Developing a Marijuana Counseling Module to Improve Mental and Physical Health Outcomes

Problem/Background: Many years of recent United States military conflict have produced a large number of experienced combat veterans who face the challenge of reintegrating back into a civilian lifestyle. Mental health conditions such as Post Traumatic Stress Disorder (PTSD) are common among these veterans. Marijuana use is common among veterans suffering from mental health conditions. Veterans frequently present to the Veteran's Affairs (VA) Hospital outpatient mental health clinic reporting marijuana use. Clinicians at the VA who are faced with providing treatment to veterans receive little to no education about the effects marijuana use has on mental health conditions. Clinicians who are not confident in their knowledge are unable to provide appropriate evidenced-based education to veterans with mental health conditions who are using marijuana. The purpose of this quality improvement project was to develop an evidenced-based education module about the effects of marijuana use and present the material to mental health clinicians. Methods: Clinicians working in the outpatient mental health clinic at the VA hospital participated in one of three different educational module presentations lasting 15-20 minutes. Pre-and post-education surveys with 14 Likert formatted questions were filled out by all participants to assess knowledge, confidence and use of screening options for marijuana use. A 30-day follow-up survey with 8 Likert formatted questions was filled out by clinicians. Participant demographic information was measured and described using summary statistics and frequency distributions. Quantitative survey data was analyzed using paired sample two-tailed t-tests. Key Findings: Pre- and post-education survey data for a total of 42 clinicians and follow up survey data for 22 clinicians was used for analysis. Likert responses were assigned scores using =Strongly Agree, 1=Agree, 2= Undecided, 3= Disagree and 4=Strongly Disagree. Lower scores in the post-education survey indicate improvement due to clinicians entering responses closer to "Strongly Agree." Combined averages of pre- and post-education question scores related to knowledge (questions 1,4,8,9 averaging pre-7.26 and post-5.79), confidence (question 6, pre-1.76 and post-1.29) and use of screening interventions (questions 12,13, 14 averaging pre-6.94 and post- 5.83) showed improvement. Paired sample two tailed t-tests were used to analyze the data obtained from the surveys. Statistically significant improvements in knowledge (questions 1,4,8,9, p<0.006), confidence (question 6, p<0.005) and use of screening interventions (questions 12,13,14, p<0.05) were observed in 8 of the 14 pre-and post-education survey questions and 2 of the 8 follow up survey questions (question 6 p<0.001 and 13 p<0.05). Conclusion: Results from this project demonstrated that presenting an educational module on the effects of marijuana to clinicians can be an effective technique for producing statistically significant improvements in clinician knowledge, understanding and confidence. Clinicians can then use the newly acquired information from the module to increase safety and improve outcomes through therapeutic conversation, the implementation of interventions and treatment plan modification in marijuana using veterans.

Running head: MARIJUANA USE INTERVENTION Developing a marijuana counseling module to improve mental and physical health outcomes Michael Speed University of Utah College of Nursing 1 MARIJUANA USE INTERVENTION 2 Abstract Problem/Background: Many years of recent United States military conflict have produced a large number of experienced combat veterans who face the challenge of reintegrating back into a civilian lifestyle. Mental health conditions such as Post Traumatic Stress Disorder (PTSD) are common among these veterans. Marijuana use is common among veterans suffering from mental health conditions. Veterans frequently present to the Veteran's Affairs (VA) Hospital outpatient mental health clinic reporting marijuana use. Clinicians at the VA who are faced with providing treatment to veterans receive little to no education about the effects marijuana use has on mental health conditions. Clinicians who are not confident in their knowledge are unable to provide appropriate evidenced-based education to veterans with mental health conditions who are using marijuana. The purpose of this quality improvement project was to develop an evidenced-based education module about the effects of marijuana use and present the material to mental health clinicians. Methods: Clinicians working in the outpatient mental health clinic at the VA hospital participated in one of three different educational module presentations lasting 15-20 minutes. Pre-and post-education surveys with 14 Likert formatted questions were filled out by all participants to assess knowledge, confidence and use of screening options for marijuana use. A 30-day follow-up survey with 8 Likert formatted questions was filled out by clinicians. Participant demographic information was measured and described using summary statistics and frequency distributions. Quantitative survey data was analyzed