Exploring child maltreatment and its relationship to alcohol and cannabis use in selected Latin American and Caribbean countries.

OBJECTIVES: Research from developed countries shows that child maltreatment increases the risk for substance use and problems. However, little evidence on this relationship is available from developing countries, and recognition of this relationship may have important implications for substance demand reduction strategies, including efforts to prevent and treat substance use and related problems. Latin America and the Caribbean is a rich and diverse region of the world with a large range of social and cultural influences. A working group constituted by the Inter-American Drug Abuse Control Commission and the Center for Addiction and Mental Health in June, 2010 identified research on this relationship as a priority area for a multinational research partnership. METHODS: This paper examines the association between self-reported child maltreatment and use in the past 12 months of alcohol and cannabis in 2294 university students in seven participating universities in six participating countries: Colombia, El Salvador, Jamaica, Nicaragua, Panama and Uruguay. The research also considers the possible impact of religiosity and minimal psychological distress as factors contributing to resiliency in these samples. RESULTS: The results showed that experience of maltreatment was associated with increased use of alcohol and cannabis. However, the effects differed depending on the type of maltreatment experienced. Higher levels of religiosity were consistently associated with lower levels of alcohol and cannabis use, but we found no evidence of an impact of minimal psychological distress on these measures. CONCLUSIONS: This preliminary study shows that the experience of maltreatment may increase the risk of alcohol and cannabis use among university students in Latin American and Caribbean countries, but that higher levels of religiosity may reduce that risk. More work to determine the nature and significance of these relationships is needed.

Cannabis dependence as a primary drug use-related problem: the case for harm reduction-oriented treatment options.

Few studies have focused on cannabis dependence as compared to other drugs more commonly acknowledged as presenting a substantial need for treatment. This paper presents findings from a 2004-2005 study of drug user treatment clients in Southern Ontario, Canada. Clients with cannabis (n = 128) or cocaine (n = 300) as their primary drug problem were compared on psychosocial and demographic characteristics, drug effects, and clinical impairment. There are more similarities than differences between groups, with DAST and DSM scores showing high rates of "dependence" and reported symptoms of "abuse." However, cannabis consistently scored lower on these items, supporting the idea of a continuum of risk on which its rank compared with other potentially misused drugs holds across a wide range of symptoms of impairment. The less disruptive nature of cannabis use-related problems poses greater challenges for drug user treatment providers guided by strict abstinence agendas. The authors call for the expansion of harm reduction treatment options and educational initiatives beyond primary prevention that acknowledge benefits of moderate controlled use when addressing cannabis misuse.

Storying the street: transition narratives of homeless youth.

Toronto Youth Street Stories is an innovative, web-based storytelling project that was conducted with homeless youths in Toronto. As a collaborative knowledge dissemination initiative, the project engaged youthful participants, authors, community mentors, youth service agencies and university-based researchers. Over 50 youths were encouraged to express their personal perspectives through author-led, creative writing workshops, resulting in youth-created stories, poems and pictures about a wide array of feelings and experiences. Across the dozens of pieces of writing, there is evidence of a chronology of street life, or an "arc of experience", that ranges from living with abuse and despair, leaving home, living on the street, experiencing a crisis or turning point, accessing services and gradually moving away from street life toward self-sustaining independence and security. This arc of experience includes the stories of youth who have transitioned away from the street as well as those still facing homelessness. This paper describes this arc of experience and illustrates it with the subjective material generated by the youths' stories about their lives on the streets of Toronto. We conclude that this project provided an important, creative outlet for the youths, and increased understanding of the challenges, stigma and resilience of homeless youth.

The drugs-violence nexus among American and Canadian youth.

This paper examines the relationship between drug use and violence among representative samples of students in the United States and Ontario, Canada. Canada has significantly lower levels of violent crime than the United States, but students report similar rates of drug use. Using logistic regression analysis, we find a similar relationship between drug use and violence among adolescents in the two countries. All the drugs considered--cannabis, cocaine, and alcohol binge drinking--are significantly related to violent behavior; whether the perpetrator or the victim. The most noteworthy difference may be that in Ontario, drug use appears to be even more highly correlated with violence than in the United States.

Introduction: the three phases of harm reduction. An examination of emerging concepts, methodologies, and critiques.

The prevention and reduction of harm related to the use and distribution of psychoactive substances has gone through three stages in the last 35 years of this century. The first saw the articulation of public health concerns for the legal drugs, alcohol and tobacco, and the provision of methadone to heroin users. The second phase, building on the public health lessons of other infectious diseases, focused on illicit drugs and the importance of specific strategies for the prevention of HIV transmission among injection drug users. The third, emerging phase is the shift toward an integrated public health perspective in the convergence of approaches to both licit and illicit drugs. The success of harm reduction as a unifying concept will depend on its innovative application in both prohibitory and regulatory frameworks, and careful evaluation of its effectiveness in a variety of cultural contexts. The papers in this special issue illustrate the types of research and critical thinking that are essential for the continued evolution of the harm-reduction paradigm.

Frequent medical visits by cocaine-using subjects in a Canadian community: an invisible problem for health practitioners?

