Prevention Profiles: Take Five - Dr. Jason R. Kilmer (University of Washington)

Rich Lucey (Host)

Hi there and welcome to “Prevention Profiles: Take Five.” This is Rich Lucey with the Drug Enforcement Administration's Community Outreach and Prevention Support Section. And I'm glad you're able to join us on this next edition of our podcast series, “Prevention Profiles: Take Five.”

This is our third episode in the relatively new podcast series. And as a reminder this is an opportunity for me to interview federal, national, state, and local individuals around the country who are working specifically around drug abuse prevention issues in higher education.

And I am very pleased to have today a really good colleague who I've admired for a very long time and a friend Jason Kilmer from the University of Washington.

And a little bit about Jason before we get started into our five questions. Dr. Jason Kilmer received his PhD in Clinical Psychology from the University of Washington in 1997. And he currently works at the University of Washington in both a research capacity and a student affairs capacity.

He is an associate professor in psychiatry and behavioral sciences and the assistant director of health and wellness for alcohol and other drug education. Jason works tirelessly to increase student access to evidence-based approaches and he has written numerous publications on the impact of college student substance use.

So, Jason, welcome to the podcast.
 

Dr. Jason Kilmer

Thank you. What a nice introduction and it's a pleasure to do this with you today.
 

Lucey

Absolutely. So, the premise around the whole podcast series – each episode is centered around five specific questions that have been developed specifically for you. So I'm going to jump right into our first question.

And I'm going to preface the first question by stating that under federal law, a reminder, that recreational and medical use of marijuana is illegal. Now, with that being said, in November 2012 voters in Washington state approved an initiative that legalizes marijuana use for adults 21 and older.

So Jason, from your perspective, what has been the biggest impact of that event on Washington State's colleges and universities?

 

Kilmer

That's a great question. I think probably one of the biggest impacts has been a need for schools to sort out what could be perceived as mixed messages for our students.

You know we've got state law, we've gotten federal law and all colleges and universities need to demonstrate compliance with the drug-free schools and campus regulations as part of the Drug-Free Schools and Communities Act.

So on college campuses, independent of what city they're in what state they're in, we've tried to continue to make clear that use, possession, public use, remains illegal.

But, you know, when people aren't entirely sure about … “I'm in a state where it's legal so what does that mean for me?” … it's really trying to make sure that as best as we can those mixed messages can be reduced.

Part of that involves consistent enforcement. Part of that involves, you know, really making sure that we're trying to clarify what the science really says.

I think the other thing we're trying to be mindful of on college campuses is – you know, and this is as important for students to be aware of as it is their parents to be aware of – is the fact that there's research that is clearly showing that the more frequently people are using marijuana, the more that's associated with taking longer to graduate, discontinuous enrollment in school, skipping class, lower grade point averages. And even when you include alcohol in the equation – alcohol and marijuana – the more heavily people use both, the more that's associated with lower GPA.

But when entered into some of the same predictive models, the effects of alcohol become a little less strong if not even nonsignificant. So there are so many important conversations happening on college campuses about how we make college more affordable for everyone. And those are fantastic conversations that we could and should be having. But part of that involves getting out on time. Part of that involves not taking five, six, seven years to get out of school and to graduate.

And so if substance use is impacting student success, we have to be mindful that what we do around alcohol and marijuana use and other drug use will pay dividends the classroom.

And so it's really keeping that focus on importance of prevention.

 

Lucey

So you brought up a couple of really good foundational principles there: consistent enforcement and follow the science. I mean those are two hallmarks of a comprehensive prevention program. And I'm glad you brought that up. And you wove in the alcohol issue because that's an excellent segue into my second question.

You have a long history of studying the impact of alcohol misuse among college students as well as looking at the impact of marijuana use among youth and young adults. So what lessons learned around alcohol misuse prevention also apply to marijuana use prevention?

