Cannabis use and Associated Health Problems ­ What's the Harm?

Aim Cannabis is the most widely used illegal drug in Ireland. We sought to describe the changing pattern of cannabis use and cannabis related health harms. Methods Data was collated from two national population surveys and three national treatment databases, focusing on people under 34 years. Results Past month cannabis use among adolescents and young adults increased after 2011, coinciding with a decline in perceived risk of regular use. The prevalence estimate for cannabis dependence increased from 1.1% to 3.6% from 2011 to 2015. From 2008 to 2016, there were increases in the rates of cannabis related addiction treatment episodes among adolescents and among young adults of 40% and 168% respectively. Cannabis related admissions to general and psychiatric hospitals increased by 90% and 185% respectively. Conclusion A concerted public health response is required to address escalating cannabis related health harms which have coincided with the arrival of more potent cannabis.

Cocaine use in Young Adults: Correlation with Early Onset Cannabis, Alcohol and Tobacco Use.

There is ongoing debate regarding the relationship between early tobacco, alcohol and cannabis use and later cocaine abuse. We utilised data from two Irish national general population surveys. Of the 1,897 young adult participants, the prevalence of lifetime use was as follows: tobacco 62%, alcohol 96%, cannabis 31% and cocaine 7.0%. Logistic regression analysis indicated that being single, earlier age of first alcohol use, and history of cannabis use were significant independent predictors of lifetime use of cocaine. The substance use route to cocaine use in this Irish sample is quite typical of that seen internationally. Those who commence alcohol use in the early teenage years are more likely to use cocaine subsequently, even after controlling for early onset cannabis use and other socio-demographic characteristics. This suggests that policies which delay age of first drinking may possibly also curtail cocaine use.

Treatment outcome for adolescents abusing alcohol and cannabis: how many 'reliably improve'?

Alcohol and cannabis are the primary substances contributing to referrals of adolescents to substance abuse treatment services. Their outcome has not been examined in Ireland. A three month follow-up was conducted in an outpatient adolescent treatment program. We followed up 35 high risk users of alcohol and 55 high risk users of cannabis. Although the high risk drinkers achieved a significant reduction in median number of days drinking (p = 0.004), only four (11 %) were abstinent at follow up. A further five (14%) achieved a reliable reduction in days of drinking. The high risk cannabis users demonstrated a significant drop in median days of use (p < 0.001), although only six (11%) were abstinent at follow up. A further 20 (36%) achieved a reliable reduction in days of use. Calculation of reliable change allows examination of outcomes which fall short of the elusive goal of abstinence.

Head shops and new psychoactive substances: a public health perspective.

In 2010, Ireland found itself at the eye of an international storm as a network of head shops emerged selling new psychoactive substances (NPS) and Irish youth rapidly became the heaviest users of NPS in Europe. Within months, the Irish government enacted novel legislation, which has since been copied by other countries, which effectively stopped the head shops selling NPS. Critics of this policy argued that it could cause harms to escalate. A number of separate studies indicate that a range of drug-related harms increased amongst Irish youth during the period of head shop expansion. Within months of their closure, health harms began to decline. NPS-related addiction treatment episodes reduced and admissions to both psychiatric and general hospitals related to any drug problem began to fall. Population use underwent sustained decline. Consequently, the closure of head shops can be viewed as a success in terms of public health.

Improvement in psychological wellbeing among adolescents with a substance use disorder attending an outpatient treatment programme.

