Mortality among individuals with cannabis, cocaine, amphetamine, MDMA, and opioid use disorders: a nationwide follow-up study of Danish substance users in treatment

This is a register-based cohort study of 20,581 individuals in treatment for illicit substance use disorders in Denmark between 1996 and 2006. All in all, 1441 deaths were recorded during 111,445 person-years of follow-up. Standardized mortality ratios (SMRs) associated with different primary substance types were calculated and Cox-regression analyses were performed in order to establish hazard ratios (HR) associated with injection drug use and psychiatric comorbidity. SMRs for primary users of specific substances were: cannabis: 4.9 (95% confidence interval (CI): 4.2-5.8), cocaine: 6.4 (CI: 3.9-10.0), amphetamine: 6.0 (CI: 4.2-8.3), heroin: 9.1 (CI: 8.5-9.8), and other opioids 7.7 (CI: 6.6-8.9). For MDMA ('ecstasy') the crude mortality rate was 1.7/1000 person-years (CI: 0.4-7.0) and the SMR was not significantly elevated. Injection drug use was associated with significantly increased hazard ratios in users of opioids and cocaine/amphetamine. Overall, psychiatric comorbidity was not associated with increased mortality (HR: 1.1 [CI: 0.9-1.2], p=.28), but an association was found specifically among cocaine/amphetamine users (HR: 3.6 [CI: 2.1-6.4], p<.001).     

Mortality following treatment for cannabis use disorders: Predictors and causes

The aim of the study was to determine excess mortality associated with cannabis use disorders. Individuals entering treatment for cannabis use disorders were followed by use of Danish registers and standardized mortality ratios (SMRs) estimated. Predictors of different causes of death were determined. A total of 6445 individuals were included and 142 deaths recorded during 26,584 person-years of follow-up. Mortality was predicted by age, comorbid use of opioids, and lifetime injection drug use. For different causes of death the SMRs were: accidents: 8.2 (95% CI 6.3–10.5), suicide: 5.3 (95% CI 3.3–7.9), homicide/violence: 3.8 (95% CI 1.5–7.9), and natural causes: 2.8 (95% CI 2.0–3.7). Following exclusion of those with secondary use of opioids, cocaine, amphetamine, or injection drug use, SMRs for all causes of death remained significantly elevated except for homicide/violence. The study underlines the need to address mortality risk associated with cannabis use disorders.     

Cannabis use among youth in the Netherlands

A nation-wide survey of cannabis use, based on a representative sample of 1,306 young people in the 15-to-24 age group, carried out in the Netherlands in 1983, showed that cannabis had been used or tried by 12.2 per cent of the respondents (13 per cent males and 11 per cent females). These results, compared with the results of a study carried out by the Central Bureau of Statistics in 1979 and 1980, showed an increase in cannabis use. In the three largest cities, the percentage of cannabis users (25 per cent) was double that of the country as a whole. The percentage of cannabis use was higher among the older age groups of respondents; the study also showed that the lower the age at first cannabis use the higher the risk of continuing and becoming involved with more dangerous drugs such as cocaine, heroin and amphetamines. The rates of alcohol drinking, tobacco smoking and the use of heroin, amphetamines, cocaine, sleeping pills and tranquillizers were significantly higher among cannabis users than among respondents who were not using cannabis. The rate of cannabis use was significantly higher among the unemployed respondents than among those who had a job. The authors suggest that these findings should be taken into account in designing preventive measures and other forms of intervention programmes to deal with cannabis-related problems among young people.     

Polysubstance Use and Heroin Relapse Among Adolescents Following Residential Treatment

This study examined posttreatment patterns of polysubstance use and heroin relapse in a sample of 43 adolescents (ages 14–20) entering short-term residential treatment for primary heroin use. At 12-month follow-up, youths that achieved heroin abstinence (N = 19) were significantly less likely than youths that relapsed to heroin (N = 24) to endorse polysubstance use and cannabis, cocaine, or benzodiazepine use. Furthermore, heroin-abstinent youths significantly reduced their cannabis and cocaine use across the study period while youths that relapsed made initial reductions before returning to their pretreatment levels of use for these drugs. Clinical implications for heroin-using youths and areas for future research are discussed.     