using paired sample two-tailed ttests. Key Findings: Pre- and post-education survey data for a total of 42 clinicians and follow up survey data for 22 clinicians was used for analysis. Likert responses were assigned scores using MARIJUANA USE INTERVENTION 3 0=Strongly Agree, 1=Agree, 2= Undecided, 3= Disagree and 4=Strongly Disagree. Lower scores in the post-education survey indicate improvement due to clinicians entering responses closer to "Strongly Agree." Combined averages of pre- and post-education question scores related to knowledge (questions 1,4,8,9 averaging pre-7.26 and post-5.79), confidence (question 6, pre-1.76 and post-1.29) and use of screening interventions (questions 12,13, 14 averaging pre6.94 and post- 5.83) showed improvement. Paired sample two tailed t-tests were used to analyze the data obtained from the surveys. Statistically significant improvements in knowledge (questions 1,4,8,9, p<0.006), confidence (question 6, p<0.005) and use of screening interventions (questions 12,13,14, p<0.05) were observed in 8 of the 14 pre-and post-education survey questions and 2 of the 8 follow up survey questions (question 6 p<0.001 and 13 p<0.05). Conclusion: Results from this project demonstrated that presenting an educational module on the effects of marijuana to clinicians can be an effective technique for producing statistically significant improvements in clinician knowledge, understanding and confidence. Clinicians can then use the newly acquired information from the module to increase safety and improve outcomes through therapeutic conversation, the implementation of interventions and treatment plan modification in marijuana using veterans. MARIJUANA USE INTERVENTION 4 Introduction Problem Description Military conflicts such as Operations Enduring Freedom and Operations Iraqi Freedom have produced a large number of veterans who face the challenge of transitioning back to a civilian lifestyle after experiencing intense combat experiences. Over 35% of these veterans who report to a Veterans Administration (VA) hospital receive a mental health diagnosis with post-traumatic stress disorder (PTSD) being the most prevalent (Elliott, Golub, Bennett, & Guarino, 2015). Some VA hospitals have reported PTSD rates in veterans seeking treatment as high as 50% (Elliott et al., 2015). In many cases, veterans turn to substance use to help deal with emotional distress related to mental health disorders and PTSD. For example, up to 80% of Vietnam veterans diagnosed with PTSD also have a Substance Use Disorder (SUD) (Elliott, Golub, Bennett, & Guarino, 2015). Marijuana is illegal under federal law and categorized as having a high potential for abuse along with the possibility of psychological dependence (Brooks, Gundersen, Flynn, Brooks-Russell, & Bull, 2017). However, many states have passed laws allowing the sale and consumption of marijuana giving rise to increased availability and accessibility of the drug. These laws have been passed despite there being insufficient evidence showing therapeutic value for some of the qualifying conditions such as PTSD, anxiety, irritable bowel syndrome and cancer (Boehnke, Gangopadhyay, Clauw, & Haffajee, 2019). Marijuana use is a growing trend in America, with veterans being no exception. A veteran's transition to civilian life has been described as a critical time period that can determine future individual functioning (Derefinko et al., 2018). During this crucial time, marijuana use among veterans who recently separated from active duty military has been reported as increasing by 23% (Derefinko et al., 2018). Another MARIJUANA USE INTERVENTION 5 research study states that the rate of marijuana use among veterans is as high as 34% (Golub & Bennett, 2014). Marijuana being used for symptoms of anger, irritability, sleep, hypervigilance, depressed mood and nightmares has been shown to increase marijuana use and associated side effects (Pederson, Villarosa-Hurlocker, & Prince, 2018). There is evidence that marijuana use increases the risk of psychotic symptoms, mania, psychosis, and cognitive dysfunction (O'Neil et al., 2017) . There are findings that suggest marijuana use in veterans is associated with suicidal behavior and suicide attempts (Kimbrel et al., 2017). Some studies reports an association between partner violence and marijuana use (Buchholz et al., 2017). Furthermore, marijuana may inhibit emotional processing of traumatic events reducing therapeutic success in veterans receiving psychotherapy (Pederson et al., 2018). Available Knowledge As marijuana use among veterans with mental health disorders continues to rise, clinicians are faced with the responsibility of educating veterans about the effects of marijuana use. Evidenced informed discussions need to take place especially with veterans who have PTSD and report marijuana use (O'Neil et al., 2017). A barrier to these types of discussions taking place is current clinician knowledge and understanding about the effects of marijuana use. In a survey among providers in Colorado, a state with laws allowing the recreational use of marijuana, few providers reported feeling completely knowledgeable or confident enough to talk to patients about the effects of marijuana use (Brooks et al., 2017). Multiple