Factors related to the low-risk perception of driving after cannabis use.

INTRODUCTION: Modifying risk perceptions related to driving after cannabis use (DACU) could deter individuals from enacting this behavior, as low-risk perception is associated with DACU engagement. This study identified sociodemographic characteristics, substance use, other driving behaviors, peer norms, and psychological characteristics that are associated with lower risk perception regarding DACU. METHODS: Canadian drivers aged 17-35 who have used cannabis in the past year (n = 1,467) completed an online questionnaire. A multivariate linear regression model allowed for identifying variables associated with the low-risk perception of DACU (i.e. believing it to be safe as one's driving ability is not impaired by cannabis or by being high). RESULTS: Lower risk perception of DACU was associated with identifying as male, weekly to daily cannabis use, engagement in DACU, general risky driving behaviors, being a passenger of a driver who engages in DACU, number of friends who engage in DACU, and peer approval of DACU. Having driven under the influence of alcohol, living in urban areas, having received traffic tickets in the past three years, and declaring past-week irritability and cognitive problems were associated with holding a higher risk perception related to DACU. DISCUSSION: Road education and prevention programs should target attitudes and perceptions regarding risks shaped by sociocultural norms and past risky driving experiences. They need to reach out more specifically to drivers with the identified characteristics associated with the low-risk perception of DACU. These interventions can potentially help reduce the rate of individuals who engage in this behavior.

Typologies of Canadian young adults who drive after cannabis use: A two-step cluster analysis.

Young adults that drive after cannabis use (DACU) may not share all the same characteristics. This study aimed to identify typologies of Canadians who engage in DACU. About 910 cannabis users with a driver's license (17-35 years old) who have engaged in DACU completed an online questionnaire. Two-step cluster analysis identified four subgroups, based on driving-related behaviors, cannabis use and related problems, and psychological distress. Complementary comparative analysis among the identified subgroups was performed as external validation. The identified subgroups were: (1) frequent cannabis users who regularly DACU; (2) individuals with generalized deviance with diverse risky road behaviors and high levels of psychological distress; (3) alcohol and drug-impaired drivers who were also heavy frequent drinkers; and (4) well-adjusted youths with mild depressive-anxious symptoms. Individuals who engaged in DACU were not a homogenous group. When required, prevention and treatment need to be tailored according to the different profiles.

Met and unmet needs of homeless individuals at different stages of housing reintegration: A mixed-method investigation.

This study aimed to identify and compare major areas of met and unmet needs reported by 455 homeless or recently housed individuals recruited from emergency shelters, temporary housing, and permanent housing in Quebec (Canada). Mixed methods, guided by the Maslow framework, were used. Basic needs were the strongest needs category identified, followed by health and social services (an emergent category), and safety; very few participants expressed needs in the higher-order categories of love and belonging, self-esteem, and self-actualization. The only significant differences between the three housing groups occurred in basic needs met, which favored permanent housing residents. Safety was the only category where individuals reported more unmet than met needs. The study results suggested that increased overall access to and continuity of care with family physicians, MD or SUD clinicians and community organizations for social integration should be provided to help better these individuals. Case management, stigma prevention, supported employment programs, peer support and day centers should particularly be more widely implemented as interventions that may promote a higher incidence of met needs in specific needs categories.

Le marché légal du cannabis suite à sa légalisation au Canada : pistes de réflexion pour un encadrement efficace.

The upcoming legalization of cannabis in Canada poses several challenges in which each province will have to respond with effective regulation. Studies show that policies alone have little impact on use rates. However, regulatory approaches and modalities seem important to reduce the possible negative consequences that may result from legalization. Although no framework system offers a perfect solution to the issues surrounding the use and sale of cannabis, it seems essential to implement a legalization model based on a public health perspective. The modalities of this model will have to ensure a compromise between restricted access to cannabis and the maintenance of a sufficient supply to counter the illegal market. We recommend controlling the legal cannabis market through the following: a state monopoly, competitive pricing in relation to the illicit market, a sales tax modeled on the THC content, the implementation of a controlled number of points of sale of small surface area and density, a legal age of purchase from the age of majority, and a complete ban on the promotion and advertising of cannabis products, as well as massive funding for prevention and research.

Formal and Informal Control of Cannabis: Regular Users' Experience.

