Supporting Future Cannabis Policy - Developing a Standard Joint Unit: A Brief Back-Casting Exercise.

The standardization of cannabis doses is a priority for research, policy-making, clinical and harm-reduction interventions and consumer security. Scientists have called for standard units of dosing for cannabis, similar to those used for alcohol. A Standard Joint Unit (SJU) would facilitate preventive and intervention models in ways similar to the Standard Drink (SD). Learning from the SD experiences allows researchers to tackle emerging barriers to the SJU by applying modern forecasting methods. During a workshop at the Lisbon Addictions Conference 2019, a back-casting foresight method was used to address challenges and achieve consensus in developing an SJU. Thirty-two professionals from 13 countries and 10 disciplines participated. Descriptive analysis of the workshop was carried out by the organizers and shared with the participants in order to suggest amendments. Several characteristics of the SJU were defined: (1) core values: easy-to use, universal, focused on THC, accurate, and accessible; (2) key challenges: sudden changes in patterns of use, heterogeneity of cannabis compounds as well as in administration routes, variations over time in THC concentrations, and of laws that regulate the legal status of recreational and medical cannabis use); and (3) facilitators: previous experience with standardized measurements, funding opportunities, multi-stakeholder support, high prevalence of cannabis users, and widespread changes in legislation. Participants also identified three initial steps for the implementation of a SJU by 2030: (1) Building a task-force to develop a consensus-based SJU; (2) Expanded available national-level data; (3) Linking SJU consumption to the concept of "risky use," based on evidence of harms.

"Tell Me How Much Your Friends Consume"-Personal, Behavioral, Social, and Attitudinal Factors Associated with Alcohol and Cannabis Use among European School Students.

BACKGROUND: Substance use in European adolescents remains a serious health concern. Assessing what affects adolescents' substance use is crucial for implementing effective prevention. This study aims to examine alcohol and cannabis use-related behavioral, social, and attitudinal variables that might directly be considered to guide prevention responses for adolescents. METHODS: Cross-sectional data of 78,554 15-16-year-old school students from the 2011 European School Survey Project on Alcohol and Other Drugs (ESPAD) from 26 European countries were analyzed. Self-reported drunkenness in the last 30 days and cannabis use in the last 12 months served as dependent variables. To investigate which factors are associated with risky substance use, multivariable logistic regressions were used. RESULTS: 17.7% of respondents reported drunkenness in the last 30 days, and 14.9% used cannabis in the last 12 months. The most important predictor for risky substance use was the perception that most/all of their friends engaged in substance use behavior, followed by lack of parental support, low personal adherence to rules, and low school performance. CONCLUSION: Interventions addressing the perceived descriptive norms either directly or by changing environmental cues, opportunities, and regulations, as well as effective parenting and academic support may prevent and reduce risky substance use behavior among adolescents.

The Experience of the Treatment Demand Indicator in Europe: A Common Monitoring Tool Across 30 Countries.

OBJECTIVE: The article describes an epidemiological indicator called Treatment Demand Indicator (TDI). The TDI aims to provide professionals and researchers with a common European methodology for collecting and reporting core data on drug users in contact with treatment services. The article discusses the implementation of the TDI in the European countries and describes the main results, limitations, and future perspectives. METHOD: The TDI provides a common format for reporting data on clients entering treatment as a result of their drug use and related problems during each calendar year. Its technical protocol defines which clients should be reported at European level and represents the minimum common set of items each national monitoring system should be able to report to the European Monitoring Centre for Drugs and Drug Addiction. RESULTS: In 2015, 29 European countries reported data on 467,811 clients entering drug treatment from 6,846 drug treatment units. Most clients were men in their 30s and had problems related to heroin or cannabis use; patterns of drug use differed geographically. Over the past decade, clients' profiles and drug use patterns changed from young heroin injectors seeking treatment to drug clients with diversified drug use patterns and profiles. CONCLUSIONS: The TDI is the largest drug dataset in Europe, and its data is increasingly used in European and national data analysis. The use of a common drug-treatment-monitoring tool across a group of countries provides a useful instrument for policymakers, professionals, and managers working in the drug treatment field.

'Are The Times A-Changin'? Trends in adolescent substance use in Europe.

