Steve Allsop

Cannabis potency and contamination: a review of the literature

AIMS Increased potency and contamination of cannabis have been linked in the public domain to adverse mental health outcomes. This paper reviews the available international evidence on patterns of cannabis potency and contamination and potential associated harms, and discusses their implications for prevention and harm reduction measures. METHODS A systematic literature search on cannabis potency and contamination was conducted. RESULTS Cannabis samples tested in the United States, the Netherlands, United Kingdom and Italy have shown increases in potency over the last 10 years. Some countries have not shown significant increases in potency, while other countries have not monitored potency over time. While there are some grounds to be concerned about potential contaminants in cannabis, there has been no systematic monitoring. CONCLUSION Increased potency has been observed in some countries, but there is enormous variation between samples, meaning that cannabis users may be exposed to greater variation in a single year than over years or decades. Claims made in the public domain about a 20- or 30-fold increase in cannabis potency and about the adverse mental health effects of cannabis contamination are not supported currently by the evidence. Systematic scientific testing of cannabis is needed to monitor current and ongoing trends in cannabis potency, and to determine whether cannabis is contaminated. Additionally, more research is needed to determine whether increased potency and contamination translates to harm for users, who need to be provided with accurate and credible information to prevent and reduce harms associated with cannabis use.

Variability in the prevalence of adult ADHD in treatment seeking substance use disorder patients: Results from an international multi-center study exploring DSM-IV and DSM-5 criteria

Background Available studies vary in their estimated prevalence of attention deficit/hyperactivity disorder (ADHD) in substance use disorder (SUD) patients, ranging from 2 to 83%. A better understanding of the possible reasons for this variability and the effect of the change from DSM-IV to DSM-5 is needed. Methods A two stage international multi-center, cross-sectional study in 10 countries, among patients form inpatient and outpatient addiction treatment centers for alcohol and/or drug use disorder patients. A total of 3558 treatment seeking SUD patients were screened for adult ADHD. A subsample of 1276 subjects, both screen positive and screen negative patients, participated in a structured diagnostic interview. Results Prevalence of DSM-IV and DSM-5 adult ADHD varied for DSM-IV from 5.4% (CI 95%: 2.4–8.3) for Hungary to 31.3% (CI 95%:25.2–37.5) for Norway and for DSM-5 from 7.6% (CI 95%: 4.1–11.1) for Hungary to 32.6% (CI 95%: 26.4–38.8) for Norway. Using the same assessment procedures in all countries and centers resulted in substantial reduction of the variability in the prevalence of adult ADHD reported in previous studies among SUD patients (2–83%→ 5.4–31.3%). The remaining variability was partly explained by primary substance of abuse and by country (Nordic versus non-Nordic countries). Prevalence estimates for DSM-5 were slightly higher than for DSM-IV. Conclusions Given the generally high prevalence of adult ADHD, all treatment seeking SUD patients should be screened and, after a confirmed diagnosis, treated for ADHD since the literature indicates poor prognoses of SUD in treatment seeking SUD patients with ADHD.

Validity of the Adult ADHD Self-Report Scale (ASRS) as a screener for adult ADHD in treatment seeking substance use disorder patients

BACKGROUND To detect attention deficit hyperactivity disorder (ADHD) in treatment seeking substance use disorders (SUD) patients, a valid screening instrument is needed. OBJECTIVES To test the performance of the Adult ADHD Self-Report Scale V 1.1(ASRS) for adult ADHD in an international sample of treatment seeking SUD patients for DSM-IV-TR; for the proposed DSM-5 criteria; in different subpopulations, at intake and 1-2 weeks after intake; using different scoring algorithms; and different externalizing disorders as external criterion (including adult ADHD, bipolar disorder, antisocial and borderline personality disorder). METHODS In 1138 treatment seeking SUD subjects, ASRS performance was determined using diagnoses based on Conners Adult ADHD Diagnostic Interview for DSM-IV (CAADID) as gold standard. RESULTS The prevalence of adult ADHD was 13.0% (95% CI: 11.0-15.0%). The overall positive predictive value (PPV) of the ASRS was 0.26 (95% CI: 0.22-0.30), the negative predictive value (NPV) was 0.97 (95% CI: 0.96-0.98). The sensitivity (0.84, 95% CI: 0.76-0.88) and specificity (0.66, 95% CI: 0.63-0.69) measured at admission were similar to the sensitivity (0.88, 95% CI: 0.83-0.93) and specificity (0.67, 95% CI: 0.64-0.70) measured 2 weeks after admission. Sensitivity was similar, but specificity was significantly better in patients with alcohol compared to (illicit) drugs as the primary substance of abuse (0.76 vs. 0.56). ASRS was not a good screener for externalizing disorders other than ADHD. CONCLUSIONS The ASRS is a sensitive screener for identifying possible ADHD cases with very few missed cases among those screening negative in this population.