studies have reported that providers want additional training about marijuana to increase comfort level when discussing the health effects of marijuana (Brooks et al., 2017). Of providers surveyed in Colorado, 70% reported that they would benefit from the availability of training materials MARIJUANA USE INTERVENTION 6 (Brooks et al., 2017). In person training about the health effects of marijuana was a preferred method in increasing provider confidence (Brooks et al., 2017). Rationale The theory of planned behavior (TPB) was used as an influence when creating the design of this this project. This theory is based on behavioral change that is dependent on motivation, intention, and a person's own ability to change (Lamorte, 2018). TPB is comprised of six constructs that are used to explain behavior (Lamorte, 2018). These constructs are attitudes, behavioral intention, subjective norms, social norms, perceived power, and perceived behavioral control (Lamorte, 2018). This quality improvement project used constructs from the TPB to educate clinicians about the adverse effects of marijuana use in veterans. The first TPB construct of attitudes was essential in determining clinicians' understanding and perspective towards marijuana use. The TPB states that the more motivational factors that are provided to influence a behavior, the more likely the behavior will occur (Lamorte, 2018). Evidence-based educational material was then used to create a module to increase knowledge and provide influencing factors that affect how often interventions are provided for veterans. Subjective norms which are defined as the belief that most people approve or disapprove of a behavior, and social norms which are behaviors that are considered standard in a defined population group are important constructs in this project (Lamorte, 2018). It is estimated that as many as 227 million people use marijuana worldwide, and during 2014, 20 million Americans reported using marijuana during the last month, making marijuana use a social norm (Kimbrel et al., 2017). And as previously stated, marijuana use in veterans has been reported as high as 34% contributing to the subjective norm that veterans peers may encourage engagement in the behavior (Golub & Bennett, 2014). It is important to identify and understand subjective and MARIJUANA USE INTERVENTION 7 social norms to provide better understand of marijuana use and the increasing frequency of use. The marijuana educational module provided to clinicians addresses the construct of perceived power and behavioral control. Increasing clinician knowledge about the effects of marijuana use and available interventions gives clinicians power through increased understanding and confidence in discussing the topic with veterans. It aids clinicians in making good clinical judgement based on symptom presentation and consideration of possible adverse effects of marijuana use. Specific Aims The quality improvement project described in this manuscript was conducted to improve clinician awareness of adverse effects associated with marijuana use in patients suffering from mental health conditions. This was done by building an evidenced-based education tool and identifying treatment recommendations about marijuana use to improve clinician knowledge on the adverse effects and to remedy the lack of training that some clinicians may have (Holland et al., 2016)(Sweet, Kim, Martin, Washington, & Brahm, 2017). The education tool was used in an outpatient mental health setting. Surveys were used to gather data about clinician knowledge and changes in clinical practice. Methods Context An outpatient mental health clinic at a VA hospital was identified as an appropriate site for this quality improvement project. The VA outpatient mental clinic is located in an urban setting with catchment areas extending into Utah, Nevada and Idaho. Veterans of any age who live in the catchment area are seen in the clinic for mental health needs including depression, anxiety, PTSD, substance abuse, psychosis and suicidality. Three interdisciplinary mental health MARIJUANA USE INTERVENTION 8 teams participated in the project. Each team consists of four psychiatric/mental health nurse practitioners, three psychiatrists, six licensed clinical social workers and two registered nurse case managers. Clinicians often meet with up to eight veterans per day, five days a week. The VA hospital had limited resources available to clinicians about the effects marijuana use has on mental health symptoms. Interventions The first step in the project was to perform an analysis of current evidence based research and VA resources containing information about the physical and mental health effects of marijuana. A PowerPoint training program was developed using current evidence based research and VA resources. The second step in the project was to assess mental health clinicians in an outpatient mental health clinic at a VA hospital on their knowledge level about marijuana use, its adverse effects and how it impacts current physical and mental health symptoms. This data was obtained using a survey distributed to clinicians directly before the educational module presentation at a weekly interdisciplinary team meeting. The survey was