The effect of COVID-19 on college student mental health is widely reported and can, in part, be evidenced by the increasing demand for counseling services. The degree to which the pandemic affected substance use patterns, including binge drinking and cannabis use, appears to be less obvious and, perhaps, more complicated. We asked two national experts what the early data show on substance use patterns over the last two years and how we might interpret what we are seeing. Their answers include the identification of looming concerns and emerging best practices.
Dr. Jason Kilmer, associate professor in psychiatry and behavioral sciences at the University of Washington, is a nationally recognized expert on cannabis use among college students. Dr. Kilmer has served as an investigator on several studies evaluating prevention and intervention efforts for alcohol, cannabis, and other drug use by college students.
Dr. Amelia Arria is the Director of the Center on Young Adult Health and Development at the University of Maryland School of Public Health. Her research focuses on substance use and untreated mental health problems among adolescents and young adults, with a special focus on the connection between behavioral health and human capital. She is the director of the Maryland Collaborative (www.marylandcollaborative.org), a network of Maryland colleges and universities working together with community partners to reduce excessive alcohol use in their campus communities. Using data-driven approaches, the Collaborative engages partners to create environments, policies, and practices that help our students make healthy decisions, succeed in college, and become productive members of their respective communities.
MCI: Data show increases in substance use among all Americans during the pandemic but trends among college students are not as clear. What are your thoughts?
Dr. Kilmer: Obviously, any one campus needs to look at their own data to see what the experience of their campus community has been over these past 22 months. Initial reports at the start of the pandemic included a number of statements that, unfortunately, could have contributed to misperceived norms related to substance use – things like “everybody’s drinking” or “everyone is drinking more.” The science has told a different story.
One of my colleagues at the University of Washington, Dr. Scott Graupensperger, showed that frequency of drinking for young adults tended to increase, but amount per occasion actually decreased. A deeper dive tells a pretty incredible story, and typical number of drinks per week from Dr. Graupensperger’s study is a great example. Pre-pandemic, participants in his sample were reporting 4.67 drinks per week; during the pandemic, the overall average was unchanged at 4.66 drinks per week. But that doesn’t paint the complete picture. For 35.8% of young adults, drinks per week decreased, 31.1% stayed the same, and 33.1% increased. It is not the case, at all, that “everyone” drinks more or that drinking went up for everybody. Certainly, we’d want to make sure support is in place for those who were drinking heavily before the pandemic and saw those rates persist, and we’d also want to know what the prevention needs are for those whose use increased. Again, for any one campus, they should see what stories emerge from their campus data.
The relationship between substance use and mental health is well established. For some, their substance use results in unwanted affect or symptoms; for others, they might turn to substances when dealing with certain feelings. Regardless of the pathway, making sure there are services on campus to support the multiple needs of students is essential.
Dr. Arria: Our early data on this topic paints an interesting picture. The prevalence of binge drinking actually decreased overall in the population. We found that the environment in which students were living was closely tied to their level of drinking. Because many college students were restricted from having access to bars and large parties during the pandemic, it wasn’t a big surprise. Parental permissiveness was related to drinking as well; if a student had less permissive parents, they drank less, regardless of where they lived. It’s important to recognize though that there was a great deal of heterogeneity in response to the pandemic, about 1 in five people drank more, some people drank less, and many drank the same amount. How we can identify students whose drinking patterns became more problematic during the pandemic and intervene with them effectively and supportively is our challenge.
The relationship between substance use and mental health is well established.
We know drinking is a maladaptive coping mechanism but it’s not as simple as “they’re stressed out so they’re drinking more.” It’s more complicated than that. We found that the vast majority of college students felt very stressed during the pandemic, but a minority drank heavily. Alcohol consumption is driven by a multitude of factors other than stress, including access, biological predispositions, marketing and promotion, and perceived norms and attitudes.
MCI: Are colleges and universities seeing this as an urgent problem to address?