 

Kilmer

You know so much of that is exactly what we're trying to even sort out. And it really is a thoughtful question because it's with less literature on all those best practices and prevention, especially with a college student population, these changes are very very new. And so even when people say well, “what are the long-term effects of this?” or, “what are the outcomes of that?” most of this around our legislation as you pointed out is only a little over five years ago.

We know from the alcohol world that if you give “fact only,” “information only” type of prevention programs, you will see an increase in knowledge but no change in behavior.

So if we're trying to reduce risks or harms, or even use itself, giving information will increase knowledge but won't necessarily change behaviors. Sometimes we want to increase knowledge. And that's actually one of the things we're looking to do.

So I think an example of that in the alcohol world is what makes up the standard drink. If you let people know what a standard drink is, [it] doesn't necessarily mean that you'll change what they do unless you can tie it back in to why it matters related to their behavior.

If someone who doesn't understand that, you know, the larger container of this versus that might mean more standard drinks, we want to get one at least on the same page.

Another good example, I think, is recognizing signs of alcohol poisoning. There's been research that's been done. It looks at reasons why students might not call for help in an alcohol emergency. And one of the primary reasons is they're not sure if help is needed.

And so increasing that knowledge doesn't necessarily mean they'll do something differently. That's on us to look at the behavioral implications beyond that.

But it does mean we have to at least make sure that if there is some information that we're trying to at least level the playing field from a knowledge standpoint that we can do that.

So, you know, sometimes when it comes to marijuana use we do on increase knowledge.

But if we're looking at what lessons we can take from alcohol prevention, I think that probably the most important thing on individually-focused approaches is we have to focus on what's most important to the student that we're working with.

We could have all the science and facts in the world but if that's less relevant to any student’s situation that's not going to be as useful. We know that in an alcohol world if we can illicit from a student we're working with personally relevant reasons to change that could prompt thinking about change or even commitment to change.

So for the student that says, “I really want to do well in school that's my value of my goal,” if the status quo is, “I'm really struggling with memories attention concentration,” we can actually connect the dots and show ways in which the more people use marijuana, the more those cognitive effects are impacted. And if that prompts either thinking about change or asking about change that would be consistent with some of the best practices we have with alcohol.

Additionally, I will say environmental approaches and individual focused approaches have to work side by side. And that's something we've definitely learned from the alcohol prevention world. And I imagine that would apply very well to the marijuana prevention world as well.

 

Lucey

Yeah, I wholeheartedly… I'm glad you mentioned that last piece. And you know in prevention we sometimes talk about chasing the drug, which is something we try to avoid. So I know that it's inevitable sometimes and it's hard to resist. But you know whether it's alcohol issues, marijuana and certainly with opioids and such, it feels like we're just chasing the drug du jour. But there are certain underlying, really sound, prevention principles that apply regardless of what drug you're you know chasing so to speak. And so you've mentioned those – I think really well – in terms of what we are looking at in terms of what we can learn from alcohol misuse prevention and how we can start applying that to marijuana use.

So that's really helpful and I'm sure that the listeners to the podcast will appreciate that.

You know you talked a little bit about … there's you know little that these changes … regardless of the state… I mean Washington and Colorado have been about five years now. And there certainly have been several other states since then that have gone in this direction. And so there is not a lot of research necessarily that is available.

But I wanted to talk a little bit about evidence-based strategies. Both the College AIM, which is the College Alcohol Intervention Matrix developed by the National Institute on Alcohol Abuse and Alcoholism, and SAMHSA's National Registry of Evidence-based Programs and Practices, many who are familiar would know that as NREPP.

Both of those are intended to help identify effective alcohol and drug abuse prevention interventions.

So as a field, how do you think we're doing in identifying and actually implementing evidence-based practices to prevent drug abuse among college students?

 

Kilmer

It's a great distinction because there's a big difference, I think, between identifying and implementing.