AIMS: To estimate temporal trends in adolescents' current cigarette, alcohol and cannabis use in Europe by gender and region, test for regional differences and evaluate regional convergence. DESIGN AND SETTING: Five waves of the European School Survey Project on Alcohol and Other Drugs (ESPAD) from 28 countries between 1999 and 2015. Countries were grouped into five regions [northern (NE), southern (SE), western (WE), eastern Europe (EE) and the Balkans (BK)]. PARTICIPANTS: A total of 223 814 male and 211 712 female 15-16-year-old students. MEASUREMENTS: Daily cigarette use, weekly alcohol use, monthly heavy episodic drinking (HED) and monthly cannabis use. Linear and quadratic trends were tested using multi-level mixed-effects logistic regression; regional differences were tested using pairwise Wald tests; mean absolute differences (MD) of predicted prevalence were used for evaluating conversion. FINDINGS: Daily cigarette use among boys in EE showed a declining curvilinear trend, whereas in all other regions a declining linear trend was found. With the exception of BK, trends of weekly drinking decreased curvilinear in both genders in all regions. Among girls, trends in WE, EE and BK differed from trends in NE and SE. Monthly HED showed increasing curvilinear trends in all regions except in NE (both genders), WE and EE (boys each). In both genders, the trend in EE differed from the trend in SE. Trends of cannabis use increased in both genders in SE and BK; differences were found between the curvilinear trends in EE and BK. MD by substance and gender were generally somewhat stable over time. CONCLUSIONS: Despite regional differences in prevalence of substance use among European adolescents from 1999 to 2015, trends showed remarkable similarities, with strong decreasing trends in cigarette use and moderate decreasing trends in alcohol use. Trends of cannabis use only increased in southern Europe and the Balkans. Trends across all substance use indicators suggest no regional convergence.

Dual diagnosis: an European perspective. / Patología dual: una perspectiva europea.

Editorial of vol 29-1.

Editorial del vol 29-1.

Patología dual: una perspectiva europea / Dual diagnosis: an European perspective

No disponible

The drug situation in Europe: an overview of data available on illicit drugs and new psychoactive substances from European monitoring in 2015.

AIM: A central task for the European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) is to produce an annual report of the latest data available on drug demand and drug supply in Europe. This paper is intended to facilitate a better understanding of, and easier access to, the main quantitative European level data sets available in 2015. METHODS: The European reporting system formally covers all 28 European Union (EU) Member States, Norway and Turkey and incorporates multiple indicators alongside an early warning system (EWS) on uncontrolled new psychoactive substances (NPS). While epidemiological information is based largely on registries, surveys and other routine data reported annually, the EWS collects case-based data on an ongoing basis. The 2015 reporting exercise is centred primarily on a set of standardized reporting tools. RESULTS: The most recent data provided by European countries are presented, including data on drug use, drug-related morbidity and mortality, treatment demand, drug markets and new psychoactive substances, with data tables provided and methodological information. A number of key results are highlighted for illustrative purposes. Drug prevalence estimates from national surveys since 2012 (last year prevalence of use among the 15-34 age band) range from 0.4% in Turkey to 22.1% in France for cannabis, from 0.2% in Greece and Romania to 4.2% in the United Kingdom for cocaine, from 0.1% in Italy and Turkey to 3% in the Czech Republic and the United Kingdom for ecstasy, and from 0.1% or less in Romania, Italy and Portugal to 2.5% in Estonia for amphetamine. Declining trends in new HIV detections among people who inject drugs are illustrated, in addition to presentation of a breakdown of NPS reported to the EU early warning system, which have risen exponentially from fewer than 20 a year between 2005 and 2008, to 101 reported in 2014. CONCLUSIONS: Structured information is now available on patterns and trends in drug consumption in Europe, which permits triangulation of data from different sources and consideration of methodological limitations. Opioid drugs continue to place a burden on the drug treatment system, although both new heroin entrants and injecting show declines. More than 450 new psychoactive substances are now monitored by the European early warning system with 31 new synthetic cathinones and 30 new synthetic cannabinoid receptor agonists notified in 2014.

Trends of heroin use and heroin injection epidemics in Europe: findings from the EMCDDA treatment demand indicator (TDI).

We estimate trends and geographical differences in the heroin epidemic in the European Union plus Croatia and Turkey by analyzing aggregated data on first heroin treatment admissions (cases) during 2000-2009. In 2005-2009 the proportion of drug injectors was higher in Central and Eastern European countries (CEECs) than in Western European countries (WECs), whereas the opposite occurred with mean age at first heroin use and first treatment. During this period, the number of cases, cases per center, and proportion of injectors in WECs declined, whereas mean age at first treatment and first heroin use increased. The opposite occurred in Turkey, except for proportion of injectors, while trends were less clear in the other CEECs. In the 7 WECs with data, trends in 2000-2005 and 2005-2009 were similar. This suggests that the number of recent-onset heroin users and heroin injectors may have declined some years before the study period, especially in WECs.

The choice of screening instrument matters: the case of problematic cannabis use screening in spanish population of adolescents.