formatted as a brief rating questionnaire using Likert scales. The third step was to present the educational module to the three interdisciplinary teams during three separate interdisciplinary team meetings. The PowerPoint training was made available to clinicians after the team meeting through email and printed materials. The fourth step of the project was to evaluate the effectiveness of the education provided. This was done by administering a follow-up assessment to participating clinicians to determine knowledge, comfort level changes and if clinicians implemented recommended interventions. MARIJUANA USE INTERVENTION 9 This information was obtained by administering a brief survey immediately after the educational module presentation. Study of interventions The educational module was presented to a total of 12 psychiatric nurse practitioners, nine psychiatrists, eighteen clinical social workers and six nurse case managers. The participants were spread through three organizationally established interdisciplinary treatment teams. The impact of the interventions was measured using change statistics to compare the knowledge level and number of conversations held with veterans about marijuana use both before and after the presentation of the educational module. The expected outcome of the project was to observe, using descriptive statistics obtained from surveys, if there is an increase in clinician knowledge and the number of reported clinical interventions for marijuana using veterans. Measures A Likert style survey was used to collect data from participants before and after the educational module. This type of survey was chosen due to the ability to quickly select responses and complete the survey. Survey administration and completion was, therefore, timely and did not subtract excessive time from the team meeting. The survey questions and design were created specifically for this quality improvement project. Surveys were approved by University of Utah faculty before administration to participants using paper copies of the survey that were filled out by hand. The responses from the paper copied surveys were collected and manually entered into the IBM SPSS data program for data organization and statistical analysis. Administration of paper copies of the survey ensured the surveys were completed by clinicians at appropriate pre-and post-intervention intervals. Manual entry of survey results does create the potential for errors in data due to human error, however the benefit of having all surveys MARIJUANA USE INTERVENTION 10 completed at the same time by participants outweighed the small possibility for human error in data entry. Collecting hand written surveys also provided an opportunity to ensure all questions were answered. The educational module was presented to each of the three teams using a 15-20 minute presentation. PowerPoint slides, a key point handout and surveys were used during the presentation. The educational module format and presentation during interdisciplinary team meetings could be feasibly reproduced on other VA outpatient mental health settings due to the standardized team construction across the nationwide VA healthcare system. Analysis Data analyzed in this project was obtained through pre- and post-educational module surveys. The Likert scale responses to the questions from the surveys provided quantitative data for analysis. The Wilcoxon signed rank test was used to measure the change between preeducational module and post-educational module. Difference between the pre- and post-surveys were analyzed using parametric t-tests. An open ended question was used on the posteducational module survey asking for suggestions on improving knowledge, treatment or policy changes regarding marijuana use among veterans. Data obtained from this question was given to VA leadership for further development of marijuana educational programs for both veterans and clinicians. Ethical Considerations No protected health information was used is this project. This study was determined to be a non-human subjects project by the University of Utah Institutional Review Board. The VA Salt Lake City Health Care System determined the project to be a non-research Veterans Health Administration activity. Marijuana or cannabinoid use for chronic pain, seizure disorders or MARIJUANA USE INTERVENTION 11 other health concerns where it has shown to provide benefit would put a veteran and VA clinician in a difficult situation as the VA does not allow clinicians to prescribe or recommend marijuana or its derivatives. Current state laws allowing the use of marijuana for medical reasons could create an ethical dilemma when a veteran who has been prescribed marijuana by a non-VA provider is later seen for treatment at the VA. Results Process Measures and Outcome Over the course of this quality improvement project, 42 participants attended the educational module presentations and completed the pre- and post-education surveys (See appendix A). The pre- and post-education survey scores were measured in a 0-4 Likert scale reflecting "strongly agree" to "strongly disagree." Demographic data consisted of questions asking years of employment at the VA and discipline title. Two participants did not completely