[Regulatory elements on marijuana, for the effective population health protection]. / Elementos regulatorios sobre la marihuana, a consideración para la efectiva protección a la salud de la población.

When discussing the public health approach to the use of marijuana, the complexity of rigorous regulatory interventions for population protection is omitted. Using the experience of governments where these practices already exist, regulation is introduced as an essential public health function, spelling out seven purposes for controlling marijuana. The technical elements of institutional capacity -including the technical and financial capacity- and of governance that must be covered by any rigorous regulation of its use are detailed below. The difficulty of regulating psychoactive substances is addressed when considering the capacity to control other legal substances manifested with their increased consumption. It is concluded that for an effective regulation of marijuana, the need for strengthening the institutional and governance aspects of the regulatory authority should not be minimized.

Al hablar del abordaje de salud pública al uso de la marihuana se soslaya la complejidad de la protección a la población a través de intervenciones regulatorias rigurosas. Considerando la experiencia de gobiernos donde ya existen estas prácticas, se introduce la regulación como una función esencial de la salud pública, haciendo explícitos siete propósitos para el control de la marihuana. Se detallan luego los elementos técnicos, de capacidad institucional (incluyendo la capacidad técnica y financiera) y de gobernanza que deben cumplirse para cualquier regulación rigurosa de su uso. Se señala la dificultad de regular sustancias psicoactivas considerando que la capacidad de control de otras actualmente legales se ha traducido en su creciente consumo. Se expone también que no debe minimizarse la necesidad del fortalecimiento institucional y gobernanza de la autoridad regulatoria para la regulación efectiva de la marihuana.

Oral health assessment for users of marijuana and cocaine/crack substances.

The objective of this study was to assess the oral health status of users of illicit drugs such as marijuana and cocaine/crack and compare it with individuals not using these chemical substances. Questionnaires were applied to 35 illicit drugs users to gather information on demographic status, general health, and use of drugs. Then, a clinical assessment of the oral health condition was performed to collect data on decayed, missing and filled teeth (DMFT) index, salivary flow rate (SFR), and mucosal lesions. The control group was composed of 35 non-illicit drug users. In the experimental group, 91.43% were males, 80% were smokers, and 42.85% were alcoholics. Cocaine was the most common drug used (77.15%), followed by marijuana (68.6%), and crack (51.4%). The average DMFT index was 9.8 and the SFR was reduced in 60% of subjects. Mucosal alterations were detected, but no potentially malignant disorders or oral cancer were diagnosed. Compared to control group, significantly higher values for gender (40%, p = 0.0001), smoking (22.86%) and heavy drinking (5.7%) habits (p = 0.0001), SFR (31.4%; p = 0.0308), and oral lesions (p = 0.0488) were found for the experimental group, although significantly higher values were found in the control group for DMFT index (p = 0.0148). It can be concluded that the use of illicit drugs contributed to an increased prevalence of oral mucosa lesions. In addition, a decline on SFR and a reduced DMFT index was observed for illicit drug users.

Do Clinicians Ask Pregnant Women about Exposures to Tobacco and Cannabis Smoking, Second-Hand-Smoke and E-Cigarettes? An Australian National Cross-Sectional Survey.

Clinicians often ask pregnant women about tobacco smoking, but their practices of asking about other smoking and nicotine exposures are unknown. This study analysed how often clinicians ask pregnant women about their use of e-cigarettes, cannabis, chewing tobacco, and second-hand smoke (SHS) exposure. Two cross-sectional surveys were undertaken. A random sample of 500 General Practitioner (GP) members were invited from the National Faculty of Aboriginal and Torres Strait Islander Health (NFATSIH) to complete an on-line survey, and 5571 GP and Obstetrician (OBS) members of the Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) were sent a paper survey by mail. Questions on frequency of asking about the exposures used Likert Scales, later dichotomized to "often-always" and "never-sometimes". Logistic regressions estimated associations between clinician type and asking about cannabis, e-cigarettes, chewing tobacco, and SHS. An adjusted model reduced potential confounders of location, guidelines, gender and population. n = 378 GPs and OBS participated (6.2% response). In total, 13-14% asked "often-always" about e-cigarettes; 58% cannabis; 38% cannabis with tobacco; 27% SHS, and 10% chewing tobacco-compared to 95% of the sample asking about cigarette smoking. After adjustment, the odds of RANZCOG GPs (OR 0.34) and OBS (OR 0.63) asking about cannabis were lower compared to NFATSIH GPs. Clinician type was non-significant for asking about e-cigarettes, chewing tobacco and SHS. Surveyed Australian GPs and obstetricians asked less frequently about e-cigarettes, chewing, SHS exposure, and cannabis, potentially missing important exposures for mother and child.