BACKGROUND: The debate on recreational use of cannabis, recently relaunched by the election of the Liberal Party of Canada that intends to legalize and regulate its use and access, implies a better understanding of social control mechanisms that are in place, and their influence on users' behaviors. OBJECTIVE: This study addresses the issue of formal and informal controls by providing, first, a theoretical perspective of this concept, and, second, by illustrating its operation from the users' perspective. METHODS: Semi-structured interviews were conducted with 164 regular, adult cannabis users recruited in four large Canadian cities (Vancouver, Toronto, Montreal, and Halifax). An initial qualitative analysis based on the principles of grounded theory was conducted. The main categories identified were then used to find and re-code relevant material on the respondents' experience with formal and informal control (secondary analysis). RESULTS: The users' perspective shows that mechanisms of informal control play an important role in defining the social context of their use (when, where, and with whom cannabis is consumed). In contrast, formal control had no deterrent impact on the cessation or reduction of use, but affected their behavior by influencing them to change the context of their practices to avoid criminal legal consequences and stigmatization. Conclusions/Importance: The regulatory controls based in public health that the Canadian government plans to implement (replacing criminal ones), should be based on a better understanding of current practices and patterns of cannabis users, and in accordance with informal controls already in place. Legislative formal controls, in a regulatory model, that are better defined and consistent with social practices, will be more accepted and respected by the user population and thus likely to be more effective in reducing harm.

Efficacy of extensive intervention models for substance use disorders: A systematic review.

ISSUES: Despite a growing trend towards considering addiction as a chronic disease, the development of intervention models addressing the chronicity of substance use disorder is relatively new, and no literature review on this topic is available. The aim of this systematic review is to evaluate the efficacy of intervention models designed within the perspective of addiction as a chronic disease and those tailored to persons with substance use disorder who revolve in and out of treatment. APPROACH: Electronic databases were searched to identify articles published between 2000 and 2015 reporting an empirical study of an intervention model with data on its effectiveness. Study selection, data extraction and quality appraisal were performed independently by two reviewers. KEY FINDINGS: The selection process yielded 16 studies meeting all the inclusion criteria. The intervention models were classified into four groups according to the duration, frequency and components of the interventions. In general, the models showed potential therapeutic effects. The outcomes tended to be positive immediately after the end of the treatment. However, months after, the benefits obtained during treatment did not persist. IMPLICATIONS AND CONCLUSION: The review highlights that models designed specifically for persons with multiple treatment re-entries are scarce, but promising. Further research is needed to determine the best match between the clinical profile of persons with substance use disorder and a model's components, intensity and duration. [Simoneau H, Kamgang E, Tremblay J, Bertrand K, Brochu S, FleuryM-J. Efficacy of extensive interventionmodels for substance use disorders: A systematic review. Drug Alcohol Rev 2017;00:000-000].

Addiction severity index profile of persons who reenter treatment for substance use disorders.

BACKGROUND: Despite a growing interest in persons with multiple treatment reentries, few studies have defined their clinical profile. The aim of this study was to compare the severity profile of substance use disorder and related problems of persons who reenter treatment with the profile of those who come in for treatment for the first time. METHODS: A data bank containing 6651 Addiction Severity Index (ASI) interviews from 3 rehabilitation centers was used for the analyses. RESULTS: All the ASI composite scores were significantly higher among persons who reentered treatment than among those who came for the first time. CONCLUSION: The results support the hypothesis of a more severe ASI profile and substance use-related problems among persons who reenter treatment compared with those who come for the first time. Consequently, they have greater needs, and the treatment offered should be adjusted accordingly.

Initiation of Addiction Treatment and Access to Services: Young Adults' Accounts of Their Help-Seeking Experiences.

Substance addiction in young adults is particularly problematic. Yet, much remain at stake in understanding the specifics of this population's access to services. The objective of this study is to explore young adults' initiation of substance misuse treatment. Our study sample was composed of 35 individuals aged 18 to 30 with problematic psychoactive substance use who have been identified in criminal courts, hospital emergency departments, and Health and Social Services Centers in Québec (Canada). A thematic analysis was performed on the 62 semi-structured interviews conducted with participants. Three components emerged. First, personal elements-expectations, individual motivations, perceptions of use, and capacity to control it-influence initiation of substance misuse treatment. Second, family and peers have noticeable influences. Finally, system characteristics and prior care experiences also shape the process. Consideration should be given to tailor interventions that can reach young adults and encourage them to initiate appropriate care.

Implementing Key Strategies for Successful Network Integration in the Quebec Substance-Use Disorders Programme.