fill out the demographics portion of the survey. Demographic frequencies show that the average years of employment at the VA was 6.64 years. The majority of participants were social workers (35.7%) followed by psychiatrists (23.8%) and APRNs (19%) (see appendix C). Analysis of means using a paired sample two tailed t-test across each of the 14 Likert scale survey questions resulted in statistically significant improvements in 8 of the 14 post-education survey questions when compared to the pre-education surveys ( See appendix D and H). The most dramatic improvements were for question 4: "Marijuana use among veterans worsens PTSD symptoms" (p<0.001), question 6: "I feel confident in my understanding about the negative effects marijuana use has one mental health" (p<0.003) and question 9: "I understand the effects of the brain caused by long term marijuana use" (p<0.001). MARIJUANA USE INTERVENTION 12 In addition to the pre- and post-education surveys, a follow-up survey was distributed to the participating treatment teams 30-45 days after the educational intervention (See appendix B). 8 of the 14 original Likert scale questions were used in the follow-up survey along with the addition of the question: "I am interested in continuing education pertaining to the effects of marijuana use". A total of 22 follow-up surveys were filled out including one participant who left the demographic area blank. The average years employment at the VA of participants who filled out the follow-up survey was 8.06 years. Once again the majority of participants in the follow-up were social workers (45.4%) followed by APRNs (22.7%), other disciplines (18.2%) and lastly psychiatrist (9.1%) (See appendix E). Analysis of the means using a paired sample two tailed t-test across each of the 8 Likert scale survey questions resulted in significant improvements in 2 of the 8 follow-up survey questions when compared to the pre-education surveys (See appendix F and I). The most significant improvement was in question 6: "I feel confident in my understanding about the negative effects marijuana use has on mental health" (p<0.001). Responses to the additional question added to the follow-up survey: "I am interested in continuing education pertaining to the effects of marijuana use" resulted in over 90% of participants responding ‘agree' and ‘strongly agree' (See appendix G). Contextual Elements The initial plan for the intervention was to present the educational module to three different treatment teams at the VA during their regularly scheduled weekly meeting times. Clinicians arriving late to the meeting were unable to fill out the pre-education survey and therefore did not fill out a post-education survey. This decreased the amount of participants in the surveys. MARIJUANA USE INTERVENTION 13 Follow-up surveys were administered 30-45 days after the initial educational module presentation. The surveys were distributed at the regularly scheduled team meetings for three different treatment teams with instructions to fill out a survey if the clinician was in attendance at the educational module presentation. There was increased resistance to filling out the follow-up survey with only 22 surveys being completed. Follow-up surveys were not linked to pre- and post-education surveys creating limitation in data analysis. Details About Missing Data Two participants filling out the pre-and post-education survey left the demographics portion blank and one participant filling out the follow-up survey left the demographics portion blank. A large number of participants who attended the educational module presentation and filled out the initial surveys did not fill out a follow-up survey as evident by the final total survey numbers (N=42 vs N=22). Only 52% of the initial 42 participants filled out a follow-up survey. Discussion Summary The study results demonstrate that providing education about marijuana use to clinicians from a variety of disciplines in an outpatient mental health setting can be an effective method to increase understanding and confidence about marijuana use. Implementing the intervention during weekly team meetings provided consistency with and uniformity on disseminating data during the education module and facilitated obtaining information through pre- and posteducation surveys. Presenting the educational material did not take excessive time from the meeting. Collection of initial survey data after the team meetings allowed for immediate review of data results. Interpretation MARIJUANA USE INTERVENTION 14 The results of the pre-and post-surveys collected during the intervention of the marijuana educational module show presenting educational material to clinicians has a positive impact on clinician knowledge, confidence and understanding as evident by statistically significant changes in eight of the fourteen survey questions. Survey questions that showed improvement after the intervention assessed understanding of the negative effects of marijuana use, personal reflection of confidence level as well as the diagnosis and screening of marijuana use. The thirty day follow-up survey reflects that clinicians had greater confidence about their personal understanding of marijuana use along with greater likelihood that