The aim of this study was to examine the feasibility of problem cannabis use screening instruments administration within wide school surveys, their psychometric properties, overlaps, and relationships with other variables. Students from 7 Spanish regions, aged 14-18, who attended secondary schools were sampled by two-stage cluster sampling (net sample 14,589). Standardized, anonymous questionnaire including DSM-IV cannabis abuse criteria, Cannabis Abuse Screening Test (CAST), and Severity of Dependence Scale (SDS) was self-completed with paper and pencil in the selected classrooms. Data was analysed using classical psychometric theory, bivariate tests, and multinomial logistic regression analysis. Not responding to instruments' items (10.5-12.3%) was associated with reporting less frequent cannabis use. The instruments overlapped partially, with 16.1% of positives being positive on all three. SDS was more likely to identify younger users with lower frequency of use who thought habitual cannabis use posed a considerable problem. CAST positivity was associated with frequent cannabis use and related problems. It is feasible to use short psychometric scales in wide school surveys, but one must carefully choose the screening instrument, as different instruments identify different groups of users. These may correspond to different types of problematic cannabis use; however, measurement bias seems to play a role too.

Cocaine-related health emergencies in Europe: a review of sources of information, trends and implications for service development.

BACKGROUND: Cocaine-related health consequences are difficult to observe. Data on drug users in health-emergency settings may be a useful source of information on consequences that are not visible via other information sources. METHODS: Thirty European countries submit an annual national report on the drug situation to the EMCDDA. All reports for the period 2007-2010 were analyzed, with particular attention given to auditing cocaine-related mentions. Analysis was also performed in order to identify sources and case definitions, assess coverage, audit cases and, where possible, to identify long-term trends. RESULTS: Considerable heterogeneity existed between countries in their approach to recording drug-related emergencies, with only Spain and the Netherlands having established formal indicators. The highest annual numbers of cocaine-related episodes were reported by the UK (3,502), Spain (2,845) and the Netherlands (1,211). A considerable (2- to 3-fold) increase in the numbers of cocaine-related episodes has been reported since the end of the 1990s in these countries; these increases peaked in Spain and England around 2007/08. CONCLUSIONS: The analysis reported here suggests the need to develop more standardized approaches to monitoring drug-related emergencies. It points to the potential value of developing effective referral links between the emergency and specialized drug services working with cocaine users.

Reducing drug related mortality in Europe - a seemingly intractable public health issue.

Drawing on an analysis of data from over 30 cohort studies, it can be estimated that between 10.000 and 20.000 opioid users die each year in Europe. Typically, annual mortality rates are between 10-20/1000, representing an excess mortality 10 to 20 times greater than expected. Most deaths occur among males in their mid-thirties. Four broad categories of cause of death can be identified: overdoses, diseases, suicide and trauma. While the long term trend in HIV related mortality among drug users is downwards, other causes of mortality have shown little sign of decreasing in recent years. Of particular concern are overdoses which account for 6300 to 8400 deaths reported annually. The fact that deaths have not decreased is surprising given the scaling up of treatment and other services. Opioid substitution treatment in particular is known to be protective and the numbers of those in substitution treatment in Europe has increased dramatically. A number of interrelated factors may help explain this intractable problem. These include: the possibility of an aging cohort becoming more vulnerable; the use of alcohol and other drugs; high levels of ill-health, risk behaviour, and co-morbidity; and social exclusion and marginalisation. Reducing overall morbidity among heroin users remains a key issue for Europe's public health services. More efforts are required to better understand and target both the direct and indirect factors associated with mortality among problem drugs users, if this major health cost associated with drug consumption is to be reduced.

Reducir la mortalidad relacionada con las drogas en Europa parece una cuestión de salud pública irresoluble / Reducing drug related mortality in Europe - a seemingly intractable public health issue

En base al análisis de los datos de más de 30 estudios de cohortes, se puede estimar que cada año mueren en Europa entre 10.000 y 20.000 usuarios de opiáceos. Generalmente las tasas de mortalidad anual se sitúan entre 10-20/1000, representando un exceso de mortalidad 10 a 20 veces superior al esperado para el grupo de edad. La mayoría de las muertes suceden entre hombres de alrededor de 35 años. Se pueden identificar cuatro grandes grupos de causas de muerte: sobredosis, enfermedades, suicidio y traumas. Mientras que la mortalidad relacionada con el VIH esta en disminución, otras causas de muerte han mostrado pocos signos de descenso en los últimos años. Particularmente preocupantes son las sobredosis, que representan 6.300 a 8.400 muertes cada año. El hecho de que las muertes no hayan disminuido es sorprendente, dada la expansión del tratamiento y otros servicios. Varios factores interrelacionados podrían ayudar a explicar este problema irresoluble, como son una creciente vulnerabilidad de una cohorte de usuarios que envejecen, el uso de alcohol y otras drogas, una salud altamente deteriorada, conductas de riesgo, la co-morbilidad, y la exclusión social y marginalización. Reducir la morbilidad general entre los usuarios de heroína continua siendo un tema clave para los servicios europeos de salud pública. Para conseguirlo es necesario profundizar en la comprensión y la actuación sobre los factores asociados, directa o indirectamente, a la mortalidad por el uso de drogas(AU)

