[Show abstract][Hide abstract] ABSTRACT: Objective:
Although cannabis is an illegal drug, 'medical marijuana programs' (MMPs) have proliferated (e.g., in Canada and several US states), allowing for legal cannabis use for therapeutic purposes. While both health risks and potential therapeutic benefits for cannabis use have been documented, potential public health impacts of MMPs - also vis-à-vis other psychoactive substance use - remain under-explored.
We briefly reviewed the emerging evidence on MMP participants' health status, and specifically other psychoactive substance use behaviors and outcomes.
While data are limited in amount and quality, MMP participants report improvements in overall health status, and specifically reductions in levels of risky alcohol, prescription drug and - to some extent - tobacco or other illicit drug use; at the same time, increases in cannabis use and risk/problem patterns may occur.
MMP participation may positively impact - for example, by way of possible 'substitution effects' from cannabis use - other psychoactive substance use and risk patterns at a scale relevant for public health, also influenced by the increasing population coverage of MMPs. Yet, net overall MMP-related population health effects need to be more rigorously and comprehensively assessed, including potential increases in cannabis use related risks and harms.
[Show abstract][Hide abstract] ABSTRACT: Background:
Non-prescribed use of opioid substitution medication (NPU) appears to represent a relevant source of opioids among European drug users. Little is known about the prevalence of NPU in Germany and possible differences between subgroups of opioid users. The present study examines NPU and other drug use patterns among drug consumption room (DCR) clients, opioid substituted DCR clients, and patients recruited in opioid substitution treatment (OST) practices.
Cross-sectional data was collected in 2011 from 842 opioid users in 10 DCRs and 12 OST practices across 11 German cities. Structured interviews comprised indicators for socio-demographics, health status, drug use, motives for NPU, and the availability and price of illicit substitution medication. Group differences were examined with one-way ANOVAs, chi-square tests, or t-tests, and factors for NPU were included in a multivariate model. Over-time comparisons were performed with similar data collected in 2008.
Lifetime, 30-day and 24-h NPU prevalence for the total sample was 76.5%, 21.9%, and 9.3%, respectively, with methadone being the most frequently used substance. NPU, poly-drug use and injection drug use were more common among DCR clients, especially among DCR clients not in OST. The three groups featured distinct socio-demographic characteristics, with substituted patients being more socially integrated, while few differences in health parameters emerged. Motives for NPU were mostly related to potential shortcomings of OST, such as insufficient dosages, difficulties with transportation, and lack of access. NPU prevalence was found to be higher than in 2008, while injection rate of substitution medication was similarly low. Main factors associated with NPU were not being in OST, past 24-h use of other drugs, and younger age.
Although diverted methadone or buprenorphine are rarely used as main drugs, NPU is prevalent among opioid users, particularly among DCR clients not in OST. OST reduces NPU if opioid users' needs are met.
No preview · Article · Dec 2015 · The International journal on drug policy
[Show abstract][Hide abstract] ABSTRACT: Background and aims:
Cannabis use is associated with several adverse health effects. However, little is known about the cannabis-attributable burden of disease. This study quantified the age-, sex- and adverse health effect-specific cannabis-attributable (1) mortality, (2) years of life lost due to premature mortality (YLLs), (3) years of life lost due to disability (YLDs) and (4) disability-adjusted life years (DALYs) in Canada in 2012.
Epidemiological modeling SETTING: Canada PARTICIPANTS: Canadians aged ≥ 15 years in 2012 MEASUREMENTS: Using Comparative Risk Assessment methodology, cannabis-attributable fractions were computed using Canadian exposure data and risk relations from large studies or meta-analyses. Outcome data were obtained from Canadian databases and the World Health Organization. The 95% confidence Intervals (CIs) were computed using Monte Carlo methodology.
Cannabis use was estimated to have caused 287 deaths (95% CI: 108, 609), 10,533 YLLs (95% CI: 4,760, 20,833), 55,813 YLDs (95% CI: 38,175, 74,094) and 66,346 DALYs (95% CI: 47,785, 87,207), based on causal impacts on cannabis use disorders, schizophrenia, lung cancer and road traffic injuries. Cannabis-attributable burden of disease was highest among young people, and males accounted for twice the burden than females. Cannabis use disorders were the most important single cause of the cannabis-attributable burden of disease.