OBJECTIVES: Adolescents with substance use disorders (SUDs) exhibit high rates of comorbid psychological problems. This study aimed to examine the impact of an outpatient substance use treatment programme upon the psychological wellbeing of adolescents. METHODS: A prospective study was carried out examining psychological symptoms in a group of adolescents attending the Youth Drug and Alcohol (YoDA) Addiction Service in Dublin. Participants were treated with evidenced based psychological models such as cognitive behavioural therapy, motivational interviewing and systemic family therapy. The Becks Youth Inventory was utilised to assess psychological symptoms at treatment entry and repeated three months later at follow up. RESULTS: Among 36 adolescents who were included in this study, poly-substance misuse was the norm. Almost three-quarter had a cannabis use disorder (CUD). There were significant reductions in mean subscale scores of depression (56.0 to 50.8, p = 0.003), anger (55.2 to 49.5, p < 0.001) and disruptive behaviour (61.6 to 56.5, p = 0.002) at follow up. Although there wasn't a statistically significant reduction in mean scores for anxiety, we observed a significant proportion of participants (p = 0.008) improving and moving out of a moderate to severe symptom range when examined by category. This was also the case for self-concept (p = 0.04). Furthermore this study revealed a positive correlation between the reduction in days of cannabis use and reduction in depressive scores (Pearson correlation 0.49, p = 0.01) among those with a CUD. CONCLUSION: The findings indicate that substance use treatment for adolescents is associated with important psychological and behavioural improvements.

Lapse and relapse following inpatient treatment of opiate dependence.

We conducted a prospective follow-up study of consecutive opiate dependent patients admitted to a residential addiction treatment service for detoxification. We measured the rate of relapse following discharge, and sought to identify factors that were associated with early relapse (i.e., a return to daily opiate use). Follow-up interviews were conducted with 109 patients, of whom, 99 (91%) reported a relapse. The initial relapse occurred within one week in 64 (59%) cases. Multivariate survival analysis revealed that earlier relapse was significantly predicted by younger age, greater heroin use prior to treatment, history of injecting, and a failure to enter aftercare. Unexpectedly, those who were in a relationship with an opiate user had significantly delayed relapse. Those who completed the entire six-week inpatient treatment programme also had a significantly delayed relapse. In order to reduce relapse and the associated increased risk of fatal overdose, services providing residential opiate detoxification should prepare people for admission, strive to retain them in treatment for the full admission period and actively support their entry into planned aftercare in order to improve outcome.

Youth mental health in deprived urban areas: a Delphi study on the role of the GP in early intervention.

BACKGROUND: GPs, as healthcare professionals with whom young people commonly interact, have a central role in early intervention for mental health problems. However, successfully fulfilling this role is a challenge, and this is especially in deprived urban areas. AIMS: To inform a complex intervention to support GPs in this important role, we aim to identify the key areas in which general practice can help address youth mental health and strategies to enhance implementation. METHODS: We conducted a modified Delphi study which involved establishing an expert panel involving key stakeholders/service providers at two deprived urban areas. The group reviewed emerging literature on the topic at a series of meetings and consensus was facilitated by iterative surveys. RESULTS: We identified 20 individual roles in which GPs could help address youth mental health, across five domains: (1) prevention, health promotion and access, (2) assessment and identification, (3) treatment strategies, (4) interaction with other agencies/referral, and (5) ongoing support. With regard to strategies to enhance implementation, we identified a further 19 interventions, across five domains: (1) training, (2) consultation improvements, (3) service-level changes, (4) collaboration, and (5) healthcare-system changes. CONCLUSIONS: GPs have a key role in addressing youth mental health and this study highlights the key domains of this role and the key components of a complex intervention to support this role.

How social context impacts on the development, identification and treatment of mental and substance use disorders among young people - a qualitative study of health care workers.

