A randomized controlled trial of brief cognitive-behavioral interventions for cannabis use disorder.

The increasing demand for treatment for cannabis dependence in Australia and internationally has led to the identification of significant gaps in knowledge of effective interventions. A randomized controlled trial of brief cognitive-behavioral interventions (CBT) for cannabis dependence was undertaken to address this issue. A total of 229 participants were assessed and randomly assigned to either a six-session CBT program (6CBT), a single-session CBT intervention (1CBT), or a delayed-treatment control (DTC) group. Participants were assisted in acquiring skills to promote cannabis cessation and maintenance of abstinence. Participants were followed-up a median of 237 days after last attendance. Participants in the treatment groups reported better treatment outcomes than the DTC group. They were more likely to report abstinence, were significantly less concerned about their control over cannabis use, and reported significantly fewer cannabis-related problems than those in the DTC group. Those in the 6CBT group also reported more significantly reduced levels of cannabis consumption than the DTC group. While the therapist variable had no effect on any outcome, a secondary analysis of the 6CBT and 1CBT groups showed that treatment compliance was significantly associated with decreased dependence and cannabis-related problems. This study supports the attractiveness and effectiveness of individual CBT interventions for cannabis use disorders and the need for multisite replication trials.

Cannabis use and dependence among Australian adults: results from the National Survey of Mental Health and Wellbeing.

AIMS: To examine: (i) the prevalence of cannabis use and DSM-IV cannabis dependence among Australian adults, and (ii) correlates of level of cannabis involvement. DESIGN: Cross-sectional survey assessing substance use and DSM-IV substance use disorders (abuse and dependence). Setting and participants. A household survey of a nationally representative sample of 10 641 Australians aged 18 years and older. MEASUREMENTS: Trained interviewers administered a structured, modified version of the Composite International Diagnostic Interview (CIDI). FINDINGS: In the past 12 months, 2.2% (95%CI:1.8, 2.6) of adults were diagnosed with DSM-IV cannabis use disorder, comprising cannabis dependence (1.5%; 95%CI: 1.2, 1.8) and cannabis abuse (0.7%, 95%CI: 0.6, 0.8). Almost one-third of cannabis users (31.7%; 95%CI: 27.7, 35.7) met criteria for cannabis dependence (21%; 95%CI: 16.7, 25.3) and abuse (10.7%; 95%CI: 8.0, 13.4). Multinomial logistic regression revealed that compared to non-dependent cannabis users, non-users were more likely to be female, aged 25 + years, out of the labour force and married/de facto, and displayed lower levels of co-morbidity. In contrast, dependent cannabis users were more likely to be 18-24 years old, unemployed, and displayed higher levels of co-morbidity than non-dependent users. CONCLUSIONS: Cannabis use disorders affect approximately 300 000 Australian adults. A better understanding of the factors associated with cannabis dependence may help identify groups who have difficulties controlling use and aid the development of strategies for reducing cannabis-related harm.

Characteristics of DSM-IV and ICD-10 cannabis dependence among Australian adults: results from the National Survey of Mental Health and Wellbeing.

A representative sample (n = 10641) of Australian adults completed a structured diagnostic interview assessing the prevalence of mental and substance use disorders in the last year. The prevalence of DSM-IV (1.5%) and ICD-10 (1.7%) cannabis dependence was similar. DSM-IV and ICD-10 dependence criteria comprised unidimensional syndromes. The most common symptoms among dependent and non-dependent users were difficulties with controlling use and withdrawal, although there were marked differences in symptom prevalence. Dependent users reported a median of four symptoms. There was good to excellent diagnostic concordance (kappas = 0.7-0.9) between systems for dependence but not for abuse/harmful use (Y = 0.4). These findings provide some support for the validity of cannabis dependence.

Clinical profile of participants in a brief intervention program for cannabis use disorder.

The increasing demand for cannabis dependence treatment has led to the identification of significant gaps in the knowledge of effective interventions. A randomized controlled trial of brief cognitive-behavioral interventions (CBT) for cannabis dependence was undertaken to address this issue. A total of 229 participants were assessed and allocated to either a 6-session CBT program, a single-session brief intervention, or a delayed-treatment control group. This paper demonstrates that individuals with cannabis use disorder will present for a brief intervention program. While they report similar patterns of cannabis use to nontreatment samples, they report a range of serious health and psychosocial consequences. While they appear relatively socially stable, they typically demonstrated severe cannabis dependence and significantly elevated levels of psychological distress, with the most commonly cited reason for cannabis use being stress relief. There were clinically relevant gender differences among the sample. This study provides more evidence of the demand for, and nature of issues relevant to, interventions for cannabis use disorders, and supports the need for further research into how best to assist individuals with these disorders.