clinicians will add the diagnosis of cannabis use disorder when applicable. This further demonstrates continued benefit from the provided education in those that were in attendance of the educational intervention. The educational module was well received by participating clinicians. This is consistent with studies that report clinicians have a desire to increase understanding and want additional training on marijuana use (Brooks et al., 2017)(Holland et al., 2016). It was expected during the design of this intervention that clinicians would report improvements in knowledge, confidence and understanding but there were not any studies reviewed during the design of the intervention that applied a similar intervention in a clinical setting which could be used to compare results. The educational module as delivered was inexpensive and did not require excessive time to coordinate the implementation of the intervention. Use of the already established weekly team meetings provided a time and location where clinicians would be available to participate in the intervention. Clinicians were not required to take additional time out of their schedules and patient care time was not affected. The time required to review previous research, create the educational material, along with collecting and analyzing data was performed by one student at MARIJUANA USE INTERVENTION 15 the clinical site. There was no direct cost associated with the implementation of this project so it could be easily reproduced in similar clinical settings. Limitations A limitation of this study was the way the 30-day follow-up survey was distributed. The initial intervention had forty-two participants with only twenty-two completing follow-up surveys. The discrepancy between participants could be due to differences in attendance to team meetings or lack of motivation to fill out the follow-up survey when it was distributed. An additional limitation in the follow-up survey was that the data was not linked to previous surveys. Linking the initial pre- and post-surveys with the follow up survey would have required obtaining additional data from participants. However, the unlinked data was still beneficial in comparing means. This intervention was applied during team meetings and only those in attendance received the education and filled out surveys. There may have been clinicians who were not in attendance that could have influenced the overall results of the project. This is a potential limitation of the project. The possibility of survey question order bias was addressed prior to distribution of the surveys due to the two surveys being filled out by participants within a short timeframe. The survey question order was randomized between the pre-and post-education surveys in an effort to reduce question order bias. The follow-up survey contained few questions and bias was not of concern. Conclusion Research suggests there is a lack of education provided in clinical settings regarding the effects marijuana use has on mental health conditions (Brooks et al., 2017). This project was MARIJUANA USE INTERVENTION 16 designed and implemented to provide education for clinicians in a clinical setting about the effects marijuana use has on mental health conditions and to address the lack of current available education. The study was beneficial for participating clinicians in improving knowledge, understanding and comfort levels. The intervention was cost effective and could be reproduced in similar clinical settings. The educational module used for this project included a PowerPoint presentation, surveys and a review of information and handouts available at the clinical site. Similar clinical educational interventions could be applied to reproduce the project for marijuana use or for a variety of other applicable topics. Continued evaluation of current research pertaining to the effects of marijuana use is suggested for further study. Information used in the educational intervention in this project can be updated as new information becomes available. Despite the challenges and limitations, this project successfully improved the knowledge, understanding and comfort levels of clinicians about the effects of marijuana use. MARIJUANA USE INTERVENTION 17 References Brooks, E., Gundersen, D. C., Flynn, E., Brooks-Russell, A., & Bull, S. (2017). The clinical implications of legalizing marijuana: Are physician and non-physician providers prepared? Addictive Behaviors, 72(), 1-7. https://doi.org/10.1016/j.addbeh.2017.03.007 Buchholz, K. R., Bohnert, K. M., Sripada, R. K., Rauch, S. A., Epstein-Ngo, Q. M., & Chermack, S. T. (2017, January). Associations between PTSD and intimate partner and non-partner aggression among substance using veterans in specialty mental health. Addict Behav, 64, 194-199. https://doi.org/10.1016/j.addbeh.2016.08.039 Derefinko, K. J., Hallsell, T. A., Isaacs, M. B., Garcia, F. S., Colvin, L. W., Burasc, Z., ... Klesges, R. C. (2018, May/June). Substance use and psychological distress before and after the military to civilian transition. Military Medicine, 183, 258-265. Retrieved from https://doi.org/10.1093/milmed/usx082 Elliott, L., Golub, A., Bennett, A., & Guarino, H. (2015, March). PTSD and cannabis-related coping among