We've definitely come a long way with alcohol. If you look at the mid-80s, for example, the number of published articles in the scientific literature showing a reduction in alcohol use, consequences, or both was actually none.

By 2002, the National Institute on Alcohol Abuse and Alcoholism was able to say here are different tiers of effectiveness because the prevention literature had grown enough to actually summarize what was out there.

With the 2015 release of College AIM we now have almost 60 individually and environmentally- focused strategies that are rated in College AIM. So we've definitely come quite a long ways.

One challenge, at least you know with other substances, is we just got a lot farther to go. With alcohol, we can see in the published literature examples of if someone makes the traits to drink for example we have to do that in a less dangerous or less risky way. We don’t have a lot of those same guidelines for harm reduction with other substances. So that definitely is one thing we're mindful of.

There are also challenges, believe it or not, even with methodology and playing catch-up. With alcohol, we can give someone a standardized, reliable, and valid measure that says:

We're going to ask you to consider your drinking over a typical week. Here's what a standard drink is.

And we can define that. We're not really there in terms of looking at what is a standard amount, for example, of marijuana use.

With alcohol, you can look on a can of Bob and look at the alcohol by volume. With marijuana, depending on how people are getting it, (outside with the exception of some legal states that have taken efforts to have things labeled) people don't actually know the potency of what they're getting.

So part of evaluating evidence-based practices is having good outcome data to look at the impact. And if we don't have good means as measurement that can be a real challenge.

I think that the “implementing” part though that's …that winds up being one of the big challenges.

With alcohol there are definitely identified strategies that work. And the question is are schools getting students connected to them in an effective way?

There's a quote I saw by Dean Fixsen, I think is really fantastic. That said, “The use of effective interventions without implementation strategies is like serum without a syringe. The cure is available but the delivery system is not.”

And I think that's so important. That, you know, if we had vaccines but no way to get it to people. The cure is available the delivery system is not.

If we have effective intervention approaches, are we appropriately and efficiently getting people connected to them? And that's where you see efforts on college campuses related to everything from screening and brief intervention with referral treatment as well as, again, things like consistent enforcement … if people have effective approaches with mandated students following a policy violation. Well the only way you're going to get people there is if there's an enforcement of those and consistent enforcement once they go to conduct, as an example.

So those types of efforts around implementation as well as identification continue to be something we look at.

 

Lucey

When I was developing the question, actually, I was really intentional about those two words. And so I'm glad you picked up on it and I wasn't like looking for that per se. But I'm glad that you differentiated the importance of both of those things.

My concern is I think that, well you've mentioned it like with the alcohol issue, we are way past the time of not knowing what works.

Because we do know what works right? I mean we've known since 2002 essentially when the NIAAA came out with the four tiers of effectiveness which was then enhanced with College AIM.

But as I said before with the whole chasing the drug issue we've known for a long time in prevention science what works.

Well I think of the strategic prevention framework, for instance, those five steps can be applied to matter whatever drug you're using. So we know how to approach things it's just I think sometimes comes down to the will to implement them.

 

Kilmer

Absolutely.

 

Lucey

So and then I'm also gonna, by the way, follow up with you to get that quote. Because I really appreciated that, so I might have you send that to me.

I'm gonna move on to our fourth question. You know a couple of years ago I had the pleasure and I was so excited that you and I were finally gonna get a chance to co-present a workshop together; and we did at the NASPA Strategies Conference. That session, you'll recall, was called “Prevention's Excellent Adventure: Where We've Been, Where We Are and Where We're Going.”

Had a great time putting it together and I really enjoyed our session and I believe that our audience did as well.

But we both know that sometimes the prevention journey isn't so excellent.

And as someone who works in research and student affairs, what keeps you up at night when it comes to preventing drug abuse among college students?

 

Kilmer

Well, first let me also say that that tag-team with you was easily one of the most rewarding opportunities in terms of my work at conference presentations. You've been such a good friend to higher education for a long time and having a chance to tag-team with you was really great.