The THC content of cannabis in Australia: evidence and implications.

OBJECTIVE: To examine evidence on three claims that: 1) the THC content of Australian cannabis plants has increased up to 30 times; 2) problems experienced by cannabis users have increased in Australia in recent years; and 3) an increase in THC content is the most likely explanation of any increase in cannabis-related problems. METHODS: These claims were assessed by examining data: 1) on THC potency in Australia, the United States and New Zealand; 2) on cannabis-related problems; and 3) from the 1998 National Drug Strategy Household Survey on patterns of cannabis use. RESULTS: 1) Published data do not show a 30-fold increase in THC potency of cannabis but show a more modest increase in the US. 2) There is suggestive evidence of an increase in cannabis-related problems among people seeking treatment for alcohol and drug problems, juvenile offenders and young adults with psychosis. 3) There are two other more plausible explanations for these reportedly higher rates of cannabis-related problems among adolescents and young adults: (i) more potent forms of cannabis ('heads') are more widely used; and (ii) cannabis users are initiating cannabis at an earlier age, thereby increasing the prevalence of harmful patterns of use. CONCLUSIONS: There has probably been a modest increase in the THC content of cannabis, but changing patterns of cannabis use have probably made a larger contribution to any increase in rates of cannabis-related problems among young Australian adults. IMPLICATIONS: Better data on the THC content of cannabis, the extent of cannabis-related problems and the ability of users to titrate the dose of cannabis would contribute to more informed debate.

One year follow-up of cannabis dependence among long-term users in Sydney, Australia.

Eighty one percent of a sample of long-term cannabis users was followed up at 1 year (162/200). Half (51%) were daily smokers, while 20% had substantially decreased or ceased use. More than half received a dependence diagnosis on each of three measures in the last year, with 44% dependent on all three. Remission was much more common than incidence of dependence. Nevertheless, use and dependence patterns were strongly related over time. Longitudinal analyses revealed that quantity of use and severity of dependence at baseline were the primary predictors of those same variables at follow-up. These data suggest that cannabis use and dependence are fairly stable among long-term users.

Transitions between routes of heroin administration: a study of Caucasian and Indochinese heroin users in south-western Sydney, Australia.

AIM: To examine patterns and correlates of routes of heroin use among Caucasian and Indochinese heroin users. DESIGN: A cross-sectional survey. SETTING AND PARTICIPANTS: Two hundred heroin users resident in South West Sydney. The sample was divided between Caucasian and Indochinese users (each n = 100), with half of each group on methadone maintenance. MEASUREMENTS: A semi-structured interview was administered, based on previous studies of transitions between routes of administration. Measures included patterns of drug use, transitions, social, health and legal issues and cultural correlates of use. FINDINGS: Almost two-thirds (61%) had smoked heroin. Smoking was more common among the Indochinese (40% were predominantly or exclusively smokers), although injecting was the dominant route for both groups. More than one-quarter (29%) had made a transition from smoking to injecting, primarily due to drug effect and perceived cost-effectiveness. Reverse transitions were rare. Smoking appeared to be more culturally acceptable than injecting among Indochinese users. Among both groups, there was a small but significant risk for the transmission of HIV and other blood-borne viruses. Polydrug use and age were positively associated with having experienced a non-fatal overdose. CONCLUSIONS: This research documents the existence of smoking as a popular route of administration among both Indochinese and Caucasian heroin users in the study sample. There is an urgent need to provide smokers and injectors with information explaining the potential risks and ways to minimize harms associated with both routes of use.

Characteristics of long-term cannabis users in Sydney, Australia.

Two hundred long-term cannabis users (58% male) were interviewed on their characteristics and experience of use. Respondents had been regularly using cannabis for an average of 11 years and more than half used daily (56%). The most common route of administration was in a waterpipe, and nearly all (93%) smoked the flowering heads ot the plant. One in 5 (21%) had a cannabis-related conviction. The benefits of use were perceived to be its relaxing, mood-enhancing effects, and its ability to alter consciousness. The most commonly cited negative aspects of use were cost, negative psychological effects and legal status. Polydrug use was common, with alcohol and tobacco almost universally used on a regular basis. More than half the drinkers in the sample were consuming alcohol at hazardous or harmful levels.

Patterns and correlates of cannabis dependence among long-term users in an Australian rural area.