recent veterans in New York City. Contemp Drug Probl, 42, 60-76. https://doi.org/ 10.1177/0091450915570309 Golub, A., & Bennett, A. S. (2014, February). Substance Use over the military-veteran life course: an analysis of a sample of OEF/OIF veterans returning to low income predominately minority communities. Addict Behav, 39, 449-454. https://doi.org/ 10.1016/j.addbeh.2013.06.020 Holland, C. L., Nkumsah, M. A., Morrison, P., Tarr, J. S., R, D., Rodriguez, K. L., ... Chang, J. C. (2016, September). "Anything above marijuana takes priority": obstetric providers' attitudes and counseling strategies regarding perinatal marijuana use. Patient Educ Couns, 99(9), 1-14. https://doi.org/10.1016/j.pec.2016.06.003 MARIJUANA USE INTERVENTION 18 Kimbrel, N. A., Newins, A. R., Dedert, E. A., VanVoorhees, E. E., Elbogen, E. B., Naylor, J. C., ... Calhoun, P. S. (2017, June). Cannabis use disorder and suicide attempts in Iraq/Afghanistan-era veterans. J Psychiatr Res., 89, 1-11. https://doi.org/10.1016/j.jpsychires.2017.01.002 Lamorte, W. W. (2018). The theory of planned behavior. Retrieved from Boston University School of Public Health website: http://sphweb.bumc.bu.edu/otlt/MPHModules/SB/BehavioralChangeTheories/BehavioralChangeTheories3.html O'Neil, M. E., Nugent, S. M., Morasco, B. J., Freeman, M., Low, A., Kondo, K., ... Kansagara, B. (2017, August 15). Benefits and harms of plant-based cannabis for posttraumatic stress disorder: a systematic review. Annals of Internal Medicine, 167, 332-341. Retrieved from https://doi.org/http:dx.doi.org.ezproxy.lib.utah.edu/10.7326/M17-0477 Pederson, E. R., Villarosa-Hurlocker, M. C., & Prince, M. A. (2018, January). Use of protective behavioral strategies among young adult veteran marijuana users. Cannabis, 1, 14-27. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5947861/ Sweet, G., Kim, S., Martin, S., Washington, N. B., & Brahm, N. (2017). Psychiatric symptoms and synthetic cannabinoid use: information for clinicians. Mental Health Clinician, 7, 156-159. https://doi.org/10.9740/mhc.2017.07.156 MARIJUANA USE INTERVENTION 19 Appendix A- question numbers added after completion of survey in order to reduce biases and to aid with data analysis. MARIJUANA USE SURVEY PRE-EDUCATION QUESTIONNAIRE Role in MH treatment (LCSW, PHD, APRN, MD) ______________ Years of employment ________ Statement Knowledge and Comfort level Question 1: Mild marijuana use among veterans has no detrimental effect to mental health Question 2: Excessive marijuana use is common among veterans seeking mental health treatment Question 3: Marijuana use among veterans decreases ADHD symptoms Question 4: Marijuana use among veterans worsens PTSD symptoms Question 5: There is a common belief among veterans that marijuana use is beneficial to their mental health Question 6: I feel confident in my understanding about the negative effects marijuana use has on mental health Question 7: I make sure to take the time with each of my patient's I know are using marijuana to discuss the negative health effects of continued use Question 8: I am aware of treatment options available for Cannabis Use Disorder Question 9: I understand the effects on the brain caused by long term marijuana use Strongly Agree 0 Agree 1 Undecided 2 Disagree 3 Strongly Disagree 4 MARIJUANA USE INTERVENTION 20 Question 10: Given the current positive cultural climate of marijuana use I would be inclined not to discourage veterans from using marijuana if they truly felt it was making them feel better Screening Question 11: Extent of marijuana use among veterans is adequately screened during outpatient mental health appointments Question 12: Veterans receive education about the effects of marijuana use Question 13: I add the diagnosis of Cannabis Use Disorder in marijuana using veterans Question 14: I order drug testing for veterans reporting marijuana use Do you have any suggestions about improving knowledge, treatment, or policy changes regarding marijuana use among veterans? MARIJUANA USE SURVEY POST-EDUCATION QUESTIONNAIRE Role in MH treatment (LCSW, PHD, APRN, MD) ______________ Years of employment ________ Statement Knowledge and Comfort level Question 7: I make sure to take the time with each of my patient's I know are using marijuana to discuss the negative health effects of continued use Strongly Agree 0 Agree 1 Undecided 2 Disagree 3 Strongly Disagree 4 MARIJUANA USE INTERVENTION 21 Question 9: I understand the effects on the brain caused by long term marijuana use Question 10: Given the current positive cultural climate of marijuana use I would be inclined not to discourage veterans from using marijuana if they truly felt it was making them feel better Question 3: Marijuana use among veterans worsens PTSD symptoms Question 5: There is a common belief among veterans that marijuana use is beneficial to their mental health Question 8: I am aware of treatment options available for Cannabis Use Disorder Question 1: Mild marijuana use among veterans has no detrimental to mental health Question 6: I feel confident in my understanding about the negative effects marijuana use has on mental health Question 2: Excessive marijuana use is common among veterans seeking mental health treatment Question 3: Marijuana use among veterans