Physical and mental health problems in amphetamine users from metropolitan Adelaide, Australia.

Phase I of this study was designed to inform the development of a range of responses to hazardous and harmful amphetamine use. Research techniques from Rapid Assessment Methodology (RAM) were utilized to collect data. A survey of current amphetamine users included the Short Form 36 (SF36) Health Status Questionnaire, for which South Australian population norms were published in 1995. This facilitated comparisons of the health of this sample of amphetamine users with that of the general population. The sample were found to have significantly poorer health than the general population. The self-reported prevalence of mental health problems in the sample was consistent with previous Australian research on amphetamine use. Approximately one-third of the sample reported that they had experienced symptoms of anxiety, depression, mood swings and aggressive outbursts prior to their use of amphetamines. Two-thirds of the sample reported symptoms of anxiety and depression since starting to use amphetamines, almost half reported mood swings and aggressive outbursts, and over a third reported panic attacks and paranoia. One of the most important findings was a strong association between mental and physical health problems and the severity of dependence on amphetamines. The implications of these results for interventions with amphetamine users are discussed.

The International ADHD in Substance Use Disorders Prevalence (IASP) study: Background, methods and study population

Attention deficit/hyperactivity disorder (ADHD) is an increasingly recognized comorbid condition in subjects with substance use disorders (SUDs).

The CLIMATE schools combined study: a cluster randomised controlled trial of a universal internet-based prevention program for youth substance misuse, depression and anxiety

BackgroundAnxiety, depressive and substance use disorders account for three quarters of the disability attributed to mental disorders and frequently co-occur. While programs for the prevention and reduction of symptoms associated with (i) substance use and (ii) mental health disorders exist, research is yet to determine if a combined approach is more effective. This paper describes the study protocol of a cluster randomised controlled trial to evaluate the effectiveness of the CLIMATE Schools Combined intervention, a universal approach to preventing substance use and mental health problems among adolescents.Methods/designParticipants will consist of approximately 8400 students aged 13 to 14-years-old from 84 secondary schools in New South Wales, Western Australia and Queensland, Australia. The schools will be cluster randomised to one of four groups; (i) CLIMATE Schools Combined intervention; (ii) CLIMATE Schools - Substance Use; (iii) CLIMATE Schools - Mental Health, or (iv) Control (Health and Physical Education as usual).The primary outcomes of the trial will be the uptake and harmful use of alcohol and other drugs, mental health symptomatology and anxiety, depression and substance use knowledge. Secondary outcomes include substance use related harms, self-efficacy to resist peer pressure, general disability, and truancy. The link between personality and substance use will also be examined.DiscussionCompared to students who receive the universal CLIMATE Schools - Substance Use, or CLIMATE Schools - Mental Health or the Control condition (who received usual Health and Physical Education), we expect students who receive the CLIMATE Schools Combined intervention to show greater delays to the initiation of substance use, reductions in substance use and mental health symptoms, and increased substance use and mental health knowledge.Trial registrationThis trial is registered with the Australian and New Zealand Clinical Trials registry, ACTRN12613000723785.

Evidence-based practice or imperfect seduction? Developing capacity to respond effectively to drug-related problems

ISSUES The last two or three decades have seen some valuable investment in workforce development. However, significant challenges remain in developing effective practice across various systems. Despite the relevance alcohol, tobacco and other drug use have for a range of staff across diverse organisations, adoption of cross-sector and collaborative effective practice is not widespread. The most common response involves a rather singular focus on strategies that develop practitioner knowledge and skills, with much less consideration given to the complex nature of the work environment and the belief systems of people who work in these environments. APPROACH This paper explores the barriers to and facilitators of effective practice, extending beyond the common focus on education and training initiatives. A model of capacity building is explored as a template to inform workforce and organisational development strategies. KEY FINDINGS Numerous barriers, outside education and training, must be considered in order to develop and maintain effective practice across various systems of prevention and treatment. The paper culminates with recommendations on how to overcome such challenges. IMPLICATIONS Workforce and organisational development must extend beyond education and training initiatives. Along with a focus on organisational and system factors, we must also attend to the marginalisation of people affected by drug use and associated pejorative attitudes. CONCLUSION Developing effective practice in the drug field involves changing the structures, and expected outcomes of these structures, in which people work, not just encouraging a few to use new ways of working in spite of the system.