BACKGROUND: Fragmentation and lack of coordination often occur among organisations offering treatment for individuals with substance-use disorders. Better integration from a system perspective within a network of organisations offering substance-use disorder services can be developed using various integration strategies at the administrative and clinical levels. This study aims to identify integration strategies implemented in Quebec substance-use disorder networks and to assess their strengths and limitations. METHODS: A total of 105 stakeholders representing two regions and four local substance-use disorder networks participated in focus groups or individual interviews. Thematic qualitative and descriptive quantitative analyses were conducted. RESULTS: Six types of service integration strategies have been implemented to varying degrees in substance-use disorder networks. They are: 1) coordination activities-governance, 2) primary-care consolidation models, 3) information and monitoring management tools, 4) service coordination strategies, 5) clinical evaluation tools and 6) training activities. CONCLUSION: Important investments have been made in Quebec for the training and assessment of individuals with substance-use disorders, particularly in terms of support for emergency room liaison teams and the introduction of standardised clinical evaluation tools. However, the development of integration strategies was insufficient to ensure the implementation of successful networks. Planning, consolidation of primary care for substance-use disorders and systematic implementation of various clinical and administrative integration strategies are needed in order to ensure a better continuum of care for individuals with substance-use disorders.

Lower Cortisol Activity is Associated with First-Time Driving while Impaired.

Driving while impaired (DWI) is a grave and persistent high-risk behavior. Previous work demonstrated that DWI recidivists had attenuated cortisol reactivity compared to non-DWI drivers. This suggests that cortisol is a neurobiological marker of high-risk driving. The present study tested the hypothesis that this initial finding would extend to first-time DWI (fDWI) offenders compared to non-DWI drivers. Male fDWI offenders (n = 139) and non-DWI drivers (n = 31) were exposed to a stress task, and their salivary cortisol activity (total output and reactivity) was measured. Participants also completed questionnaires on sensation seeking, impulsivity, substance use, and engagement in risky and criminal behaviors. As hypothesized, fDWI offenders, compared to non-DWI drivers, had lower cortisol reactivity; fDWI offenders also showed lower total output. In addition, cortisol activity was the most important predictor of group membership, after accounting for alcohol misuse patterns and consequences and other personality and problem behavior characteristics. The findings indicate that attenuated cortisol activity is an independent factor associated with DWI offending risk at an earlier stage in the DWI trajectory than previously detected.

Traumatic brain injury and early life experiences among men and women in a prison population.

This study examined the proportion of men and women reporting previous traumatic brain injury (TBI) in an Ontario (Canada) prison sample by demographic characteristics; adverse life experiences; and criminal, drug, and alcohol use history. Using data from The Cost of Substance Abuse in Canada study based on a random sample from four Ontario prisons, this study found 50.4% of males and 38% of females reporting previous TBI. More TBIs occurred before the first crime for women than for men. Women with TBI experienced more early physical and sexual abuse than those without TBI. Additionally, this study shows high prevalence of early life experiences among persons, particularly women, with a history of TBI. Prisoners and prison staff should be educated on TBI and best practice for rehabilitation of TBI.

Implementing an indoor smoking ban in prison: enforcement issues and effects on tobacco use, exposure to second-hand smoke and health of inmates.

OBJECTIVES: To describe the issues encountered during the implementation of an indoor smoking ban in prison and its effects on self-reported tobacco use, perceived exposure to second-hand smoke (SHS) and perceived health status of inmates in Quebec's provincial correctional facilities. METHODS: Quantitative data were obtained from 113 inmates in three provincial correctional facilities in the province of Quebec, Canada. Qualitative data were obtained from 52 inmates and 27 staff members. Participants were recruited through a self-selection process. Particular efforts were made to enrol proportions of men, women, smokers and non-smokers similar to those generally found among correctional populations. RESULTS: Despite the indoor smoking ban, 93% of inmates who declared themselves smokers reported using tobacco products inside the correctional facilities and 48% did not report any reduction in their tobacco use. Only 46% of smokers declared having been caught smoking inside the facility, and more than half of them (58%) reported no disciplinary consequences to their smoking. A majority of inmates incarcerated before the implementation of the ban (66%) did not perceive a reduction of their exposure to SHS following the indoor ban. Enforcement issues were encountered during the implementation of the indoor ban, notably because of the amendment made to the original regulation (total smoking ban) and tolerance from smokers in the staff towards indoor smoking. They were also related to perceptions that banning indoor smoking is complex and poses management problems. CONCLUSION: This study's findings emphasize the importance of considering organizational and environmental factors when planning the implementation of an indoor smoking ban in correctional facilities.

[The impact of opening a heroin-assisted treatment clinic on the surrounding neighborhood]. / Effet de l'implantation d'une clinique de prescription médicale d'héroïne sur l'environnement communautaire.