You also know me well because I am a worrier. So asking me what keeps me up at night is unfortunately an often lengthy list.

I do what I can to make that list feel shorter, but, you know, there are a lot of things that I think are anxiety-provoking right now.

If I try and keep that list somewhat manageable, I do worry about the abstainer that mistakenly thinks they're the only one on the campus that doesn't drink. Most students don't drink heavily.

And there are, you know, depending on which survey you look at, well over 20 percent if not higher of students that do not drink at all.

And whether those students are lifelong abstainers, students in recovery, students that used to drink but it's been more than 12 months – it's important for those students to know they're not alone and feel supported in the decision to not drink.

I do worry about high-risk events. You're talking to me … what … finals start at my campus in 19 hours. And so then we're going to have spring break. There's been some research that looks at among first-year students the week of spring break being the single heaviest quantity in terms of drinking week of a first-year college students first year school.

Twenty first birthdays or 21 runs – these high risk events where even if people don't typically drink heavily if it's associated with risk-taking some of the tragic things that can happen there.

I think there's some anxiety about that.  

There's even been research that is probably outside the scope of what we're talking about now but that looks at the role of for our students that do drink heavily and often who may be able to “hold their liquor.” The sense of having tolerance. There's research that shows there's a big environmental component to that. For decades we thought tolerance was very physical. But now there's research that pretty convincingly shows that there's an environmental element.

If you look Pavlov and Pavlovian conditioning, we can make a dog salivate when a bell rings. If someone always drinks around the same group of friends in the same environment, in essence every time they drink they're pairing that environment and those friends with alcohol.

Why that matters is as we know in Physiology there's something called the opponent-process theory that says if you shove the body one way, the body shoves back the other. We jack up the heat, people sweat. We make it really cold, people shiver. If you have a drug like alcohol that as a depressant slows down the central nervous system, someone drinks slows down the body.  Drink… slows down the body. In time, in response to cues that signal the alcohol is about to show up, the body will make an anticipatory response in the direction opposite the way the drug acts.

In essence, the body prepares to receive the drug. The researchers call it a conditioned compensatory response. When that happens, if someone drinks the same amount they usually do, they might not feel it the same way because there's the same depressant dose but in some ways it's being offset by this compensatory response. So they tend to drink more. They don't look any different, but they are getting to a higher blood alcohol level.

So imagine if someone developed tolerance and then goes to an environment they’ve never been … like a road trip during spring break. All the cues associated with their drinking are no longer there and if they drink the same amount they drank one week earlier it could hit them much, much, much harder and increase risk for overdose.

So, in answer to your question about what else keeps me up at night:  technically, as much as I love working with college students – even the fall – what do our campuses represent to our incoming first-year students? People from our campuses are in brand new environment. And for those who come into college already drinking, and potentially heavily, who have tolerance the word used in our field is the word “fail.”

Tolerance fails to follow someone to a new set of cues. So short of making sure everyone knows about who Pavlov is … understanding in one fell swoop someone who has done something routinely but that same behavior could hit them so much harder is very very concerning to me.

I can continue with this list …

 

Lucey

Yeah … no. You know, whenever I go to conferences, I learn and now doing these podcasts I always – I mean I've been doing this now for 25 plus years – I always try to learn something new coming out of these workshop sessions or interviews. And I gotta tell you that right there is, for me, something new.

I had not known that. Is that relatively new?

 

Kilmer

The first article that really got our attention was in 2002 by Shepard Siegel and Barbara Ramos.

And the research that's come out since then is, to me, absolutely mind-blowing.

There's been research that even shows that taste is acute. If someone always drinks the same drink, in essence, when that taste and smell … when they smell it, when they take a sip … those depth of cues, the cue that tells the body, “Hello, here comes my favorite drink.” There was even a study out of Canada, where the drinking age is lower, where they had students drink a drink that looked, tasted, and smelled like beer everything, about it was familiar. They had another drink that was the same size, the same alcohol by volume, got them to the same blood-alcohol level, but it was really, really bright blue and really peppermint-y.