A scoping review and meta-analysis of psychosocial and pharmacological treatments for cannabis and tobacco use among African Americans.

The rates of co-occurring cannabis and tobacco use are higher among African Americans relative to other racial/ethnic groups. One plausible approach to treating co-use among African Americans is to examine the effectiveness of treatments for the sole use of cannabis and tobacco to identify effective approaches that might be combined to treat the dual use of these substances. The current meta-analysis sought to include studies that reported cannabis and/or tobacco use outcomes from randomized clinical trials (RCTs) with 100% African American samples. A total of 843 articles were considered for inclusion, 29 were reviewed by independent qualitative coders, and 22 were included in the review. There were no articles on cannabis use treatment with a 100% African American sample, resulting in a need to lower the threshold (60%) and conduct a scoping review of cannabis studies. Preliminary evidence from a small number of studies (k = 7) supports the use of Motivational Interviewing and Cognitive-Behavioral Therapy to treat cannabis use among African Americans, but not Contingency Management. Results from a meta-analysis of 15 tobacco studies found higher rates of smoking abstinence in the treatment condition relative to control conditions overall and across short and long-term follow-up periods. Significant differences in smoking abstinence were also found when examining the effects of pharmacological treatments relative to their control conditions. The clinical and research implications of these findings for future psychosocial and pharmacological trials for cannabis and tobacco use and co-use among African Americans are described. (PsycINFO Database Record

Changes in Specific Substance Involvement Scores among SBIRT recipients in an HIV primary care setting.

BACKGROUND: Substance use is common among people living with HIV (PLHIV) and is associated with worse outcomes along the HIV care continuum. One potentially effective clinic-based approach to addressing unhealthy substance use is screening, brief intervention, and referral to treatment (SBIRT). METHODS: We conducted a two-arm randomized trial to examine the effects of a self-administered, computerized SBIRT intervention compared to a clinician-administered SBIRT intervention in an HIV primary clinic. Patients were surveyed before receiving the intervention and again at 1, 3, and 6 months. We administered the WHO Alcohol, Smoking and Substance Involvement Screening Test to determine Specific Substance Involvement Scores (SSIS) and to assign participants to categories of lower, moderate, or high risk to health and other problems for each substance. We collapsed moderate or severe risk responses into a single moderate-high risk category. Based on low rates of participation in the computerized arm, we conducted an "as treated" analysis to examine 6-month changes in mean SSIS among SBIRT intervention participants. RESULTS: For the overall sample (n = 208), baseline mean SSIS were in the moderate risk category for alcohol, tobacco, cannabis, cocaine, amphetamine, sedatives and opioids. Of those enrolled, 134 (64.4%) received the intervention, and 109 (52.4%) completed the 6-month follow up. There was a statistically significant decline in mean SSIS for all substances except tobacco and cannabis among participants who were at moderate-high risk at baseline. We also observed a statistically significant increase in mean SSIS for all substances except amphetamines and sedatives among participants who were at lower risk at baseline. CONCLUSIONS: Substance use among patients in this urban, safety-net, HIV primary care clinic was near universal, and moderate risk substance use was common. Among participants who received the SBIRT intervention, mean SSISs decreased among those at moderate-high risk at baseline, but increased among those at lower risk at baseline over the 6-month study period. Additional research should examine the clinical significance of SSIS changes for PLHIV, which SBIRT components drive changes in substance use scores, and what other interventions might support those patients at lower risk to maintain health and engagement along the HIV care continuum. Trial registration ClinicalTrials.gov study NCT01300806.

Does Cannabis Use Cause Declines in Neuropsychological Functioning? A Review of Longitudinal Studies.