The cannabis-attributable burden of disease in Canada in 2012 included 55,813 years of life lost due to disability, mainly caused by cannabis use disorders. Although the cannabis-attributable burden of disease was substantial, it was much lower compared with other commonly used legal and illegal substances. Moreover, the evidence base for cannabis-attributable harms was smaller. This article is protected by copyright. All rights reserved.
[Show abstract][Hide abstract] ABSTRACT: Background. There is evidence of increasing trends in substance use and related harms among Aboriginal populations in Canada. This paper provides a review of data on alcohol, tobacco, and illicit drug use and related harms. Methods. A comprehensive review of public data, journal publications, and grey literature published between 2000 and 2014 were reviewed if data included: people who self-identify as Aboriginal and who live in Canada; drug use; and morbidity and mortality related to drug use. Data were structured by major substance categories and compared with non-Aboriginal sample data where possible. Results. Over 100 documents were reviewed and revealed a disproportionate burden of substance use and harms, particularly among Aboriginal youth. Significant gaps in data exist, specifically, for urban populations. Conclusion. This review reinforces concerns of many Aboriginal communities and organizations in Canada as well as highlights where prevention, programming, and policy efforts might be most effective.
No preview · Article · Nov 2015 · Journal of Health Care for the Poor and Underserved
[Show abstract][Hide abstract] ABSTRACT: Background:
By the year 2000, Canada faced high levels of illicit drug use and related harms. Simultaneously, a fundamental tension had raisen between continuing a mainly repression-based versus shifting to a more health-oriented drug policy approach. Despite a wealth of new data and numerous individual studies that have emerged since then, no comprehensive review of key indicators and developments of illicit drug use/harm epidemiology, interventions and law/policy exist; this paper seeks to fill this gap.
We searched and reviewed journal publications, as well as key reports, government publications, surveys, etc. reporting on data and information since 2000. Relevant data were selected and extracted for review inclusion, and subsequently grouped and narratively summarized in major topical sub-theme categories.
Cannabis use has remained the principal form of illicit drug use; prescription opioid misuse has arisen as a new and extensive phenomenon. While new drug-related blood-borne-virus transmissions declined, overdose deaths increased in recent years. Acceptance and proliferation of - mainly local/community-based - health measures (e.g., needle exchange, crack paraphernalia or naloxone distribution) aiming at high-risk drug users has evolved, though reach and access limitations have persisted; Vancouver's 'supervised injection site' has attracted continued attention yet remains un-replicated elsewhere in Canada. While opioid maintenance treatment utilization increased, access to treatment for key (e.g., infectious disease, psychiatric) co-morbidities among drug users remained limited. Law enforcement continued to principally focus on cannabis and specifically cannabis users. 'Drug treatment courts' were introduced but have shown limited effectiveness; several attempts cannabis control law reform have failed, except for the recent establishment of 'medical cannabis' access provisions.
While recent federal governments introduced several law and policy measures reinforcing a repression approach to illicit drug use, lower-level jurisdictions (e.g., provincial/municipal levels) and non-governmental organizations increasingly promoted social- and health-oriented intervention frameworks and interventions, therefore creating an increasingly bifurcated - and inherently contradictory - drug policy landscape and reality in Canada.