Patterns of simultaneous polysubstance use in drug using university students

Simultaneous polysubstance use (SPU) is a common phenomenon, yet little is known about how various substances are used with one another. In the present study 149 drug-using university students completed structured interviews about their use of various substances. For each substance ever used, participants provided details about the type, order and amount of all substances co-administered during its most recent administration. Alcohol, tobacco and cannabis were frequently co-administered with each other and with all other substances. Chi-squared tests revealed that when alcohol was used in combination with any of cannabis, psilocybin, MDMA, cocaine, amphetamine, methylphenidate (ps < 0.01) or LSD (p < 0.05) its initial use preceded the administration of the other substance. Paired samples t-tests revealed that when alcohol was used with cocaine (p < 0.01) or methylphenidate (p < 0.05) it was ingested in greater quantities than when used in their absence. Patterns of cannabis use were not systematically related to other substances administered. Finally, using one-sample t-tests, tobacco use was demonstrated to be increased relative to 'sober' smoking rates when used with alcohol, cannabis, psilocybin, MDMA, cocaine, amphetamine (ps < 0.001), LSD (p < 0.01) or methylphenidate (p < 0.05). Results suggest that many substances are routinely used in a SPU context and that the pattern in which a substance is used may be related to other substances co-administered.     

Multiple drug use: patterns and practices of heroin and crack use in a population of opiate addicts in treatment

One hundred and sixteen opiate addicts attending treatment services in south London were interviewed about their drug use patterns. In the month before interview, 90% reported heroin use, while 60% had used crack cocaine and 58% alcohol. In the same period, 70% of participants reported multiple drug use, particularly concurrent heroin and crack cocaine use. Of the patients who reported using other drugs with heroin, two-third used crack cocaine, 11% diazepam, 9% methadone and 8% cocaine powder. Twenty-six per cent of crack users sample had injected crack cocaine, which provides confirmation of the increasing prevalence of this recent trend in studies using similar samples. Male participants were significantly more likely to use benzodiazepines with heroin, while women were more likely to use crack alongside heroin (and used larger quantities). These findings have implications for the treatment and management of multiple drug users, for whom opiates may be only a part of their drug-using repertoire.     

Non-fatal injuries and the use of psychoactive drugs among young adults in Spain

We compared the prevalence of injuries requiring medical treatment in the general population, in cocaine users and in heroin users, and we studied the factors associated with the occurrence of injuries in these groups, using data from two interview surveys carried out in 1993 in Spain: the National Health Interview Survey, a national representative sample of the non-institutionalized general population, and a survey of a non-probability sample of heroin or cocaine users selected from the community. The subjects included in the study were persons 16–40 years of age in urban areas: 4261 persons from the general population, 369 cocaine users and 215 heroin users. The annual prevalence of injuries requiring medical treatment was 7.9% in the general population, 10.8% in cocaine users and 35.2% in heroin users. There was a statistically significant positive association of injury occurrence (1) among the general population: with male sex, alcohol use, use of tranquillizers/sleeping pills, and the use of antidepressants or stimulants; (2) in cocaine users: with the use of opiates other than heroin; and (3) in heroin users: with alcohol use, the use of tranquillizers/sleeping pills, and the injected route. The only statistically significant negative association was with the amount of cocaine consumed among heroin users. The results suggest that other psychoactive substances besides alcohol are positively associated with injury occurrence, and that cocaine use may contribute to a reduced risk of injuries associated with the use of depressants (alcohol, tranquillizers, heroin).     

Sequence of onset of different drug use among opiate addicts

The temporal sequence of drug use should reveal which drugs are precursors to heroin and which drugs are used subsequent to the establishment of heroin addiction as adjunctive drugs. This temporal sequence was examined in an epidemiological study. Out of 249 opiate addicts interviewed in the area of Penang, Malaysia, this sequence of drugs could be obtained in 248 cases. The mean (median) age for first use of nicotine is 15.5 (15) years, alcohol 18.4 (18) years, cannabis 17.8 (17) years, heroin 21.8 (21) years, opium 22.8 (22) years, and benzodiazepines 25.8 (25) years. The age of first use of different drug types is presented in some detail. The patterns of sequence of drug use was analyzed for the five major and most frequently reported drugs, i.e. alcohol, cannabis, heroin, opium and benzodiazepines. Nicotine, used as first drug in almost all cases, was omitted in this analysis. A clear trend to multiple drug abuse emerges from this analysis; the biggest number of cases were users of 4 drugs (81 cases), followed by 3 drugs (59 cases) and 5 drugs (58 cases). Thus, nicotine, alcohol and cannabis are precursors of heroin addiction. Other adjunctive drugs become important only after heroin addiction. Among these substances, opium and benzodiazepines are numerically preponderant.     