Screening for harmful alcohol use in Australian trauma settings

INTRODUCTION High rates of trauma recidivism associated with alcohol use indicate the need to screen for alcohol consumption and related harm. Routine collection of prevalence data relating to alcohol use in Australian trauma settings is not undertaken currently, and diverse screening approaches are used across different settings. This study sought to examine the feasibility of routine screening for alcohol related injury and harmful alcohol use, and determine the prevalence of alcohol related injury and risky alcohol consumption amongst trauma patients in Western Australia. METHODS A step-down model of screening for alcohol-related injury and harmful alcohol consumption was developed and trialled. Over a four month period at a statewide trauma service, 729 non-head injured trauma patients were screened using a two-item measure in emergency and acute surgical settings, and 538 patients who screened positive were subsequently administered a standardised self report measure of alcohol consumption. RESULTS There was a 49% compliance rate with the Emergency Department brief screening protocol for alcohol related injury. Of those screened, 77% were identified by clinical staff as potentially having had an alcohol related injury or be engaging in risky drinking regularly. Sixty per cent of the screened patients who subsequently completed a standardised self report measure were identified as drinking at harmful levels (41% hazardous; 7% harmful; 12% dependent). Of these, 15% and 24% met the DSM-IV-TR criteria for alcohol abuse and dependence respectively. Approximately 30% of patients diagnosed with an alcohol use disorder were not identified by staff as having an alcohol-related injury or problem. Higher alcohol consumption was significantly associated with greater risk of depression and PTSD. CONCLUSIONS Preliminary findings suggest a high prevalence of alcohol-related injury, and harmful alcohol consumption. These findings point to an urgent need to develop reliable and economical screening protocols for harmful alcohol use across Australian trauma settings and the adoption of strategies to ensure their compliance, to enable accurate identification of those most likely to benefit from interventions to reduce alcohol related harm.

Characteristics of individuals presenting to treatment for primary alcohol problems versus other drug problems in the Australian patient pathways study

BackgroundPeople seeking treatment for substance use disorders often have additional health and social issues. Although individuals presenting with alcohol as the primary drug of concern (PDOC) account for nearly half of all treatment episodes to the Australian alcohol and other drug (AOD) service system, previous treatment cohort studies have focused only on the profile of Australian heroin or methamphetamine users. While studies overseas indicate that clients seeking treatment primarily for their drinking are less likely to experience social and economic marginalisation than those seeking treatment primarily for illicit or pharmaceutical drug use, very little research has directly compared individuals presenting with alcohol as the PDOC to those primarily presenting with other drugs as their PDOC.MethodsSeven hundred and ninety-six participants were recruited at entry to specialist AOD treatment in Victoria and Western Australia, and completed measures of demographic and social factors, substance use, quality of life, service use, and criminal justice involvement. We compared those with alcohol as their PDOC to those with other drugs as their PDOC using Pearson chi-square and Mann–Whitney U tests.ResultsRates of social disadvantage, poor quality of life, high severity of substance dependence, and past-year AOD, mental health, acute health, and social service use were high in all groups. However, participants with alcohol as the PDOC were older; more likely to have an educational qualification; less likely to report criminal justice involvement, housing/homelessness service use, tobacco smoking, or problems with multiple substances; and reported better environmental quality of life; but were more likely to have used ambulance services, than those with other drugs as their PDOC.ConclusionsWhile those seeking treatment primarily for alcohol problems appear less likely to suffer some forms of social and economic disadvantage or to use multiple substances than those with a primary drug problem, they experience similarly high levels of substance dependence severity and mental health and AOD service use. These findings reinforce the need for AOD services to integrate or coordinate care with programs that address the many complexities clients frequently present with, while also acknowledging differences between those seeking treatment for alcohol versus other drug problems.

Risk behaviours among substance use disorder treatment seekers with and without adult ADHD symptoms.

BACKGROUND Impulsivity and consequent risk-taking are features of both Attention Deficit Hyperactivity Disorder (ADHD) and substance use disorder (SUD). To date there are no data on the impact of comorbid ADHD on the likelihood and frequency of risk-taking behaviour among individuals with SUD. The current study aimed to examine drug-related, sexual and driving-related risk behaviours in people seeking treatment for SUD with co-occurring symptoms of Attention Deficit Hyperactivity Disorder (ADHD), taking into account potential confounders. METHODS 489 Australian adult SUD treatment seekers were administered a structured interview assessing demographics, drug use and SUD treatment history, psychiatric history, self-reported adult ADHD symptoms and self-reported drug-related, sexual and driving-related risk behaviours. RESULTS Almost a third (32%) screened positive for adult ADHD symptoms with onset prior to age 12. Those screening positive were more likely to report early onset (<15 years) nicotine and illicit drug use and to have a prior diagnosis of childhood ADHD, anxiety, depression and personality disorder. ADHD symptom status was not independently associated with injecting drug use-related or sexual risk-taking in the preceding month, but was an independent predictor of a greater overall number of driving offences, a higher frequency of driving without a seatbelt, a greater likelihood of having driven without a valid licence, more at-fault accidents and having ones licence disqualified at the time of interview. CONCLUSIONS These findings suggest that the risk-taking behaviour that is common among people with SUD is further increased among those with comorbid ADHD symptoms, particularly with respect to dangerous driving practices.