No preview · Article · Sep 2015 · The International journal on drug policy
[Show abstract][Hide abstract] ABSTRACT: Crack-cocaine use is prevalent in numerous countries, yet concentrated primarily - largely within urban contexts - in the Northern and Southern regions of the Americas. It is associated with a variety of behavioral, physical and mental health and social problems which gravely affect users and their environments. Few evidence-based treatments for crack-cocaine use exist and are available to users in the reality of street drug use. Numerous pharmacological treatments have been investigated but with largely disappointing results. An important therapeutic potential for crack-cocaine use may rest in cannabinoids, which have recently seen a general resurgence for varied possible therapeutic usages for different neurological diseases. Distinct potential therapeutic benefits for crack-cocaine use and common related adverse symptoms may come specifically from cannabidiol (CBD) - one of the numerous cannabinoid components found in cannabis - with its demonstrated anxiolytic, anti-psychotic, anti-convulsant effects and potential benefits for sleep and appetite problems. The possible therapeutic prospects of cannabinoids are corroborated by observational studies from different contexts documenting crack-cocaine users' 'self-medication' efforts towards coping with crack-cocaine-related problems, including withdrawal and craving, impulsivity and paranoia. Cannabinoid therapeutics offer further benefits of being available in multiple formulations, are low in adverse risk potential, and may easily be offered in community-based settings which may add to their feasibility as interventions for - predominantly marginalized - crack-cocaine user populations. Supported by the dearth of current therapeutic options for crack-cocaine use, we are advocating for the implementation of a rigorous research program investigating the potential therapeutic benefits of cannabinoids for crack-cocaine use. Given the high prevalence of this grave substance use problem in the Americas, opportunities for such research should urgently be created and facilitated there.
No preview · Article · Sep 2015 · The International journal on drug policy
[Show abstract][Hide abstract] ABSTRACT: Canada has featured the second-highest levels of prescription opioid (PO) use globally behind the United States, and reported extensive PO-related harms (e.g., non-medical PO use [NMPOU], PO-related morbidity and mortality). A recent comprehensive review synthesized key data on PO use, PO-related harms, and interventions in Canada, yet a substantive extent of new studies and data have emerged.
To conduct and present a comprehensive review update on PO use, PO-related harms, and interventions in Canada since 2010.
Narrative review METHODS: We conducted literature searches, employing pertinent keywords, in key databases, focusing on PO-related studies/data in/for Canada since 2010, or pertinent studies/data from earlier periods not included in our previous review. In addition, we identified relevant data from "grey" literature (e.g., government, survey, other data or system reports). Relevant data were screened and extracted, and categorized into 4 main sections of indicators: 1) PO dispensing and use, 2) non-medical PO use, 3) PO-related morbidity/mortality, 4) PO-related interventions and impacts.
PO-dispensing in Canada overall continued to increase and/or remain at high levels in Canada from 2010 to 2013, with the exception of the province of Ontario where marked declines occurred starting in2012; quantitative and qualitative PO dispensing patterns continued to vary considerably between provinces. Several studies identified common "high PO dosing" prescribing practices in different settings. Various data suggested declining NMPOU levels throughout most general (e.g., adult, students), yet not in special risk (e.g., street drug users, First Nations) populations. While treatment demand in Ontario plateaued, rising PO-related driving risks as well as neo-natal morbidity were identified by different studies. PO-related mortality was measured to increase - in total numbers and proportionally - in various Canadian jurisdictions. Select reductions in general PO and/or high-dose PO dispensing were observed following key interventions (e.g., Oxycodone delisting, prescription monitoring program [PMP] introduction in Ontario/British Columbia). While physician education intervention studied indicated mixed outcomes, media reporting was found to be associated with PO prescribing patterns.
The present review did not utilize systematic review standards or meta-analytic techniques given the large heterogeneity of data and outcomes reviewed.
Recently emerging data help to better characterize PO-related use, harm and intervention indicators in Canada's general context of comparatively high-level PO dispensing and harms, yet major gaps in monitoring and information persist; this continues to be a problematic challenge, especially given the implementation of key PO-related interventions post-2010, the impact of which needs to be properly measured and understood.
Prescription opioids, use, dispensing, dosing, education, non-medical use, Canada, morbidity, mortality, monitoring, interventions, policy, review.
[Show abstract][Hide abstract] ABSTRACT: Cannabis is the most prevalently used drug globally, with many jurisdictions considering varying reform options to current policies to deal with this substance and associated harm. Three policy options are available: prohibition, decriminalization, and legalization, with prohibition currently the dominant model globally. This contribution gives reasons why legalization with strict regulation should be considered superior to other options with respect to public health in high income countries in North America.
No preview · Article · Feb 2015 · Clinical Pharmacology & Therapeutics
[Show abstract][Hide abstract] ABSTRACT: Background
Consumption levels of prescription opioids (POs) have increased substantially worldwide, particularly the United States. An emerging perspective implicates increasing consumption levels of POs as the primary system level driving factor behind the observed PO-related harms. As such, the present study aimed to assess the correlations between consumption levels of POs and PO-related harms, including non-medical prescription opioid use (NMPOU), PO-related morbidity and PO-related mortality.