Introduction Social context has a major influence on the detection and treatment of youth mental and substance use disorders in socioeconomically disadvantaged urban areas, particularly where gang culture, community violence, normalisation of drug use and repetitive maladaptive family structures prevail. This paper aims to examine how social context influences the development, identification and treatment of youth mental and substance use disorders in socioeconomically disadvantaged urban areas from the perspectives of health care workers. METHOD: Semi-structured interviews were conducted with health care workers (n=37) from clinical settings including: primary care, secondary care and community agencies and analysed thematically using Bronfenbrenner's Ecological Theory to guide analysis. RESULTS: Health care workers' engagement with young people was influenced by the multilevel ecological systems within the individual's social context which included: the young person's immediate environment/'microsystem' (e.g., family relationships), personal relationships in the 'mesosystem' (e.g., peer and school relationships), external factors in the young person's local area context/'exosystem' (e.g., drug culture and criminality) and wider societal aspects in the 'macrosystem' (e.g., mental health policy, health care inequalities and stigma). CONCLUSIONS: In socioeconomically disadvantaged urban areas, social context, specifically the micro-, meso-, exo-, and macro-system impact both on the young person's experience of mental health or substance use problems and services, which endeavour to address these problems. Interventions that effectively identify and treat these problems should reflect the additional challenges posed by such settings.

Trends in treated opiate misuse in Dublin: the emergence of chasing the dragon.

AIMS: To examine trends in treated opiate misuse and identify factors associated with route of heroin use. DESIGN: Cross-sectional survey. SETTING: Services providing addiction treatment in Dublin. PARTICIPANTS: Individuals making their first ever contact seeking treatment for current opiate misuse, between January 1991 and December 1996. MEASUREMENTS: Data on socio-demographics and current drug use. FINDINGS: The study population was 3981. Over the 6-year period, there was a 330% increase in the number of new attenders. The proportion of females increased. The mean age of first opiate use declined and users began presenting earlier in their opiate-using careers, causing a decline in the age profile of new attenders. Heroin users were more likely to smoke (chase) rather than inject after 1994 (odds ratio 3.3, 95% confidence interval 2.4-4.5). Apart from year of presentation, the other significant independent predictors of chasing as the preferred route of heroin use were being in employment, shorter history of use, less frequent use, younger age, longer period in education and absence of polydrug use. Gender did not independently predict route of use. CONCLUSIONS: Ireland has joined the growing number of European countries witnessing a movement towards heroin chasing. This has coincided with a surge in the number of people entering treatment. We are concerned that the greater acceptability of this route of use may be drawing increased numbers of individuals into heroin use.

Syringe borrowing persists in Dublin despite harm reduction interventions.

AIMS: To measure the frequency of syringe borrowing in young Irish injecting drug users (IDUs) and identify associated characteristics. DESIGN: Cross-sectional survey. SETTING: Addiction treatment services in Dublin. PARTICIPANTS: Treated IDUs (N = 246). MEASUREMENTS: Data on drug injecting and syringe borrowing in the previous 6 months. FINDINGS: The median age was 22 years and the median length of injecting history was 19 months. Syringe borrowing was reported by 173 (70.3%) participants. A multivariate analysis identified seven characteristics significantly associated with syringe borrowing. These included early school leaving and parental unemployment. IDUs with long injecting histories who had injected less frequently were more likely to borrow. Injection of more than one substance was significantly associated with borrowing of syringes. Syringe borrowing was associated with having more intimate social relationships with other IDUs, less perceived risk in borrowing from acquaintances and usually opting to inject in the company of other IDUs. CONCLUSIONS: Syringe borrowing is commonly practised by young IDUs. Those with a background of social deprivation are more likely to engage in this risk behaviour. IDUs who report borrowing are more intimately involved with other IDUs and tend to perceive less risk or dangerousness in borrowing. In addition to syringe exchange, there is a need to work cognitively with IDUs to identify and challenge assumptions that they may have regarding the safety involved in borrowing from others, particularly from those with whom they have close social relationships.

Bloodborne viral infection in Irish injecting drug users.