Cannabis use has been linked to impairments in neuropsychological functioning across a large and continually expanding body of research. Yet insight into underlying causal relations remains limited due to the historically cross-sectional nature of studies in this area. Recently, however, studies have begun to use more informative design strategies to delineate these associations. The aim of this article is to provide a critical evaluation and review of research that uses longitudinal designs to examine the link between cannabis use and neuropsychological functioning. In summarizing the primary findings across these studies, this review suggests that cannabis use leads to neuropsychological decline. However, across most studies, these associations were modest, were present only for the group with the heaviest cannabis use, and were often attenuated (or no longer significant) after controlling for potential confounding variables. Future studies with neuropsychological data before and after initiation of cannabis use, along with careful measurement and control of "shared risk factors" between cannabis use and poorer neuropsychological outcomes, are needed to better understand who, and under what conditions, is most vulnerable to cannabis-associated neuropsychological decline. (JINS, 2017, 23, 893-902).

Trasplante de médula ósea alogénico en un paciente con fusariosis diseminada y leucemia mieloide aguda / Allogeneic hematopoietic cell transplantation in a patient with disseminated fusariosis and acute myeloid leukemia

La infección diseminada por Fusarium se ha convertido en un problema creciente en las personas con neoplasias hematológicas malignas, principalmente en pacientes con leucemias agudas; se describen cada vez más casos en aquellos sometidos a un trasplante de médula ósea. No existe un tratamiento óptimo establecido para la fusariosis diseminada. La mortalidad global comunicada de esta infección oscila entre el 50 y el 80%. Se presenta a continuación el caso de un paciente de sexo masculino de 29 años, con diagnóstico de leucemia mieloide aguda, que presenta como complicación una fusariosis diseminada, y logra sobrellevar un trasplante alogénico de médula ósea en el Hospital Italiano de San Justo (Argentina) de forma exitosa. (AU)

Disseminated fusariosis has become an increasing problem in people with hematopoietic neoplasms, mainly in patients affected by acute leukemias, and even more in those who undergo hematopoietic cell transplantation. There is not an optimal treatment for disseminated fusariosis. The global mortality described in the literature is between 50% and 80%. We introduce a case of a 29 year old patient with diagnosis of acute myeloid leukemia complicated with disseminated fusariosis, who copes with an allogeneic hematopoietic cell transplantation with a successful outcome in the "Hospital Italiano de San Justo" (Argentina). (AU)

Dolor, cannabis, psicosis. ¿Una sucesión lógica? / Pain, cannabis, psychosis. A logical sequence?

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Is being Punished at School an Indicator of Psychosocial Risk?

Research carried out in different cultural contexts shows that the use of exclusively coercive disciplinary measures does not improve the behavior of those punished, and may even increase the risks underpinning those behaviors. The aim of this research was to study whether there is a link between repeatedly suffering punishment at school and psychosocial risks in adolescence. A non-experimental design was implemented with selected groups. The participants were 507 adolescents from four groups with different risk levels: in social protection (n = 189); subject to court measures (n = 104); in treatment for drug abuse (n = 25); and comparison group (n = 189). A questionnaire was applied collectively. The variables measured were school punishments, violence, drug consumption and commission of crimes. The mild punishments variable predicted and increased the probability of consuming alcohol, tobacco and cannabis by 34% (95% CI [1.1, 1.5]), and increased the probability of using illegal drugs by 11% (95% CI [1.11, 1.30]). Te severe punishments variable increased the probability of using illegal drugs by 86% (95% CI [1.41, 2.49]) and increased the probability of committing crimes by 40% (95% CI [1.13, 1.73]). School punishments, particularly if severe, stand as a visible indicator of psychosocial risk. Behaviors subjected to punishment should alert us to the need to intervene with individuals who manifest them for which the use of exclusively coercive measures is ineffective. A wider educational intervention is required to help them find their place in school instead of excluding them from it.

Frequency of Cannabis Use Among Primary Care Patients in Washington State.