Drawing on an analysis of data from over 30 cohort studies, it can be estimated that between 10.000 and 20.000 opioid users die each year in Europe. Typically, annual mortality rates are between 10-20/1000, representing an excess mortality 10 to 20 times greater than expected. Most deaths occur among males in their mid-thirties. Four broad categories of cause of death can be identified: overdoses, diseases, suicide and trauma. While the long term trend in HIV related mortality among drug users is down wards, other causes of mortality have shown little sign of decreasing in recent years. Of particular concern are overdoses which account for 6300 to 8400 deaths reported annually. The fact that death shave not decreased is surprising given the scaling up of treatment and other services. Opioid substitution treatment in particular is known to be protective and the numbers of those in substitution treatment in Europe has increased dramatically. A number of interrelated factors may help explain this intractable problem. These include: the possibility of an aging cohort becoming more vulnerable; the use of alcohol and other drugs; high levels of ill-health, risk behaviour, and co-morbidity; and social exclusion and marginalisation. Reducing overall morbidity among heroin users remains a key issue for Europe’s public health services. More efforts are required to better understand and target both the direct and indirect factors associated with mortality among problem drugs users, if this major health cost associated with drug consumption is to be reduced(AU)

Estimating the total mortality among problem drug users.

This paper's objective is to develop a method to estimate the total mortality among problem drug users. The total mortality is given by a base rate of mortality not related to drugs and the deaths that are directly and indirectly related to drugs. A fatal poisoning by drugs (overdose) is directly related to drugs, whereas a casualty due to a drug-related disease or a drug-related accident is indirectly related to drugs. As an example of a method to estimate the total mortality, the results from a cohort study among methadone patients in Amsterdam were projected on the whole population of problem drug users in The Netherlands. Due to differences between the problem drug users in Amsterdam and the rest of the country, adjustments were required. It was found that an initial estimation did not require adjustment for injection behavior and gender but did require adjustment for age and the percentage of HIV infection. In a first unadjusted estimation, the total number of deaths among problem drug users in The Netherlands in 2001 was estimated at 606 deaths. After adjustment for age, the estimated mortality decreased to 573 deaths, and after adjustment for HIV infection, this estimation again decreased to 479 deaths. From the ultimately estimated mortality, 11% was considered to be not related to drugs, 23% was attributed directly to drugs, and 66% was attributed indirectly to drugs. The number of direct deaths, as estimated by this method, falls in the same order of magnitude as the number extracted from the Causes of Death Statistics, when selecting cases according to the Drug-Related Deaths Standard as established by the European Monitoring Centre for Drugs and Drug Addiction (EMCDDA). Further cross-validation with other measures will be needed to assess the accuracy of the method, the limitations of which are discussed with respect to stipulating directions for future research.

Drug-related mortality and its impact on adult mortality in eight European countries.

OBJECTIVE: To estimate the mortality rates from drug-related deaths and other causes among problem drug users and population attributable risk of death due to opiate use in eight study sites in Europe. METHODS: Opiate users were recruited from drug treatment centres during the period 1990-1998 and deaths followed up through national or local mortality registries. Gender-specific overall mortality rate, proportion of deaths by cause (drug-related, HIV, other), standardized mortality ratios (SMRs), and the attributable risk fraction (ARF) were estimated. RESULTS: Crude mortality rates varied from 1 per 100 person-years in the Dublin and London cohorts to 3.8 per 100 person-years in Barcelona. The highest drug-related mortality rate was 10 per 1,000 person-years in Barcelona; the rates were approximately 7 per 1,000 person-years in Denmark, London, Rome, and Vienna, and <3.5 per 1,000 person-years for the others cohorts. The mortality rate for AIDS was <2 per 1,000 person-years in all the cohorts except Lisbon, Rome, and Barcelona, for which it was approximately 6 per 1,000 person-years. The highest SMR among males was 21.1 in Barcelona, and among females the highest SMRs were 53.7 and 37.7 in Barcelona and Rome, respectively. In Denmark the ARF was 5%, whereas it was >10% in all other study sites and 24% in Barcelona. CONCLUSION: Cohort mortality studies, especially in combination with estimates of prevalence, provide useful insights into the impact of opiate use on mortality across European countries and emphasize how preventing overall and drug-related deaths among opiate users can significantly improve the health of the population.