OBJECTIVES: Heroin-assisted treatment clinics are currently the focus of a social debate. In spite of the clinics' effectiveness in reducing illicit opiate use, some decision-makers refuse to set them up because of their possible negative impact. These clinics could attract new drug users into the neighbourhood which could lead to an accumulation of injection debris and to a decrease in the sense of security in the community. This study assesses the impact on some elements observed in the surrounding community following the opening of the Montreal heroin-assisted treatment clinic. METHODS: Ethnographical walks were taken in order to collect data on the amount of injection debris, street debris and deviant activities. Data were then aggregated on a daily basis and our interrupted time series were analyzed using the segmented regression methodology. RESULTS: Results show that the opening of the clinic was followed by a significant drop in the amount of injection and street debris. This reduction appears proportional to the number of clinic participants. CONCLUSION: The Montreal heroin-assisted treatment clinic did not produce any negative impact on the surrounding community. In fact, implementation of this kind of clinic was followed by a positive effect on the neighbourhood. In addition to the ethnographical walks, further studies should include surveys in order to estimate the impact of heroin-assisted treatment clinics on residents' sense of security. Even if there appears to be a positive impact, it is possible that the mere presence of these clinics negatively affects community members' sense of security.

Whither RDS? An investigation of Respondent Driven Sampling as a method of recruiting mainstream marijuana users.

BACKGROUND: An important challenge in conducting social research of specific relevance to harm reduction programs is locating hidden populations of consumers of substances like cannabis who typically report few adverse or unwanted consequences of their use. Much of the deviant, pathologized perception of drug users is historically derived from, and empirically supported, by a research emphasis on gaining ready access to users in drug treatment or in prison populations with higher incidence of problems of dependence and misuse. Because they are less visible, responsible recreational users of illicit drugs have been more difficult to study. METHODS: This article investigates Respondent Driven Sampling (RDS) as a method of recruiting experienced marijuana users representative of users in the general population. Based on sampling conducted in a multi-city study (Halifax, Montreal, Toronto, and Vancouver), and compared to samples gathered using other research methods, we assess the strengths and weaknesses of RDS recruitment as a means of gaining access to illicit substance users who experience few harmful consequences of their use. Demographic characteristics of the sample in Toronto are compared with those of users in a recent household survey and a pilot study of Toronto where the latter utilized nonrandom self-selection of respondents. RESULTS: A modified approach to RDS was necessary to attain the target sample size in all four cities (i.e., 40 'users' from each site). The final sample in Toronto was largely similar, however, to marijuana users in a random household survey that was carried out in the same city. Whereas well-educated, married, whites and females in the survey were all somewhat overrepresented, the two samples, overall, were more alike than different with respect to economic status and employment. Furthermore, comparison with a self-selected sample suggests that (even modified) RDS recruitment is a cost-effective way of gathering respondents who are more representative of users in the general population than nonrandom methods of recruitment ordinarily produce. CONCLUSIONS: Research on marijuana use, and other forms of drug use hidden in the general population of adults, is important for informing and extending harm reduction beyond its current emphasis on 'at-risk' populations. Expanding harm reduction in a normalizing context, through innovative research on users often overlooked, further challenges assumptions about reducing harm through prohibition of drug use and urges consideration of alternative policies such as decriminalization and legal regulation.

A heroin prescription trial: case studies from Montreal and Vancouver on crime and disorder in the surrounding neighbourhoods.

BACKGROUND: This study evaluates whether the instauration of a heroin prescription trial ('NAOMI') generated an impact on the occurrence of crime and disorder in surrounding areas. The clinical trial was initiated in Vancouver and Montreal in 2005, with the aim of assessing the benefits of heroin-assisted treatment (HAT) in Canada. While experiences from other jurisdictions where HAT trials have been implemented clearly demonstrate substantial crime reduction effects for trial participants, there is overall concern that HAT clinics - similar to other interventions aiming at problematic street drug users - may induce a 'honeypot' effect, leading to increases in crime and/or disorder problems in the vicinity of interventions. It has been argued that HAT clinics will attract undesirable behaviour associated with cultures of street drug use and thereby produce negative impacts on the community. METHODS: This study examined the incidence of crime and disorder in the Vancouver and Montreal sites before and during the NAOMI trial (2002-2006), using police calls for service and arrest data. Data were analysed by autoregression analyses. RESULTS: The analysis suggested that most indicators remained stable during the pre- and implementation phase of the NAOMI trial in both sites. CONCLUSION: While the attribution of observed crime and disorder trends to the specific clinical interventions in Montreal and Vancouver is difficult and many extrinsic factors may play a role, this study has not generated any clear evidence from institutional police data to suggest increases or decreases in community-based problems associated with HAT programs in Canada.

[The place of syringe exchange programs in reducing harm in Canadian prisoners]. / La place des programmes d'échanges de seringues parmi les stratégies de réduction de méfaits dans les pénitenciers canadiens.

