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Problem cannabis use: what is it and

how to assess it?

François Beck
National Institute for Prevention and Health
Education (INPES).
Laboratory “Psychotrops, Mental Health and Society”
(CESAMES), National Scientific Research Center (CNRS) and
National Institute of Health and Medical Research (INSERM)
Plan

• Why measuring
problem cannabis use?

• What do we need to
measure?

• how to measure
Problem cannabis use?
Cannabis lifetime prevalence at age 16
European comparisons : 1995

1995
Source : ESPAD 1995, CAN

Expérimentation de cannabis 1995


(en %)

1-10 (13)
11-20 (6)
21-30 (1)
31-40 (2)
nc (23)
Cannabis lifetime prevalence at age 16
European comparisons : 1995 and 1999

1995 1999
Sources : ESPAD 1995 et 1999, CAN

Expérimentation de cannabis 1995 Expérimentation de cannabis 1999


(en %) (en %)
1-10 (13)
1-10 (5)
11-20 (6)
11-20 (10)
21-30 (1)
21-30 (4)
31-40 (2)
31-40 (4)
nc (23)
NC (22)
European trends in cannabis last year prevalence
among 15-34 years old
Increasing treatment demand for cannabis:
Percent of new clients admitted to treatment for cannnabis as main drug in
since the late 90’s in France (velvet)
Répartition des patients suivant le produit n°1 à l'origine de la prise en charge
ou posant le plus de problèmes (en % )

100%

Autres
90%

Méthadone.,
80%
BHD

70% Méd
psychotropes

60% Amphét.,
41,4% 37,9%
43,1% ecstasy
48,2% 47,1% 47,4%
50% 54,6%
Cocaïne et
crack
40%
Opiacés

30%
28,5% Cannabis
25,0% 29,3%
20%
19,6% 21,8% 20,6%
16,1% Alcool
10%
7,9% 9,1% 8,3% 10,8%
6,1% 7,4% 6,8%
0%
1998 1999 2000 2001 2002 2003 2004
Rapports d'activité des CSST, DGS/OFDT
Concepts

• Problematic cannabis use general definition:


– use leading to negative consequences on a social or health
level, both for the individual user and the larger community
• Several standardised grids (DSM4, ICD10) for
several concepts :
– Abuse (DSM4)
– Harmful use (ICD10)
– Physiological dependence (tolerance and withdrawal)
– Psychological dependence
Concepts and their adaptation

• Measuring problematic cannabis use requires:


– Setting criteria to define cannabis problem use
– Developing questions that can be used to diagnose whether
a respondent conforms to these criteria
– Designing a questionnaire that adequately reflects the
criteria defining problematic use,
– Ensuring that responses are accurate, valid and actionable
– Measuring the quality of the screening test:
• comparing the screening test with the reference test
• assessing the quality of the screening test in a clinical situation
where a practitioner’s diagnosis can be compared with the result of
the test
From concepts to screening tests: difficulties and
criticism

• Some criteria have been criticised, for example:


– Criterion 7 of the DSM-IV: Continued using cannabis despite knowing
it caused significant problems
– Spending a great deal of time around the substance might, for instance,
be confounded by the level of legality of the drug
– Feeling of guilt after using cannabis can also be confounded by the
illegality of the drug
• Assessement instruments used in general population surveys
may not reach a part of illegal drug users. Even if this is less
true for cannabis than for other illicit drugs, many users are in
institutions or homeless.
• There is not a consensus on a precise definition of what
cannabis related problems are.
Extract from the
general public booklet
of the 2005 cannabis
campaign in France:

The Cannabis Abuse


Screening Test (CAST):
Back from epidemiology to
clinic…
Cannabis Abuse Screening Test (CAST)

• Have you ever smoked cannabis before midday?


– never (0) – rarely (0) – from time to time (0) – fairly often (1) – very often (1)

• Have you ever smoked cannabis when you were alone?


– never (0) – rarely (0) – from time to time (0) – fairly often (1) – very often (1)

• Have you ever had memory problems when you smoked cannabis?
– never (0) – rarely (0) – from time to time (0) – fairly often (1) – very often (1)

• Have friends or members of your family ever told you that you ought to reduce your
cannabis use?
– never (0) – rarely (0) – from time to time (0) – fairly often (1) – very often (1)

• Have you ever tried to reduce or stop your cannabis use without succeeding?
– never (0) – rarely (0) – from time to time (0) – fairly often (1) – very often (1)

• Have you ever had problems because of your use of cannabis (argument, fight,
accident, bad result at school, etc.) Precise : /_____________/?
– never (0) – rarely (0) – from time to time (0) – fairly often (1) – very often (1)
Existing screening tests for problematic cannabis
use
• NAME Number of items Authors
• CAGE-cannabis 4 Midanik et al, 1998
• SDS (Severity of Dependence Scale) 5 Gossop et al, 1995
• Ontario alcohol and other drug opinion survey 5 Ferris et al.., 1994
• CAST (Cannabis abuse screening test) 6 Beck and Legleye, 2003
• PUM (Problematic use of Marijuana) 8 Okulicz-Kozaryn, 2007
• CUDIT (Cannabis Use Disorders Identification Test) 11 Adamson and Sellman, 2003
• MINI-cannabis 11 Sheehan et al, 1997
• ALAC (Alcohol Advisory Council of New Zealand)11 ALAC, 1996

• DSM-IV dependence adapted in


– National Household Survey on Drug Abuse 15 Kandel et al, 1997
• Knowing cannabis test 16 Kerssemakers, 2000
• CAPQ-SF (Cannabis-Associated Problem Quest.) 22 Lavender et al, 2008
• MSI-X (Marijuana Screening Inventory) 39 Dale, 2003
• CPQ (Cannabis Problem Questionnaire) 46 Copeland et al, 2005
• MCQ (Marijuana Craving Questionnaire) 47 Heishman et al, 2001
• MEEQ (Marijuana Effect Expectancy Quest.) 70 Schafer and Brown, 1991
Problematic cannabis use: general findings

• According to the litterature, about 0.5% to 3% of the


whole population fulfill criteria for cannabis
dependence or abuse in the last 12 months in Europe
(Rehm et al., 2005) as well as in Australia or the
United-States (Swift et al., 2001 ; SAMSHA, 2002).
• Figures are higher for men and for young adults
• Early substance use is known to be associated with a
high risk of developing substance use disorders
• ESPAD 2007 also provides a very relevant European
comparison on 17 countries, n~51,000
(Piontek et al., 2009)
Results from the CAST in the ESPAD study
(Piontek et al., 2009)
Conclusions

• Measuring the proportion of problematic or


dependent cannabis users is complex
• A great number of concepts and tools exist to monitor
problematic cannabis use
• Implementing a common screening tool can deliver
important information for prevention at the European
level (ESPAD 2007)
• We still need to develop and validate screening tests
which are more reliable in measuring adverse effects
of cannabis use
Contact

INPES
42, Bld de la Libération
93203 Saint-Denis Cedex
Tel : 01 49 33 22 22

www.inpes.fr
inpes@inpes.sante.fr