AIM: To examine prevalence and correlates of cannabis dependence among long-term cannabis users. DESIGN: A cross-sectional survey of patterns and experiences of cannabis use and dependence. SETTING AND PARTICIPANTS: A snowball sample of 243 long-term cannabis smokers, who were currently smoking 3-4 times a week, were recruited from the New South Wales North Coast, an area long associated with cannabis cultivation and use. MEASUREMENTS: A structured interview was administered, incorporating the following dependence measures: an approximation to a life-time DSM-III-R diagnosis, an approximation to a 12-month ICD-10 diagnosis, and the Severity of Dependence Scale (SDS). FINDINGS: Prevalence of a life-time DSM-III-R diagnosis of cannabis dependence was 57%, while 57% received an ICD-10 dependence diagnosis for the last year. Substantially fewer (15%) of the sample were diagnosed as dependent according to the Severity of Dependence Scale (SDS). Only 26% believed they had a problem with cannabis at least sometimes. There was general concordance between DSM-III-R and ICD-10 measures, but not between these and the SDS. ICD-10 and DSM-III-R dependence diagnoses were modestly correlated with age, life-time illicit drug use and quantity of cannabis use. Principal components analyses of the dependence measures provided little evidence for a unidimensional dependence syndrome for ICD-10 and DSM-III-R criteria. There was strong support for unidimensionality of the SDS. CONCLUSIONS: Symptoms of cannabis dependence were common among these long-term users but only one-quarter perceived that they had a cannabis problem. There was no strong evidence for a unidimensional cannabis dependence syndrome.

Long-term cannabis use: characteristics of users in an Australian rural area.

AIM: To investigate the characteristics and patterns of cannabis and other drug use among long-term cannabis users in an Australian rural area. DESIGN: Cross-sectional survey of a "snowball" sample of long-term cannabis users. SETTING: The North Coast of New South Wales is an area with high levels of cannabis cultivation and use, and many long-term users. PARTICIPANTS: The study involved 268 long-term cannabis users who had regularly used cannabis for at least 10 years. MEASUREMENTS: A structured interview schedule obtained information on: demographics, social circumstances, patterns of cannabis and other drug use, contexts of use, perceptions about cannabis and legal involvement. FINDINGS: The mean age of the sample was 36 years and 59% were made. The median length of regular cannabis use was 19 years. Most (94%) used two or more times a week and 60% used daily, with a median of two joints per day. Two-thirds (67%) used cannabis in social settings and two-thirds grew cannabis for their own use. The most common reasons for using cannabis were for relaxation or relief of tension (61%) and enjoyment or to feel good (27%). The most commonly reported negative effects were feelings of anxiety, paranoia, or depression (21%), tiredness, lack of motivation and low energy (21%) and effects of smoke on the respiratory system (18%). The majority drank alcohol (79%) and over one-third were drinking at hazardous levels. Most were current (64%) or ex-tobacco smokers (24%). One-quarter (25%) had been charged with possession of cannabis, 11% for cultivation and 6% for supply, with non-drug offences low (8%or less). Overall, three-quarters (72%) believed that the benefits of cannabis use outweighed the risks, 21% felt there was an even balance, and 7% said cannabis had done them more harm than good. CONCLUSIONS: Among long-term cannabis users in this Australian rural area, cannabis use was an integral part of everyday life and it was primarily used in social situations for the same reasons that alcohol use is used in the wider community.

Choosing a diagnostic cut-off for cannabis dependence.

AIM: While cannabis dependence has been increasingly recognized, there is little research on the measurement issues involved in operationalizing the dependence syndrome for this drug. This paper aimed to investigate the diagnostic utility and appropriate diagnostic cut-offs of three short dependence measures among long-term cannabis users. SETTING AND PARTICIPANTS: Two hundred long-term, regular cannabis users were recruited and interviewed in Sydney, Australia. MEASUREMENTS: Receiver Operating Characteristic analyses compared the diagnostic performance of the short University of Michigan CIDI, a measure of ICD-10 dependence and the Severity of Dependence Scale against the "gold standard" of moderate or more severe DSM-III-R cannabis dependence, as diagnosed by the Substance Abuse Module of the CIDI. FINDINGS: The measures were of equal utility in diagnosing at least moderate DSM-III-R cannabis dependence. While the optimal diagnostic cut-offs for the short University of Michigan CIDI and the ICD-10 dependence measure remained unchanged from those conventionally applied, a more liberal cut-off was optimal for the Severity of Dependence Scale. The amended prevalence of cannabis dependence was 77% using the short University of Michigan CIDI, 72% by the ICD-10 measure and 62% by the Severity of Dependence Scale. CONCLUSIONS: The three instruments were able to diagnose cannabis dependence at levels substantially better than chance. They were generally robust in terms of the optimal diagnostic cut-off in a population of long-term cannabis users. This paper provides guidelines for choosing optimal cut-offs within different contexts.