Dr. Kilmer: I would hope that there’s always an urgency to address substance use by students – it’s the right thing to do and has huge impacts for a number of outcomes. You can’t be an administrator who supports student success, including things like graduation rates and retention, and not support alcohol and other drug prevention. What gets done about substance use by students pays dividends in the classroom. Schools that I’ve seen address substance use well have tremendous administrative support and buy-in, and that makes a huge difference.
I often quote Laurie Davidson, who worked with so many schools in her work with the Higher Education Center and the Suicide Prevention Resource Center, and once declared that, “If you want to be a campus that does good suicide prevention, do good alcohol prevention.” Why? Because “alcohol prevention is suicide prevention.” What campuses do to reduce high-risk drinking will also pay dividends on things like mental health and even suicide.
In the National Institute on Alcohol Abuse and Alcoholism’s (NIAAA’s) College Alcohol Intervention Matrix (CollegeAIM), campuses are reminded that a “mix of strategies” is best. Ideally, campuses realize that having a comprehensive strategic plan includes numerous components: policies, enforcement of those policies, education, prevention, intervention, treatment, and other factors.
Dr. Arria: Most college campuses are trying to constructively address substance use. In the Maryland Collaborative, we advocate for using evidence-based practices to inform decision-making. Colleges need to have the resources and personnel to engage in environmental-level strategies in combination with more individually-focused interventions to see improvement.
We found that the environment in which students were living was closely tied to their level of drinking.
For example, if the data show that it looks like athletes and individuals who are members of fraternities or sororities are more likely than others to be excessive drinkers, then it behooves student leaders and the college administrators to examine access and availability of alcohol in those environments. We also promote having meaningful conversations with students of concern. If student athletes say their coaches have never spoken to them about drinking, then there’s an opportunity to train those coaches about how to have that conversation and refer students to available resources. The same goes for student health center personnel who might screen for alcohol problems at routine health encounter visits.
Another issue is that the personnel that are tasked with addressing substance use – in student affairs or at the counseling center – are not in the position to implement environmental-level approaches. For instance, individuals are needed to broker relationships with bar owners to promote responsible beverage service or liquor store owners to be vigilant about false ID use. Having buy-in from the president and the cabinet to engage community partnerships is critical.
MCI: What are your thoughts and/or concerns about cannabis use during the pandemic and in general?
Dr. Kilmer: Early on, the National Institute on Drug Abuse (NIDA) warned that because it attacks the lungs, COVID-19 could be a particular risk for those who smoke or vape cannabis or tobacco. By summer of 2020, we started hearing about research out of Stanford University that showed an increased risk, including for more severe infection, for those who smoke or vape cannabis or tobacco. Their own follow-up research, while not unique to cannabis, demonstrated a 5x increase in risk of testing positive for 13-24-year-olds who vape, and a 7x increase for those who vape and smoke. Certainly, if someone chooses to avoid vaping or smoking outright, or has historically done so and chooses to quit, the science would support this.
I was honored to be one researcher on a team of scientists who generated a consensus statement about the risks associated with high potency cannabis, or anything over 10% THC. High potency cannabis is dominating the retail markets in states that have legalized for medical or non-medical purposes, so it is definitely something to have on people’s radar. Among the conclusions reached by the research team were that high-potency cannabis is associated with greater risk to mental health and there are more adverse and unwanted outcomes with use of high potency cannabis, particularly for adolescents and young people. With so much attention to mental health during the pandemic, being aware of substance use that can worsen mental health is important.
Dr. Arria: The patterns of cannabis use overall are a concern, particularly given the high potency of these products and the widespread misperceptions around their use. Students’ perceptions are driven by so much more information than the scientific literature offers. They’re told it doesn’t have negative effects, or even worse, that it can alleviate mental health problems, when the scientific evidence shows just the opposite. The idea that cannabis use promotes disengagement isn’t really on their minds because they see it as a way to connect with their friends who also use. Cannabis use can raise the risk of not getting the most out of college – to exercise critical thinking, to be part of a bigger community. How to correct those misperceptions and how to get the people who are unsure about the effects to question the validity of their information sources, that’s a big issue.