Pearson’s product-moment correlations were computed using published data from the United States (2001 – 2010). Consumption levels of POs were extracted from the technical reports published by the International Narcotics Control Board, while data for NMPOU was utilized from the National Survey on Drug Use and Health. Additionally, data for PO-related morbidity (substance abuse treatment admissions per 10,000 people) and PO-related mortality (PO overdose deaths per 100,000 people) were obtained from published studies. Consumption levels of POs were significantly correlated with prevalence of NMPOU in the past month (r =0.741, 95% CI =0.208–0.935), past year (r =0.638, 95% CI =0.014–0.904) and lifetime (r =0.753, 95% CI =0.235-0.938), as well as average number of days per person per year of NMPOU among the general population (r =0.900, 95% CI =0.625-0.976) and NMPOU users (r =0.720, 95% CI =0.165–0.929). Similar results were also obtained for PO-related morbidity and PO-related mortality measures.
These findings suggest that reducing consumption levels of POs at the population level may be an effective strategy to limit PO-related harms.
Full-text · Article · Oct 2014 · Substance Abuse Treatment Prevention and Policy
[Show abstract][Hide abstract] ABSTRACT: Prescription opioid (POs, i.e. opioid analgesics requiring a prescription) related harms are extensive in North America; non-medical PO use (NMPOU), PO-related morbidity (e.g. hospital or treatment admissions) and mortality (e.g. overdose deaths) are high in the general population. Most recommendations towards reducing PO-related problems to date have focused on rather narrow and specific areas (e.g. improved PO monitoring, clinical PO use guidelines, detection of patients with PO abuse, tamper-resistant PO formulations). An integrated population health framework for POs – i.e. an evidence-based approach towards largest possible reductions of PO-related harms in the population, as is well established for other psychoactive drug (e.g. alcohol) fields – is currently missing. Recent PO-focused policy initiatives launched in Canada present long lists of recommendations – the feasibility and impact of which on PO-related harms is uncertain – yet also are notably silent on population health-based considerations or approaches. We outline select principal pillars – including general and targeted prevention, and treatment – for a population health framework for PO-related harms and offer suggestions for implementation, with Canada as the principal case study. Given the extensive burden and known population-level determinants of PO-related harms, the development of an evidence-based population health approach to reduce this burden is urgently advised.
No preview · Article · Oct 2014 · Drugs: Education Prevention and Policy
[Show abstract][Hide abstract] ABSTRACT: Hepatitis C virus (HCV) currently infects approximately 250,000 individuals in Canada and causes more years of life lost than any other infectious disease in the country. In August 2011, new therapies were approved by Health Canada that have achieved higher response rates among those treated, but are poorly tolerated. By 2014/2015, shortcourse, well-tolerated treatments with cure rates >95% will be available. However, treatment uptake is poor due to structural, financial, geographical, cultural and social barriers. As such, 'Barriers to access to HCV care in Canada' is a crucial topic that must be addressed to decrease HCV disease burden and potentially eliminate HCV in Canada. Understanding how to better care for HCV-infected individuals requires integration across multiple disciplines including researchers, clinical services and policy makers to address the major populations affected by HCV including people who inject drugs, baby boomers, immigrants and Aboriginal and/or First Nations people. In 2012, the National CIHR Research Training Program in Hepatitis C organized the 1st Canadian Symposium on Hepatitis C Virus (CSHCV) in Montreal, Quebec. The 2nd CSHCV was held in 2013 in Victoria, British Columbia. Both symposia were highly successful, attracting leading international faculty with excellent attendance leading to dialogue and knowledge translation among attendees of diverse backgrounds. The current article summarizes the 3rd CSHCV, held February 2014, in Toronto, Ontario.