Treatment needs of women with alcohol and other drug problems: experiences and views of Australian treatment personnel.

One hundred treatment personnel completed a structured interview as part of an Australian national study of the treatment needs of women with alcohol and other drug problems. The aim of the survey was to ascertain personnel's experiences of, and beliefs about providing services to women. Respondents had a broad range of qualifications and experience, and were generally supportive of provision of gender-sensitive services to women. The interview addressed a number of issues, including: barriers to treatment access, ability to provide gender-sensitive services, appropriateness of women-only services, and addressing sexual abuse issues. It is concluded that while many agencies attempted to provide appropriate services for women, many experienced difficulties, such as a lack of resources and funding. There is a continuing need for research into the best method of service delivery for women.

Characteristics of women with alcohol and other drug problems: findings of an Australian national survey.

Two hundred and sixty-seven women were interviewed in a national survey examining the characteristics, treatment needs and treatment experiences of Australian women who had received treatment for their alcohol and other drug problems. More than half the women were mothers, of whom almost one-third had surrendered custody of their children. Polydrug use was the norm among these women, who in general had substantial experience with the legal system. A sizeable proportion of women had experienced physical and psychological health problems such as hepatitis, eating disorders, self-mutilation, suicide attempts and low self-esteem. The majority of the sample had a life-time history of physical or sexual violence. The implications of these findings are discussed and recommendations are provided for attracting and retaining women in appropriate services.

Treatment needs and experiences of Australian women with alcohol and other drug problems.

Two hundred and sixty-seven women were interviewed as part of a national survey examining the treatment needs and experiences of Australian women who had received assistance for their alcohol and other drug problems. The majority of women had previously received assistance for their substance use, and of these most had left alcohol and other drug treatment programs before completion. While the women cited a number of ways in which they were helped by such services, several areas were identified by the women as important and amenable to improvement. Among the service issues raised were access, models of service delivery, service structure and staffing, physical environment, physical and psychological safety and the handling of issues such as health status and sexual assault.

Five-year outcome from eating disorders: relevance of personality disorders.

In order to assess the relationship of personality disorder and eating disorder outcome 30 eating disordered patients were followed up 4-5 years after taking part in a study examining the prevalence of personality disorders in eating disordered individuals. Subjects with personality disorders did not differ from those without personality disorders in the amount of symptomatic change over time, although their psychopathology generally remained more severe. The relationship of personality disorder and clinical outcome ratings varied depending on the personality measure. SCID-II personality disorder diagnoses were not significantly associated with outcome ratings, but were related to a greater likelihood to be hospitalized and treated with psychotropic medications. Results with a new personality measure, the Wisconsin Personality Inventory, did display an association between personality disturbance and eating disorder outcome ratings and also suggested that borderline personality was a significant predictor of outcome.

Predictors of injecting and injecting risk-taking behaviour among methadone-maintenance clients.

A sample of 222 methadone maintenance clients were interviewed regarding current injecting and needle risk-taking in order to ascertain factors associated with these behaviours. Just over half (55%) of subjects had injected in the month preceding interview. Current injecting was associated with being female, having a regular sexual partner who was a current injecting drug user, polydrug use and higher levels of global psychopathology. Approximately 15% of subjects had shared needles in the month preceding interview, predominantly with one other person. Needle sharing was associated with having a regular sexual partner who was a current injecting drug user, current criminality and injecting at places other than home. Needle-sharing episodes in the study period were considered safe by practically all sharers. The implications of these findings are discussed.

Prevalence, symptoms and correlates of antisocial personality disorder among methadone maintenance clients.

A sample of 222 methadone maintenance (MM) clients were tested for a diagnosis of antisocial personality disorder (ASPD). The majority (60.8%) of clients qualified for a lifetime diagnosis of ASPD, 25.7% received a current diagnosis of ASPD, and a conduct disorder of childhood was diagnosed for 68.5% of subjects. The most common symptoms of ASPD among MM clients were unlawful behaviours, aggressiveness and recklessness. Lack of remorse was reported by less than a third of subjects with a lifetime diagnosis of ASPD. Subjects with a current diagnosis of ASPD had been retained in treatment as long as other clients, and were no more likely to be currently injecting or sharing injecting equipment. It is concluded that clients with ASPD can be retained in MM treatment, and can respond to MM treatment as well as other clients.