The purpose of this study was to examine the frequency of medical visits by cocaine-using subjects in a Canadian community. A sample of 100 subjects reporting cocaine use at least 10 times in the previous 12 months were recruited in an urban setting in Canada and interviewed in a structured manner to address aspects of their use of cocaine and their responses to those agents. The respondents reported a total of 488 medical visits in the 12 months prior to interview. The frequency of visits correlated with the use of cocaine, barbiturates, hallucinogens, narcotics, and amphetamines. Medical visits also varied with the frequency with which the subjects reported certain adverse reactions to cocaine. Logistic regression modeling was used to assign subjects into a higher medical contact group (three or more medical visits per 12 months) and a lower medical contact group (two or fewer medical visits per 12 months). Membership in the higher or lower contact group was differentiated by a simple model in which the classifying variables were whether or not the subjects reported using crack cocaine in the previous year, whether or not they reported using hallucinogens in the previous year, and whether or not they reported experiencing aggressive reactions with the use of cocaine. Thus, users of cocaine report frequent visits to physicians. Medical visits are more likely if they also used crack cocaine, if they experienced aggressive reactions to cocaine, and if other substances were also used. Recognition of this behavior may facilitate earlier intervention by primary care physicians.

Harm reduction: what it is and is not.

The meaning of the term "harm reduction" has changed over the decades of its existence but it is now increasingly being aligned with public health approaches. An agreed meaning for the term would be helpful and should be sought. Antecedents are easy to find. Emphasis on small achievable steps is an important element; neither inherently supportive of prohibition nor of legalization, harm reduction is essentially pragmatic and tends to favour regulatory approaches. HIV has focused attention on harm reduction but even in the illicit drug field, a strong tradition of research and policy with an identical philosophical framework can be traced back well before the AIDS era. Harm reduction primary prevention educational approaches are more open, honest and respectful of responsible decision making processes. With current illicit drug users, harm reduction emphasizes the need to understand existing individual control mechanisms. The concept can be well understood if contrasted with prevailing approaches to drugs which generally emphasize punishment, lack of regulation and often augment harm.

The law, social control, and drug policy: models, factors, and processes.

The law is governmental social control; it is the state's most direct intervention in the normative life of its citizens. Psychoactive drugs are controlled through regulation and prohibition, depending on the legal status of the particular substance. Licit drugs are made available through a regulatory scheme of medical prescription and legal sale; health is protected through investigating, licensing, and monitoring the quality and quantity of drugs and the circumstances in which they are consumed. Illicit drugs are forbidden by criminal statutes which create offenses related to both use (i.e., possession) and distribution (i.e., trafficking, importing); no level of use is acceptable and there is no legal source of supply. The agents of control for licit drugs are physicians, scientists, and health bureaucrats. In contrast, the agents that enforce illicit drug laws are the police, prosecutors, courts, and customs officials. The general preventive effect of the criminal law is activated through the threat of punishment and the setting of educative and moral standards of permitted behavior. The acceptability of drug-use behavior has varied widely across time, culture, and substance. What have we learned about the legal control of psychoactive substances? It is evident that a state may become increasingly overdependent on the law and neglect other alternatives of social control that may sometimes be more effective or less costly in reducing the possible harmful effects of drug use. The law is a powerful but also blunt instrument of social control.

Future research needs in policy, prevention, and treatment for drug abuse problems.

This paper outlines major research issues for the areas of illicit drug use. Research questions are posed for the following areas: (1) epidemiology and etiology; (2) social policy development; (3) prevention; and (4) treatment.

Past, current, and future directions in Canadian drug policy.

Canada's earliest drug laws were directed at the opiates and cocaine. More recent concerns have been with cannabis, other hallucinogens, and the reemergence of cocaine, especially in the form of crack. Renewed enforcement efforts, combined with the redirection of priorities toward demand reduction via educational intervention, have been the hallmarks of recent Canadian drug policy initiatives. Some implications of these strategies for the future definition of the boundaries of Canada's drug problems, and likely policy directions, are discussed.

Living with prohibition: regular cannabis users, legal sanctions, and informal controls.

Adult cannabis users have received much less attention from researchers than their youthful counterparts. Yet significant proportions of adults persist in cannabis use, disregard drug laws, and fulfill otherwise conventional adult roles. This paper addresses the questions of how older, regular users learn to live with these apparent contradictions, how they are influenced by legal sanctions and informal controls, and why they have not (as prophesied in the early 1970s) become an active force for drug law reform.

Sex differences in cocaine use and experiences: a double standard revived?

Women's use of prescription medication exceeds that of men's and yet is not viewed with the alarm and disapproval that accompanies women's lower levels of use of alcohol and illicit drugs. Reports in the media, based on anecdotal accounts, have identified women as a group at particular risk for cocaine addiction and have suggested that their problems with cocaine are greater than men's. After reviewing the scientific literature and analyzing the results of an original research study, this paper argues that there is no evidence that women's cocaine use exceeds that of men's, that women's rates of use are growing faster than men's, or that female cocaine users experience more problems than male cocaine users. Since the deviant image of the female cocaine user is a social construction lacking a factual basis, we conclude that a different standard is being applied to women who use cocaine than to men who use cocaine.

Illicit drug use, peer attitudes, and perceptions of harmful effects among convicted cannabis offenders.

A sample of criminalized cannabis users provided information about their use of other illicit drugs and friends' attitudes toward various substances. The majority of those surveyed were regular, heavy users of cannabis, had friends who were similarly involved, and were more experienced with a variety of other illicit drugs than youthful groups from the larger population. In its perception of harmful effects of various substances, the offender sample held fairly conventional, high-risk views on opiates and amphetamines. Opinion was more divided over the psychedelics and cocaine. Cannabis was considered least harmful of all the other illicit drugs and alcohol. Those convicted of the offense of cannabis possession displayed the knowledgeable insider's perspective of a hierarchy of dangerousness for drugs that is at variance with their largely undifferentiated legal status.