INTRODUCTION: Over 12% of US adults report past-year cannabis use, and among those who use daily, 25% or more have a cannabis use disorder. Use is increasing as legal access expands. Yet, cannabis use is not routinely assessed in primary care, and little is known about use among primary care patients and relevant demographic and behavioral health subgroups. This study describes the prevalence and frequency of past-year cannabis use among primary care patients assessed for use during a primary care visit. METHODS: This observational cohort study included adults who made a visit to primary care clinics with annual behavioral health screening, including a single-item question about frequency past-year cannabis use (March 2015 to February 2016; n = 29,857). Depression, alcohol and other drug use were also assessed by behavioral health screening. Screening results, tobacco use, and diagnoses for past-year behavioral health conditions (e.g., mental health and substance use disorders) were obtained from EHRs. RESULTS: Among patients who completed the cannabis use question (n = 22,095; 74% of eligible patients), 15.3% (14.8% to 15.8%) reported any past-year use: 12.2% (11.8% to 12.6%) less than daily, and 3.1% (2.9%-3.3%) daily. Among 2228 patients age 18 to 29 years, 36.0% (34.0% to 38.0%) reported any cannabis use and 8.1% (7.0% to 9.3%) daily use. Daily cannabis use was common among men age 18 to 29 years who used tobacco or screened positive for depression or used tobacco: 25.5% (18.8% to 32.1%) and 31.7% (23.3% to 40.0%), respectively. CONCLUSIONS: Cannabis use was common in adult primary care patients, especially among younger patients and those with behavioral health conditions. Results highlight the need for primary care approaches to address cannabis use.

Family Physicians' Perceived Prevalence, Safety, and Screening for Cigarettes, Marijuana, and Electronic-Nicotine Delivery Systems (ENDS) Use during Pregnancy.

OBJECTIVE: Assess perceptions of prevalence, safety, and screening practices for cigarettes and secondhand smoke exposure (SHSe), marijuana (and synthetic marijuana), electronic nicotine delivery systems (ENDS; eg, e-cigarettes), nicotine-replacement therapy (NRT), and smoking-cessation medications during pregnancy, among primary care physicians (PCPs) providing obstetric care. METHODS: A web-based, cross-sectional survey was e-mailed to 3750 US physicians (belonging to organizations within the Council of Academic Family Medicine Educational Research Alliance). Several research groups' questions were included in the survey. Only physicians who reported providing "labor and delivery" obstetric care responded to questions related to the study objectives. RESULTS: A total of 1248 physicians (of 3750) responded (33.3%) and 417 reported providing labor and delivery obstetric care. Obstetric providers (N = 417) reported cigarette (54%), marijuana (49%), and ENDS use (24%) by "Some (6% to 25%)" pregnant women, with 37% endorsing that "Very Few (1% to 5%)" pregnant women used ENDS. Providers most often selected that very few pregnant women used NRT (45%), cessation medications (ie, bupropion or varenicline; 37%), and synthetic marijuana (23%). Significant proportions chose "Do not Know" for synthetic marijuana (58%) and ENDS (27%). Over 90% of the sample perceived that use of or exposure to cigarettes (99%), synthetic marijuana (99%), SHS (97%), marijuana (92%), or ENDS (91%) were unsafe during pregnancy, with the exception of NRT (44%). Providers most consistently screened for cigarette (85%) and marijuana use (63%), followed by SHSe in the home (48%), and ENDS (33%) and synthetic marijuana use (28%). Fewer than a quarter (18%) screened consistently for all substances and SHSe. One third (32%) reported laboratory testing for marijuana and 3% reported laboratory testing for smoking status. CONCLUSION: This sample of PCPs providing obstetric care within academic settings perceived cigarettes, marijuana, and ENDS use to be prevalent and unsafe during pregnancy. Opportunities for increased screening during pregnancy across these substances were apparent.

Prevalence of poor mental health among medical students in Nepal: a cross-sectional study.