The epidemiology of illicit drug use in Spain

On the basis of a review of the available information, this article summarizes the situation, patterns and trends in respect of the use of cannabis, heroin and other opiates, cocaine, amphetamines, hallucinogens and inhalants, as well as multiple drug use. The review clearly shows that since the early 1980s there has been an increasing trend in the use of drugs, particularly heroin and cannabis. Drug use predominantly affects young people. The use of two or more drugs simultaneously or successively, often involving alcohol, is reported as the most common pattern of drug use among youth. Drug use has become incorporated into the current youth culture, with all the individual, social and economic implications this engenders. The average age of users at first use of inhalants was 16.3 years, cannabis 17.5 years, hallucinogens 18.8 years, cocaine 20.6 years and amphetamines 23.5 years.     

Polysubstance use among alcoholics.

Contemporary alcoholics often use multiple substances, but there is little systematic research on this. This study examines the drug use comorbidity of alcoholics (DSM diagnosis, frequency and quantity of drug use); the relationship between drinking and drug use; the relative severity of alcohol- and drug-related problems; and the validity of reports of illicit drug use. Data on substance use were collected from 248 treatment-seeking alcoholics using an expanded Time-line Follow-Back (TLFB) interview. Self-reports of substance use were validated with data from biological specimens (urine and hair). Lifetime diagnosis of joint alcohol and drug dependence/abuse was 64%. Two-thirds (68%) reported using drugs in the past 90 days: 33% powder cocaine; 29% crack cocaine; 15% heroin, and 24% cannabis. The mean proportions of exposed days on which users reported consuming a substance were 57% (alcohol), 26% (powder cocaine), 46% (crack cocaine), 47% (heroin), and 29% (cannabis). Subjects reported consuming an average of 14 standard drinks on a drinking day and $67 worth of drugs on a using day. Drug users reported drinking less than nonusers on a drinking day. Frequency of drinking and drug use were positively correlated; almost all drug users reported simultaneous drinking and drug use; and they rated drugs as the bigger problem. Considerable under-reporting of drug use occurred for the previous 3-4 days, but was more accurate for the previous month.     

Characteristics of drug-related hospital separations in Australia

BACKGROUND: To examine (a) numbers of alcohol and drug-related hospital separations, 1999-2005; (b) demographics of these separations; (c) principal diagnoses co-occurring with drug-related problems; (d) length of hospital stay. METHODS: Data from the National Hospital Morbidity Database (NHMD) were analysed. Hospital separations where alcohol, opioids, amphetamine, cannabis, cocaine, other drugs (such as sedatives and hypnotics) and pharmaceutical poisoning were mentioned were examined. RESULTS: Numbers per million persons were highest for alcohol, followed by other drugs, particularly sedatives and hypnotics. Alcohol and opioid-related problems were prominent among older age groups, whereas cannabis and pharmaceutical poisoning problems had greater proportions among 15-24 year olds. Opioid-related separations were relatively high in number within the context of prevalence of use, and often accompanied by principal diagnoses of physical or general health problems. Almost half of amphetamine and cannabis-related separations were accompanied by principal diagnoses of mental health problems. CONCLUSIONS: This research highlights the complexities of drug-related hospital presentations, indicating the need for thorough assessment of physical and mental problems, as well as a drug use history at the time of admission. Continued development of integrated models of care, targeting both mental health and drug use are essential. Consistent with the international literature, many of these separations are preventable, particularly those for pharmaceutical poisoning. Finally, ongoing efforts to reduce the significantly greater harms related to opioid use, as well as increasing treatment opportunities for opioid-dependent people in Australia is an important public health priority.     

Prevalence of drug use in French seamen

The main objective of the present study is to determine the prevalence of lifetime use and use in the past 30 days of narcotics in French seamen and to assess factors correlated with positive urine test in seamen as a whole. A stratified survey conducted in 19 French ports collected 1,928 self-administered questionnaires on cigarette, alcohol and narcotics consumption. Seafarers were randomly selected and interviewed during their annual seafaring aptitude consultation. Only the 1847 male respondents were included in analysis. Nearly half of the seamen had tried cannabis at some point in their life, and 16% were users in the past 30 days. Lifetime use of certain other illegal drugs (cocaine, heroin, hallucinogenic mushrooms, poppers and ecstasy) was non-negligible, but cocaine and heroin were the only ones showing exceptional prevalence of consumption over the previous 30 days. Lifetime use of drugs was non-negligible among seamen. Prevalence of recent cannabis use was elevated. Recent consumption as indicated by positive urine test correlated with age group, family situation, occupational category, geographical area, young age of first alcohol consumption and experimentation with other drugs.     