The prevalence rates of illicit drug consumption within the prison system are much higher than those in the Canadian population in general. Of the substances used in detention, those of most concern to prison and public health authorities are injection drugs, as the sharing of injection drug equipment may be responsible for the high prevalence of blood-borne diseases in prison facilities. Faced with this situation, the Correctional Service of Canada put in practice a number of harm reduction strategies targeting injection drug users, such as methadone maintenance programs and access to bleach. However, despite their use in the community, needle-exchange programs are not yet allowed in penitentiaries. This article analyzes the limits of harm reduction strategies approved by the prison authorities and discusses the sources of resistance that continue to impede the realization of a pilot project to assess the feasibility of needle-exchange programs in detention in Canada.

Does the transtheoretical model predict attrition in domestic violence treatment programs?

Attrition in intervention programs for domestically violent men is considered to be a serious and enduring problem. Researchers have found a number of sociodemographic variables that partially explain this phenomenon; however, models based on these variables have a limited predictive power. Scott (2004) argues that a firm theoretical base is needed in future investigations of the problem and suggests the use of the transtheoretical model of behavior change (TTM), which was found to predict dropout with accuracy in other areas of behavioral change. This study investigated the relationship between four TTM constructs (Stages of Change, Decisional Balance, Self-Efficacy, and Processes of Change) and premature termination with a sample of Canadian French-speaking men (N = 302) in five domestic violence treatment programs. Contrary to the initial hypotheses, the TTM constructs did not predict dropout. Discussion investigates how social desirability bias affects results being obtained by current TTM measures and whether more motivation to change at intake necessarily relates to involvement in treatment for longer periods of time.

Therapeutic alliance, patient behaviour and dropout in a drug rehabilitation programme: the moderating effect of clinical subpopulations.

AIM: Treatment dropout is an important concern for professionals working in mental health. While this problem is common, the highest attrition rates have been observed in drug rehabilitation programmes. The present study focuses on the therapeutic alliance, a process variable that has been associated repeatedly with positive treatment outcome in the scientific literature. Respondent behaviour indicative of commitment or resistance to treatment was examined in combination with therapist prognoses. DESIGN: A total of 248 subjects, classified into three subpopulations (justice, n = 50; mental health, n = 53; comparison group, n = 145), participated in the study. Analyses aimed at predicting dropout were conducted using Cox proportional-hazards regressions. The moderating effect of sub-population was tested. MEASUREMENTS: Respondents completed a multi-dimensional measure of alliance [California Psychotherapeutic Alliance Scale (CALPAS-P)]. Therapists rated the behaviour of respondents in treatment and made prognoses about perseverance and improvement. FINDINGS: An increased risk of dropout was predicted when patients viewed themselves as less committed and perceived the therapist as less understanding and less involved. Therapist prognosis of perseverance was also predictive of dropout. The relationship between patient/therapist evaluations and dropout is affected differently across subpopulations by means of a moderation effect. CONCLUSION: This paper demonstrates the capacity to predict dropout by measuring therapeutic alliance, therapist prognoses and therapist appraisal of patient behaviour. Moreover, the moderation effect of clinical subpopulation on treatment process variables and dropout is supported in the context of drug rehabilitation programmes.

The costs of alcohol, illegal drugs, and tobacco in Canada, 2002.

OBJECTIVE: The aim of this study was to estimate costs attributable to substance use and misuse in Canada in 2002. METHOD: Based on information about prevalence of exposure and risk relations for more than 80 disease categories, deaths, years of life lost, and hospitalizations attributable to substance use and misuse were estimated. In addition, substance-attributable fractions for criminal justice expenditures were derived. Indirect costs were estimated using a modified human capital approach. RESULTS: Costs of substance use and misuse totaled almost Can. $40 billion in 2002. The total cost per capita for substance use and misuse was about Can. $1,267: Can. $463 for alcohol, Can. $262 for illegal drugs, and Can. $541 for tobacco. Legal substances accounted for the vast majority of these costs (tobacco: almost 43% of total costs; alcohol: 37%). Indirect costs or productivity losses were the largest cost category (61%), followed by health care (22%) and law enforcement costs (14%). More than 40,000 people died in Canada in 2002 because of substance use and misuse: 37,209 deaths were attributable to tobacco, 4,258 were attributable to alcohol, and 1,695 were attributable to illegal drugs. A total of about 3.8 million hospital days were attributable to substance use and misuse, again mainly to tobacco. CONCLUSIONS: Substance use and misuse imposes a considerable economic toll on Canadian society and requires more preventive efforts.