1. Lydia A. Shrier, MD, MPH David Williams, PhD Division of Adolescent/Young Adult Medicine and the Clinical Research Center, Boston Children’s Hospital Department of Pediatrics, Harvard Medical School Acknowledgements Pamela J. Burke, PhD, RN, FNP, PNP and Amanda Rhoads, FNP

2. Disclosures I have no conflicts of interest to disclose.

3. Ecological Momentary Interventions (EMIs) Use mobile technology to deliver interventions in real time and in real life Can be applied in moments leading up to potential substance use event, when substance desire and efforts to avoid use are occurring

4. Pilot Study of MOMENT Intervention To reduce marijuana use among youth in primary care MET (Motivational Enhancement Therapy): 2 sessions EMI: 2 weeks of mobile reporting 4-6 times/day of Marijuana desireTriggers for use Effort to avoid useUse followed by responsive motivational messages Baseline – Intervention – Follow-up at 3 months Momentary assessments at each study phase 27 medical outpatients (70% F) Age 15-24 years (M = 19.2) Used marijuana >3 times a week (Mdn = 6)

5. Initial Findings and New Questions Desire to use marijuana and marijuana use declined over the study (Shrier, et al. 2014) Why did marijuana use decrease? Was decreased desire related to decreased use? Did participants consciously try to avoid use? If so, when and how?

6. Methods Analytic Sample: 1544 reports from 14 participants across 3 study phases (response rate 61%) Measures Desire to use (0-9) Used marijuana (Y/N) Tried to avoid use (Y/N) If yes, what did you do? 15 strategies adapted from Coping Strategies Scale

7. Methods Age- and sex-adjusted GEE models Desire, Avoid, Use across study phases Desire, Avoid  Use Tested for mediation and moderation of association between study phase and use Explored specific strategies to avoid use

8. Changes in Use, Desire, and Effort to Avoid Use Before, During, and After MOMENT Intervention Use % Reports N = 518N = 649N = 377 * p < 0.05 in model adjusted for age and sex. *

9. Changes in Use, Desire, and Effort to Avoid Use Before, During, and After MOMENT Intervention * Use % Reports 32103210 Mean Desire Desire N = 518N = 649N = 377 * p < 0.05 in model adjusted for age and sex. *

10. Changes in Use, Desire, and Effort to Avoid Use Before, During, and After MOMENT Intervention N = 518N = 649N = 377 Use Desire Avoid * p < 0.05 in model adjusted for age and sex. * Mean Desire 32103210 % Reports * *

11. Desire and Effort to Avoid Use Independently Predicted Use βAdjusted OR95% CIp Marijuana desire0.121.131.07 – 1.19<.0001 Effort to avoid use-1.530.220.11 – 0.44<.0001 Adjusted for age, sex, and study phase.

12. Desire Partially Mediated Association Between Study Phase and Use Model without Desire βAORp Intervention vs. Baseline -0.130.880.48 Follow-up vs. Baseline -0.450.640.045 Adjusted for age and sex.

13. Desire Partially Mediated Association Between Study Phase and Use Model without DesireModel with Desire βAORpβ p Intervention vs. Baseline -0.130.880.48-0.090.920.63 Follow-up vs. Baseline -0.450.640.045-0.300.740.22 Adjusted for age and sex. by 32% by 33% NS

14. Effort to Avoid Use Moderated Association Between Study Phase and Use + Effort to Avoid UseβAdjusted OR95% CIp Intervention vs. Baseline-1.750.170.05-0.640.008 Follow-up vs. Baseline-0.0020.9980.13-7.400.998 - Effort to Avoid UseβAdjusted OR95% CIp Intervention vs. Baseline2.4811.91.17-1210.04 Follow-up vs. Baseline-1.420.240.004-14.50.50 Adjusted for age, sex, and desire.

15. Avoidance Strategies N = 123

16. Avoidance Strategy and Probability of Use Avoidance Strategy (vs. No Effort to Avoid) OR95% CIp Avoided situation0.160.04-0.570.005 Distracted self 0.330.14-0.810.02 Waited it out0.930.58-1.490.78 Ignored urge2.271.22-4.250.01 Adjusted for age and sex.

17. Change in Avoidance Strategies % Reports of Effort to Avoid

18. Conclusions Desire and effort to avoid use both linked to use Desire partially mediated use following MOMENT Focus on personal motivation + timely messages More “active” strategies to avoid use more effective? Avoiding situation, distracting self Efforts decreased & strategy type changed over study

19. Limitations Small participant sample Self-report data Non-response may not have been random Illusion of control

20. Implications Reduction in marijuana use a process Target momentary desire Assess not just whether, but what efforts made to avoid use, and how these change Reinforce active avoidance strategies More research needed on efforts to avoid use EMI may be a good approach to targeting these variable and modifiable momentary phenomena