Onset and pattern of substance use in intravenous drug users of an opiate maintenance program

OBJECTIVES: To assess the initiation of substance use of participants in an opiate maintenance program by a cross-sectional survey. METHOD: Participants (n=184) filled out a questionnaire assessing age at initial substance use and age at onset of regular drug use. RESULTS: Of 15 substances investigated, alcohol, nicotine, analgesics and marijuana were initiated and consumed regularly before the age of 18 years. Barbiturates, benzodiazepines, cocaine, and opiates were begun later. The time gap between initial and regular use varied depending on the substance. Regular use exceeded 50% for alcohol, benzodiazepines, cocaine, heroin, marijuana and nicotine. CONCLUSIONS: Specific knowledge about the age of onset and sequence of substances used by drug addicts may help to prevent substance use more age specifically.     

Adjunctive drug use among opiate addicts

In a study of 249 opiate (mainly heroin) addicts special attention was paid to adjunctive drug use. Generally, nicotine (cigarette smoking), alcohol and cannabis preceded the use of heroin, and continued to be used as adjunctive drugs after the establishment of heroin addiction. Nicotine was the most common substance used together with opiates. Alcohol and cannabis were used as adjunctive drugs in about two-thirds of the cases. In the late stages of heroin addiction, benzodiazepines were also used concomitantly with opiates. The most frequently reported reason for the use of adjunctive drugs was to intensify the effect of the opiate. Three-quarters or more of the addicts had used different adjunctive drugs to boost the euphoric feeling derived from the primary drug, i.e. heroin. Attempt at self-treatment of withdrawal symptoms was a less frequently reported reason for adjunctive drug use. The findings show that heroin addiction is the major problem. The use of adjunctive drugs, especially benzodiazepines, can be partly explained on economic grounds. They must be clearly distinguished from the primary drug of abuse, heroin. For policy-making decisions, it is important that the elimination of heroin abuse through effective prevention measures would ultimately wipe out the problem of adjunctive drug use, while reduction of the overall supply of heroin without reduction in actual demand might result in an increasing trend to adjunctive drug use.     

Cross-generational effects on gender differences in psychoactive drug abuse and dependence

BACKGROUND: Studies of patients with cocaine and heroin use disorders have shown gender differences in prevalence, course, and outcome. These differences may be decreasing in successive generations. Less is known about gender differences in course and symptomatology for other illicit drug use disorders, especially in community samples. METHOD: Participants (1323 men and 1384 women) who were biological or step-parents of twins and born in the 1940-1960s, from the Minnesota Twin-Family Study (MTFS) were divided into two cohorts based on the median birth year. A structured interview was used to assess DSM-III-R cannabis, amphetamine, cocaine and hallucinogen use disorders. RESULTS: There was a higher prevalence of each of these drug disorders and earlier onset of cannabis and amphetamine use disorders in later-born participants. For most drug use disorder categories, men and women were similar with respect to age of onset and severity of disorder but women had a shorter course of drug use disorders. Women with amphetamine disorders were atypical with respect to having a higher frequency of use but similar number of lifetime uses compared to men, and more emotional effects of amphetamine intoxication than men. In addition, women with amphetamine disorders were more likely to have anorexia nervosa than those without amphetamine disorders. CONCLUSIONS: These results have several implications for prevention, etiology and treatment.     

A review of drug use and driving: epidemiology, impairment, risk factors and risk perceptions