decreases ADHD symptoms Screening Question 13: I add the diagnosis of Cannabis Use Disorder in marijuana using veterans Question 14: I order drug testing for veterans reporting marijuana use Question 11: Extent of marijuana use among veterans is adequately screened during outpatient mental health appointments Question 12: Veterans receive education about the effects of marijuana use Do you have any suggestions about improving knowledge, treatment, or policy changes regarding marijuana use among veterans? MARIJUANA USE INTERVENTION 22 Appendix B- question numbers added after completion of survey in order to reduce biases and to aid with data analysis. MARIJUANA USE SURVEY FOLLOW-UP QUESTIONNAIRE Role in MH treatment (LCSW, PHD, APRN, MD) ______________ Years of employment ________ Statement Knowledge and Comfort level Question 6: I feel confident in my understanding about the negative effects marijuana use has on mental health Question 7: I make sure to take the time with each of my patient's I know are using marijuana to discuss the negative health effects of continued use Question 8: I am aware of treatment options available for Cannabis Use Disorder Question 10: Given the current positive cultural climate of marijuana use I would be inclined not to discourage veterans from using marijuana if they truly felt it was making them feel better New-Question 15: I would find continuing education about the effects of marijuana use beneficial Screening Strongly Agree 0 Agree 1 Undecided 2 Disagree 3 Strongly Disagree 4 MARIJUANA USE INTERVENTION 23 Question 11: Extent of marijuana use among veterans is adequately screened during outpatient mental health appointments Question 12: Veterans receive education about the effects of marijuana use Question 13: I add the diagnosis of Cannabis Use Disorder in marijuana using veterans Question 14: I order drug testing for veterans reporting marijuana use Appendix C Pre and post-education survey participants Title Cumulative Frequency Valid Missing APRN Percent Valid Percent Percent 8 19.0 20.0 20.0 MD 10 23.8 25.0 45.0 LCSW 15 35.7 37.5 82.5 Other 7 16.7 17.5 100.0 Total 40 95.2 100.0 2 4.8 42 100.0 System Total Appendix D Paired Samples Test Paired Differences 95% Confidence Interval of the Std. Deviation Difference Sig. (2-tailed) MARIJUANA USE INTERVENTION 24 Lower Upper Pair 1 Prequestion1-postquestion1 .862 -.662 -.118 .006 Pair 2 Prequestion2-postquestion2 .862 -.078 .459 .160 Pair 3 Prequestion3-postquestion3 .877 -.204 .350 .596 Pair 4 Prequestion4-postquestion4 1.008 .329 .957 .000 Pair 5 Prequestion5-postquestion5 .565 -.105 .252 .412 Pair 6 Prequestion6-postquestion6 .969 .174 .778 .003 Pair 7 Prequestion7-postquestion7 1.068 -.239 .435 .562 Pair 8 Prequestion8-postquestion8 1.097 .215 .907 .002 Pair 9 Prequestion9-postquestion9 .820 .424 .942 .000 Pair 10 Prequestion10- .992 -.517 .117 .210 .872 -.129 .414 .294 .841 .048 .571 .022 1.051 .014 .686 .042 .844 .155 .695 .003 postquestion10 Pair 11 Prequestion11postquestion11 Pair 12 Prequestion12postquestion12 Pair 13 Prequestion13postquestion13 Pair 14 Prequestion14postquestion14 Appendix E Follow-up survey participant title Title Cumulative Frequency Valid Valid Percent Percent APRN 5 22.7 23.8 23.8 MD 2 9.1 9.5 33.3 10 45.5 47.6 81.0 other 4 18.2 19.0 100.0 Total 21 95.5 100.0 1 4.5 22 100.0 LCSW Missing Percent System Total Appendix F MARIJUANA USE INTERVENTION 25 Pre-education question compared to follow-up survey questions, Paired Samples Test Paired Differences 95% Confidence Interval of the Difference Mean Std. Deviation Lower Upper Sig. (2-tailed) Pair 1 Prequestion6-followup6 .909 .921 .501 1.317 .000 Pair 2 Prequestion7-followup7 .048 1.024 -.418 .514 .833 Pair 3 Prequestion8-followup8 .273 .935 -.142 .687 .186 Pair 4 Prequestion10-followup10 .238 1.136 -.279 .755 .348 Pair 5 Prequestion11-followup11 .136 1.167 -.381 .654 .589 Pair 6 Prequestion12-followup12 .318 .995 -.123 .759 .148 Pair 7 Prequestion13-followup13 .750 1.482 .056 1.444 .036 Pair 8 Prequestion14-followup14 -.105 1.150 -.659 .449 .695 Appendix G Follow-up question "I am interested in continuing education pertaining to the effect of marijuana use" Frequency Valid strongly agree agree undecided Total Missing System Total Valid Percent 9 40.9 11 50.0 2 9.1 22 100.0 0 22 Appendix H Graph using 0=Strongly Agree, 1=Agree, 2= Undecided, 3= Disagree, 4=Strongly Disagree MARIJUANA USE INTERVENTION 26 Pre-Test to Post-Test Comparison 3.00 Response 2.50 2.00 1.50 1.00 0.50 0.00 1 2 3 4 5 6 7 8 9 10 11 12 13 14 Question number Series1 Series2 Appendix I Graph using 0=Strongly Agree, 1=Agree, 2= Undecided, 3= Disagree, 4=Strongly Disagree Follow-up survey compared to pre-education survey 3.00 2.50 2.00 1.50 1.00 0.50 0.00 Question Question Question Question Question Question Question Question 6 7 8 10 11 12 13 14 Series1 Series2 Appendix J Survey response averages Question 1 2 3 4 Pre 2.27 1.48 2.83 1.69 Post 2.64 1.29 2.74 1.05 Follow-up n/a n/a n/a n/a MARIJUANA USE INTERVENTION 5 6 7 8 9 10 11 12 13 14 0.9 1.76 0.139 1.5 1.8 1.98 2.02 2.26 2.25 2.43 0.85 1.29 1.29 0.98 1.12 2.23 1.88 1.95 1.88 2 27 n/a 0.77 1.32 1.09 n/a 1.86 1.77 2.09 1.8 2.42 Table using 0=Strongly Agree, 1=Agree, 2= Undecided, 3= Disagree, 4=Strongly Disagree