[Show abstract][Hide abstract] ABSTRACT: While prohibition has been the dominant regime of cannabis control in most countries for decades, an increasing number of countries have been implementing cannabis control reforms recently, including decriminalization or even legalization frameworks. Canada has held out from this trend, although it has among the highest cannabis use rates in the world. Cannabis use is universally criminalized, and the current (conservative) federal government has vowed not to implement any softening reforms to cannabis control. As a result of several higher court decisions, the then federal government was forced to implement a 'medical marijuana access regulations' program in 2001 to allow severely ill patients therapeutic use and access to therapeutic cannabis while shielding them from prosecution. The program's regulations and approval processes were complex and subject to extensive criticism; initial uptake was low and most medical marijuana users continued their use and supply outside the program's auspices. This year, the government introduced new 'marijuana for medical purposes regulations', which allow physicians to 'authorize' medical marijuana use for virtually any health condition for which this is considered beneficial; supply is facilitated by licensed commercial producers. It is expected that some 500,000 users, and dozens of commercial producers will soon be approved under the program, arguably constituting - as with medical marijuana schemes elsewhere, e.g. in California - de facto 'legalization'. We discuss the question whether the evolving scope and realities of 'medical cannabis' provisions in Canada offer a 'sneaky side door' or a 'better third way' to cannabis control reform, and what the potential wider implications are of these developments.
No preview · Article · Sep 2014 · International Journal of Drug Policy
[Show abstract][Hide abstract] ABSTRACT: Introduction
Studies have shown important gender differences among drug (including crack) users related to: drug use patterns; health risks and consequences; criminal involvement; and service needs/use. Crack use is prevalent in Brazil; however, few comparative data by sex exist. We examined and compared by sex key drug use, health, socio-economic indicators and service use in a bi-city sample of young (18–24 years), regular and marginalized crack users in Brazil.
Study participants (total n = 159; n = 124 males and n = 35 females) were recruited by community-based methods from impoverished neighborhoods in Rio de Janeiro and Salvador. Assessments occurred by an anonymous interviewer-administered questionnaire and serum collection for blood-borne virus testing between November 2010 and June 2011. Descriptive statistics and differences for key variables by sex were computed; in addition, a ‘chi-squared automatic interaction detector’ (‘CHAID’) analysis explored potential primary factors differentiating male and female participants.
Most participants were non-white, and had low education and multiple income sources. More women had unstable housing and income from sex work and/or panhandling/begging, whereas more men were employed. Both groups indicated multi-year histories of and frequent daily crack use, but virtually no drug injection histories. Men reported more co-use of other drugs. More women were: involved in sex-for-drug exchanges; Blood-Borne Virus (BBV) tested and HIV+. Both groups reported similar physical and mental health patterns; however women more commonly utilized social or health services. The CHAID analysis identified sex work; paid work; begging/panhandling; as well as physical and mental health status (all at p < 0.05) as primary differentiating factors by sex.
Crack users in our study showed notable differences by sex, including socio-economic indicators, drug co-use patterns, sex risks/work, BBV testing and status, and service utilization. Results emphasize the need for targeted special interventions and services for males and female crack users in Brazil.
Full-text · Article · Aug 2014 · International Journal for Equity in Health
[Show abstract][Hide abstract] ABSTRACT: Five years ago, we highlighted Canada's emerging problem of prescription opioid (PO)-related harms and emphasized the need for targeted surveillance, research and interventions. Overall levels of PO use in the Canadian population have grown by 70% since then, while at the same time levels of non-medical PO use (NMPOU) in general and in key risk populations have continued to be high; furthermore, PO-related harms - specifically morbidity (e.g., treatment admissions) and mortality (e.g., overdose deaths) - have risen substantively. Unfortunately, major knowledge gaps related to systematic monitoring of PO-related harms continue to exist; for example, no national morbidity or mortality statistics are available. Investigator-driven research has generated important insights into the epidemiology and impacts of PO-related harms: high correlations between population-level PO dispensing and/or PO dosing and harms; high rates of co-occurrence of NMPOU and co-morbidities; and distinct NMPOU-related risk dynamics among street drug users. Select policy measures have been implemented only recently at the federal and provincial levels; these interventions remain to be systematically evaluated, especially given preliminary indications of reductions in PO-related harms (e.g., NMPOU) unfolding prior to the interventions. For these purposes, improvements in surveillance tools and research resources devoted to the extensive public health problem of PO-related harms in Canada continue to be urgently needed.