting to think about. And if I come up with another study, I probably would ask the difference between those. So thank you for the question. Something good to think about. Abby, very quickly, I'm just wondering your thoughts about what did you hypothesize is the explanation between your residents versus your attendings, the discrepancies there? Yes, good question. What my thoughts are with it is I think just more comfort in years training, as well as, so having attendings feeling more comfortable, talking to patients about cannabis, as well as the belief that attendings had a more negative view might be, whether or not possibly they've seen more negative interactions with it, while we've kind of come up with the time more that's shown more positive light on cannabis, whether or not the scientific research backs that up, but that could possibly be a difference. Thank you, Abby. I also see a question here, Jessica, there's a couple for you. Do you mind picking one or two? We'll see how much time you have, but pick one and answer that for us. Sure, yeah, just briefly, a couple of really, really great questions. The first one was about sort of the, couldn't it be that there's maybe different moral values in collision in substance use disorder, rather than just sort of the survival needs and the moral values, such as the collision between the individual, how the individual views themselves and maybe how the society or social standards view them, to which I say, absolutely. Like I think it's all potentially fodder for needing to work through and needing to understand better. And then the second question just had to do with 12 steps and kind of like, isn't this, is this the same territory that 12 steps is talking about when they talk about making amends and forgiveness and doing a moral inventory? And I definitely think we're in the same territory here. And I think even more incentive to sort of continue understanding and plugging away and better integrating this into SUD treatment. Thanks, Jessica. And then one question did come through the chat, which is, I told you Bernard to put it in the chat. So, but what kinds of thoughts, behaviors have you found to be characterized by the term spiritual distress in the context of moral injury? So maybe even just explaining the difference between those two as well. Oh, sure. I mean, you're asking a chaplain to talk about spiritual distress and I could take much more time. I'll just say really briefly that, yeah, because, so I think both moral injury, like addiction actually is kind of has bio, psychosocial and spiritual components. So the spiritual components specifically, you can think about sort of like ways our meaning making is challenged, questions about sort of like, why did this happen? Why did this happen to me? Who am I in the context of this and whether that's in a overtly religious formulation. So, why did God allow this to happen or my higher power allow this to happen? Can God forgive me? Or whether that's just in a more general spiritual, like a sense of loss of meaning making or a sense of needing forgiveness and sort of both are examples of how this might impact the human spirit. Thank you, Jessica. I'll move on to Bernard. Bernard, you had a question about the college students being on anti-anxiety or antidepressant medications and what were the PHQ-9 and GAD results if they were? Right, so unfortunately we didn't look into that, but it's totally possible with the healthy mind survey data set because it does ask questions about whether you're utilizing therapy or treatment and what medication you are. So, it's definitely possible and an interesting question to look at in the future, to look at the PHQ-9, GAD-7, FS scores related to cannabis users who are being treated for anxiety, depression versus cannabis users who are not treated. And I'm sure we'll find a meaningful difference there. Yeah, I also had another question I could talk about. Yeah, it was asking, consider looking at other states that had more subtle changes in their legislation in terms of allowing for advertisements of medical marijuana, which I didn't know was a state by state basis, like some states can advertise while others could. So, that's a very interesting thing that I mentioned was expanding the scope of the study to other states. And of course the common states would be Oregon, Washington, Colorado. There was actually a Healthy Mind Study done using the Healthy Mind Study data in 2017, looking at Oregon, which did find significant increases in cannabis use within the time period of 2012 to 2016 that we could look at in the future, as well as other states that the question attendee asked. Thank you so much, Bernard. I'm gonna go back to Adeolu and put you on the spot just a little bit. You were our first presenter and I know some of our presenters, I mean, our participants showed up a little bit late. So, any chance you could give us like a 60 second kind of recap of your study. I know you were talking about a nationwide inpatient sample. I wasn't exactly sure what that sample was coming from, but also you were looking at the effect of cannabis use in patients with bipolar disorder and that effect on medication taking behaviors. And I was just wondering if you could summarize very quickly for the audience. Absolutely. Thank you again. I know I was very early on. People were trying to trip me in when I was about to round it up. So, generally what we did was that, so the database is an inpatient database. It's a large database. It's a US based database. So, it's kind of like more like a cross-sectional study, but then we went retrospective looking at data from 2010 to 2014, and we have data up to like 2019 at the moment. But then we kind of like looked at the patients who had strictly bipolar disorder and tried to like distribute those who were cannabis users and those who were not cannabis users and tried to like see their use of medication, whether they were now the term adherence is more accepted than compliance. So, we kind of saw the distribution and we saw that the use of cannabis was kind of influencing their medication compliance. So, more patients flipped towards the side of non-compliance to their medications based on substance use like cannabis. And we actually extensively went on to like check some of the other substances and they were on the high side, generally speaking. So, I think our study were kind of like a wake up call to do more study and investigation into what's going on because the rates are high. It's as high as 69% of people having problems with compliance with medication and cannabis use and other substances on the rise. And it's like the trajectory in which I didn't present here, it's like an increasing trend and we need to do something about that or else we will be, I mean, it's already a crisis, but it could get worse. Thank you, Adeolu. And then Chris, last but not least, you were our last presenter and I guess I don't think any questions came in through this but I was wondering from you, what are your next steps? Well, this area of, you know, so polysubstance abuse or polysubstance use is such a poorly understood area, both in the adult space, but also the young person space. And it's really the norm in our patient populations and much of how we focus on treatment sort of ignores that. And so really it's studies like this that are using previous collected clinical trial data are just sort of preliminarily examining things. But next steps related to this are, I'm in the process of putting in grants to study this prospectively and look at how cannabis and tobacco use change prospectively over time in this population. Thank you so much. This has been a terrific paper session. So thank you all so much for joining us. We've reached the end of this year's annual meeting. Thank you for joining us this year. And remember that all sessions are being recorded and the recordings will be made available after the holidays. We will be sure to notify you via email when they do become available. Thank you all very, very much for a successful annual meeting and we'll see y'all next year.

cannabis use

mental health

medication non-compliance

bipolar disorder patients

providers' perceptions

comfort with medical cannabis

moral injury

substance use disorders

treatment outcomes