When students drink a drink that had no – I mean, who drinks blue peppermint drinks? – when someone drinks a drink that was completely novel, their objective self-report is that it was hitting them harder. What's striking is that, objectively, they actually showed greater signs of impairment.

A drink that was the exact same alcohol by volume, got them to the same blood alcohol level, that had novel taste and smell cues actually hit them harder.

So go back to the idea of a 21 run. If someone is going to a bar for the first time, what does that bar represent to them? A brand new environment.

The tolerance they had in their room, or in you know friend's room, will fail us all when they go out.

And this has been replicated with other substances even. And so the research on this, I think thanks to Siegel and colleagues, has really, really grown. And implications for us on college campuses, to me, are absolutely huge.

 

Lucey

OK Jason. Thanks for telling us [about] unfortunately those things that keep you up at night. And those of us at work in prevention for as long as we have, we all have those moments unfortunately in our field.

But as I move into our fifth question, I'm flipping this on a on a more positive note. I want to give you the opportunity to talk to your peers; those professionals that are working to prevent drug abuse among college students, what do you want to say to encourage them?

 

Kilmer

I generally believe I hope no one ever questions the value of what we do in prevention. I also think we're all in this together.

I would fear the person that claims they have all the answers. That's definitely not me. And I just I know that the number of times something has come up the importance of consulting with peers getting support from peers and really trying to get a sense of lessons learned becomes so important.

The more we can collaborate the more we can be mindful of not reinventing the wheel and the more we can keep up with changing trends the better. Part of keeping up with changing trends includes things like conference attendance, listening to podcasts, listening to webinars, but also doing what we can to bridge the gap between science and practice.

I feel lucky that I have a job that lets me do that on a daily basis with a foot in both the research world in the student affairs world. But the number of journal articles that are out there … it's almost impossible to kind of stay up on all of them.

It's really doing what we can to make sure that the research is informing what we do, but that also what we do is informing some of the some of the research that's taking place.

So, really approaching things as collaboratively as possible and not losing sight of how truly valuable prevention is on college campuses I think is essential.

 

Lucey

Absolutely. To pick up on the phrase that you use to have the folks listening to this podcast and others … “to keep up with changing trends.” I mean that's a real big part of what we do in prevention. It’s never stagnant. It's always changing and we always are trying to stay a step ahead, if you will, and I really appreciate the advice that you gave.

 

Kilmer

Can I say too, Rich? Yeah, I appreciate that, thank you.

Part of trying to stay up is that sometimes it feels like, you know, we're trying to research something that's moving so quickly. I think one of the great examples of that … you asked the question about marijuana use. When we look at changes in potency over the last 20 years, in some ways this is a completely different animal than what we were looking at even in the 80s, 90s … certainly even as recent as five years ago.

In a state like mine where there's been legal marijuana, average potency is even higher than what we're seeing in the nation. And so if we're truly trying to say we want to make sure that we're making science-based decisions, what does the science say about, you know, cannabis in 2018? A lot of that research hasn't been done yet. And so I do think that there's a degree of playing catch-up as well.

So you're very right we want to stay up on it as much as possible. But where one of the extra challenges becomes when the very thing we're trying to research is changing so quickly.

 

Lucey

Well, I think that's a great note to end on. In just five questions, you've in each one of those five questions, you gave some great advice, and things for people to hang on to, and to look into further.

And so we're going to close with that Jason. I really can't say thank you enough to you for participating in our podcast series.

 

Kilmer

It's completely my honor. Thanks for the opportunity.

 

Lucey

Absolutely. And I'll certainly be talking to you soon. And to all of the listeners who've been tuning in to our podcast series, we really appreciate it. And we'll be in touch very soon thank you and have a good day.