BACKGROUND: Poor mental health among medical students is widely acknowledged. Studies on mental health among medical students of Nepal are lacking. Therefore, we conducted a study to determine the prevalence of mental disorders. METHODS: A cross-sectional study was conducted among medical students at KIST Medical College and Teaching Hospital, Nepal from December 2016 to February 2017. Our survey instrument consisted of the Patient Health Questionnaire (PHQ) and questions about socio-demographic factors, smoking, marijuana use, suicidal ideation and thoughts of dropping out of medical school. RESULTS: The prevalence rates were 29.2% (95% CI, 24.4% - 34.3%) depression, 22.4% (95% CI, 18.0% - 26.9%) medium to highly severe somatic symptoms, 4.1% (95% CI, 2.0% - 6.2%) panic syndrome, 5.8% (95% CI, 3.4% - 8.3%) other anxiety syndrome, 5% (95% CI, 2.7% - 7.3%) binge eating disorder and 1.2% (95% CI, 0.0% - 2.3%) bulimia nervosa. Sixteen students [4.7% (95% CI, 2.4% - 6.9%)] seriously considered committing suicide while in medical school. Thirty-four students [9.9% (95% CI, 6.8% - 13.1%)] considered dropping out of medical school within the past month. About 15% (95% CI, 11.1% - 18.6%) of the students reported use of marijuana during medical school. CONCLUSIONS: We found high prevalence of poor mental health among medical students of Nepal. Future studies are required to identify the factors associated with poor mental health.

Empirical Profiles of Alcohol and Marijuana Use, Drugged Driving, and Risk Perceptions.

OBJECTIVE: The present study sought to inform models of risk for drugged driving through empirically identifying patterns of marijuana use, alcohol use, and related driving behaviors. Perceived dangerousness and consequences of drugged driving were evaluated as putative influences on risk patterns. METHOD: We used latent profile analysis of survey responses from 897 college students to identify patterns of substance use and drugged driving. We tested the hypotheses that low perceived danger and low perceived likelihood of negative consequences of drugged driving would identify individuals with higher-risk patterns. RESULTS: Findings from the latent profile analysis indicated that a four-profile model provided the best model fit. Low-level engagers had low rates of substance use and drugged driving. Alcohol-centric engagers had higher rates of alcohol use but low rates of marijuana/simultaneous use and low rates of driving after substance use. Concurrent engagers had higher rates of marijuana and alcohol use, simultaneous use, and related driving behaviors, but marijuana-centric/simultaneous engagers had the highest rates of marijuana use, co-use, and related driving behaviors. Those with higher perceived danger of driving while high were more likely to be in the low-level, alcohol-centric, or concurrent engagers' profiles; individuals with higher perceived likelihood of consequences of driving while high were more likely to be in the low-level engagers group. CONCLUSIONS: Findings suggested that college students' perceived dangerousness of driving after using marijuana had greater influence on drugged driving behaviors than alcohol-related driving risk perceptions. These results support targeting marijuana-impaired driving risk perceptions in young adult intervention programs.

"Retweet to Pass the Blunt": Analyzing Geographic and Content Features of Cannabis-Related Tweeting Across the United States.

OBJECTIVE: Twitter data offer new possibilities for tracking health-related communications. This study is among the first to apply advanced information processing to identify geographic and content features of cannabis-related tweeting in the United States. METHOD: Tweets were collected using streaming Application Programming Interface (March-May 2016) and were processed by eDrugTrends to identify geolocation and classify content by source (personal communication, media, retail) and sentiment (positive, negative, neutral). States were grouped by cannabis legalization policies into "recreational," "medical, less restrictive," "medical, more restrictive," and "illegal." Permutation tests were performed to analyze differences among four groups in adjusted percentages of all tweets, unique users, personal communications only, and positive-to-negative sentiment ratios. RESULTS: About 30% of all 13,233,837 cannabis-related tweets had identifiable state-level geo-information. Among geolocated tweets, 76.2% were personal communications, 21.1% media, and 2.7% retail. About 71% of personal communication tweets expressed positive sentiment toward cannabis; 16% expressed negative sentiment. States in the recreational group had significantly greater average adjusted percentage of cannabis tweets (3.01%) compared with other groups. For personal communication tweets only, the recreational group (2.47%) was significantly greater than the medical, more restrictive (1.84%) and illegal (1.85%) groups. Similarly, the recreational group had significantly greater average positive-to-negative sentiment ratio (4.64) compared with the medical, more restrictive (4.15) and illegal (4.19) groups. Average adjusted percentages of unique users showed similar differences between recreational and other groups. CONCLUSIONS: States with less restrictive policies displayed greater cannabis-related tweeting and conveyed more positive sentiment. The study demonstrates the potential of Twitter data to become a valuable indicator of drug-related communications in the context of varying policy environments.