The existing literature on the prevalence of drug driving, the effects of drugs on driving performance, risk factors and risk perceptions associated with drug driving was reviewed. The 12-month prevalence of drug driving among the general population is approximately 4%. Drugs are detected commonly among those involved in motor vehicle accidents, with studies reporting up to 25% of accident-involved drivers positive for drugs. Cannabis is generally the most common drug detected in accident-involved drivers, followed by benzodiazepines, cocaine, amphetamines and opioids. Polydrug use is common among accident-involved drivers. Studies of impairment indicate an undeniable association between alcohol and driving impairment. There is also evidence that cannabis and benzodiazepines increase accident risk. The most equivocal evidence surrounds opioids and stimulants. It is apparent that drugs in combination with alcohol, and multiple drugs, present an even greater risk. Demographically, young males are over-represented among drug drivers. Although there is an association between alcohol use problems and drink driving, it is unclear whether such an association exists between drug use problems and drug driving. Evidence surrounding psychosocial factors and driving behaviour is also equivocal at this stage. While most drivers perceive drug driving to be dangerous and unacceptable, there is less concern about impaired driving among drug drivers and drink drivers than from those who have not engaged in impaired driving. Risk perceptions differ according to drug type, with certain drugs (e.g. cannabis) seen as producing less impairment than others (e.g. alcohol). It is concluded that drug driving is a significant problem, both in terms of a general public health issue and as a specific concern for drug users. [Kelly E, Darke S, Ross J. A review of drug use and driving: epidemiology, impairment, risk factors and risk perceptions. Drug Alcohol Rev 2004;23:319-344]     

Validity of self-reports and drug use among young people seeking treatment for substance abuse or dependence

The present study assessed drug use and the validity of self-reports of drug use among young people seeking treatment. On admission the participants (n = 316), 215 males and 101 females, were interviewed about their drug use. Urine samples were collected to screen for alcohol, amphetamine, benzodiazepines, cannabis, cocaine, methylenedioxymethamphetamine (MDMA) and opiate use. Self-reports of substance use were compared with urinalysis results. Seventy-three percent of the participants reported use of two or more substances. Single substance users were primarily alcohol users. Kappa agreement between self-report and urinalysis results was of acceptable concordance (> or = 0.65) except for alcohol (kappa = 0.19). Conditional kappa values were good (> or = 0.85) with exception of opiates (cond. kappa = 0.57). The self-reports were generally reliable among young people seeking treatment. No significant differences (p > or = 0.54) were found in the validity of self-reports between the genders.     

Substance use initiation: The role of simultaneous polysubstance use

Introduction and Aims. Simultaneous polysubstance use (SPU) is a common phenomenon, yet little is known about its role in substance use initiation. Design and Methods. In the present study, 226 cannabis users completed structured interviews about their substance use history. For each substance ever used, participants provided details of their age of first use, their use in the preceding 30 days and whether they co‐administered any other licit or illicit substances the first time they used the substance. Results. For most illicit substances [powder cocaine, crack, amphetamine, methamphetamine, 3,4‐methylenedioxymethamphetamine (MDMA; ecstasy), heroin, opium, gamma‐hydroxybutyric acid (GHB), ketamine, psilocybin (magic mushrooms), mescaline, phencyclidine (PCP), peyote and inhalants], results showed that a clear majority of participants (≥75%) reported SPU during their first‐ever use of the substance. While SPU was less common on occasions of first use of alcohol, tobacco and cannabis, a high proportion of SPU on occasions of first use of ‘harder’ drugs could be accounted for by the co‐use of alcohol, tobacco and/or cannabis. Discussion and Conclusions. Such findings raise the possibility that specific alcohol, tobacco and/or cannabis use episodes might directly contribute to the initiation of new substance use. Understanding the role of SPU on occasions of first use might help better identify risk factors for substance use progression and improve intervention efforts.[Olthuis JV, Darredeau C, Barrett SP. Substance use initiation: The role of simultaneous polysubstance use. Drug Alcohol Rev 2013;32:67–71]     

Differences in the acceptability of non-abstinence goals by type of drug among American substance abuse clinicians

To assess whether acceptability of non-abstinence outcome goals varied depending on the specific drug a client consumes (alcohol, cannabis, amphetamine, heroin, cocaine, MDMA/ecstasy, polydrug), severity of diagnosis (DSM-IV Abuse vs. Dependence), and finality of outcome goal (intermediate vs. final), we recruited 432 clinicians to complete a web-based questionnaire. More respondents rated non-abstinence acceptable as an intermediate goal for clients diagnosed with alcohol abuse (44%) or cannabis abuse (43%) than for clients diagnosed as abusing the other listed drugs (23 to 31%). Similarly, larger proportions of respondents rated non-abstinence as acceptable as a final goal for clients diagnosed with alcohol abuse (30%) or cannabis abuse (24%) than for clients diagnosed as abusing the other drugs (11 to 13%). Only 9 to 13% of respondents rated non-abstinence as an acceptable final goal for clients diagnosed with dependence, but 20% to 30% rated non-abstinence as acceptable as an intermediate goal for clients diagnosed as dependent.