AIMS: In Dublin, harm reduction strategies have greatly expanded since 1990. We sought to determine the prevalence of, and factors associated with, hepatitis C (HCV), hepatitis B (HBV) and HIV infections among injecting drug users (IDUs) against this background. DESIGN: Cross-sectional survey. SETTING: Addiction treatment clinic. PARTICIPANTS: Seven hundred and thirty-five IDU tested for antibody to HCV (anti-HCV) between September 1992 and September 1997. MEASUREMENTS: Socio-demographic and drug use characteristics. Serology tests for anti-HCV, HBV surface antigen (HBsAg) and HIV. FINDINGS: The vast majority (89%) commenced injecting since 1990. Prevalence of anti-HCV was 61.8% (453/733), of HBsAg was 1.0% (7/729) and of HIV was 1.2% (7/600). Logistic regression analyses indicated that longer history of injecting and increased daily drug expenditure were the only independent variables associated with significantly increased risk of HCV. The only characteristic associated with increased prevalence of HBsAg was a history of injecting prior to 1990 (3.8%, 3/80). HIV prevalence was significantly higher when aged over 24 years (3.7%, 6/162), when injecting commenced prior to 1990 (6.3%, 4/64) and when injecting over 5 years (6.5%, 4/62). CONCLUSIONS: HIV prevalence has sustained a low level in this population. Interventions which aim to halt transmission of HCV are necessary and will need to target IDU very early in their injecting careers and also those at risk of commencing to inject.

Heroin smoking by "chasing the dragon" in young opiate users in Ireland: stability and associations with use to "come down" off "Ecstasy".

We explored the frequency of commencing opiate use by "chasing the dragon" to "come down" off Ecstasy and the stability of heroin smoking in young opiate takers by assessing 102 subjects in Dublin using a semistructured interview. Ninety-two subjects had used Ecstasy. Of these, 68 reported "chasing" to "come down" off Ecstasy at some point in their history and were found to have used Ecstasy more frequently and in larger amounts. Thirty-six reported that their first experience of using opiates was to "come down" off Ecstasy, 28 citing this as their main reason for commencement.Eighty-six of the 102 commenced opiates by "chasing" heroin, 61 of whom progressed to injecting after a mean of 2.9 years. This was associated with starting illicit drug use earlier, starting heroin earlier, and a history of using Ecstasy. Implications for service planners in developing responses to illicit drug use among adolescents are discussed.

Assessment of hepatitis C infection in injecting drug users attending an addiction treatment clinic.

BACKGROUND: Injecting drug users represent a high risk group for hepatitis C (HCV) infection. Currently, screening of this group for HCV is inconsistently implemented. AIM: We designed a HCV assessment algorithm and sought to determine the frequency with which injecting drug users completed the assessment process. METHODS: Prospective study of a HCV assessment algorithm in the setting of a specialist outpatient addiction treatment clinic. Participants consisted of consecutive new attenders over a six-month period with a history of injecting. RESULTS: Only 21 (18%) of 119 patients reached a satisfactory endpoint of assessment. Forty-eight injectors were tested for antibody to HCV, of whom 26 (54%) tested positive. Thirteen of those with positive test results were no longer attending when the test result became available. Only four of the 19 patients who were referred, attended the on-site hepatology clinic. CONCLUSIONS: Thorough screening of injecting drug users for HCV within one treatment service is difficult. There is a need for explicit policies on this issue involving co-operation between primary care providers and addiction services and hepatology services.

Alcohol screening and brief intervention among drug users in primary care: a discussion paper.

BACKGROUND: Problem alcohol use is common among problem drug users (PDU) and associated with adverse health outcomes. Primary care has an important role in the overall stepped approach to alcohol treatment, especially screening and brief intervention (SBI). AIM: To discuss three themes that emerged from an exploration of the literature on SBI for problem alcohol use in drug users attending primary care. METHODS: Material for this discussion paper was gathered from three biomedical databases (PubMed, PsycINFO and Cochrane library), conference proceedings and online resources of professional organisations or national health agencies. RESULTS: Themes discussed in this paper are: (a) the potential of primary care for delivery of alcohol SBIs to PDUs, (b) screening methods and (c) application of brief interventions to PDUs. CONCLUSIONS: Although SBI improves health outcomes associated with problem alcohol use in the general population, further research is needed among high-risk patient groups, especially PDUs.