G. Verstuyf,
team member help,
attached to the Association for Alcoholism and Other Addictions.
During the last decade, the use of cannabis as a narcotic turned into a significant social phenomenon across Europe, including Belgium. Now it is mainly at the youth culture that must be taken into account cannabis, despite its illegality, or perhaps precisely because of it.
In this article we will discuss the problem from a social perspective and health. To this end, we will use the results of studies ideologically neutral and well designed.
Epidemiological
In 2001, 9% of the Flemish population aged 15 and over had already tested at least once cannabis.1 The recent use of cannabis was reported by 2% of the population 15 years and older. Users are primarily in the age group 15 to 34 years. Cannabis is used in all social classes. Experimental use is most common in older educated.
During the last decade, cannabis use has increased among students in secondary education (2). Over the past year, up 15% of students had fallen cannabis.3 However, the use has not increased for the 2000-2001 school year (3). The trend is part of a broader development: in most European countries, cannabis use has stabilized in recent years (4).
Briefly
In cannabis, the active ingredient is THC. The drug is smoked or ingested.
Smoking is the most effective way to bring the THC to the brain. Cannabis is slowly eliminated from the body, the urine may still contain traces of a few weeks after consumption.
THC
All parts of the plant Cannabis sativa, or Indian hemp, contain psychoactive cannabinoids. Concentrations much higher levels are found in the flowers of the female plant. The most active compound is D-9-tetrahydrocannabinol (THC), which is fat soluble.
dried female flowers are known as marijuana (weed) resin squeezed from the plant called hash. From this, it also makes the hash oil.
The brain has two specific types of cannabinoid receptors, indicating that it exists in the body of endocannabinoids acting on these receptors.
Ways to
mode most effective use of cannabis is to smoke it. A few seconds after the first puff, the drug enters already in the brain and reaches the cannabinoid receptors.
Sometimes the cannabis is ingested, such as an ingredient of a space cake (cake with cannabis). THC is easily absorbed through the intestines but the process is slow and unpredictable. In addition, the bulk of the product is quickly degraded in the liver before reaching the circulation.
The most used cannabis: smoking a joint.
Elimination The elimination of THC from the body takes several days. Indeed, THC and certain fat-soluble metabolites are rapidly disappearing from circulation and concentrated in adipose tissue. The metabolites are excreted in the urine gradually and feces.
The period during which the THC is detectable can vary from five days when using single or very sporadic in several weeks if used quotidien.5 This finding is important in clinical practice: Because residues Cannabis / THC may persist for several weeks in the body, a positive urine test does not always give an accurate idea of using the substance at the time of sample collection.
The time in which we find traces of cannabis use varies greatly depending on the user's circumstances, the concentration of THC in cannabis and mode of use.
Briefly
Cannabis is used because of its hallucinogenic action, with effects such as relaxation and cheerfulness. The drug causes a decrease in blood pressure and heart rate accelerates. Smoking cannabis is bad for the lungs.
effects and risks of cannabis use
effects most often reported by users are relaxation, gaiety (high) and the laughter, stimulation of appetite, slight dizziness ( stoned), an increase of sensory perception and a change of perception time.
In the following paragraphs, we give an overview of what the literature says about the effects and risks associated with cannabis use (6).
Accessories User's cannabis cigarette paper to roll a joint and a pipe
Heart and Lung
Cannabis use causes a decrease in blood pressure and rapid heartbeat. Consequently, cannabis is not safe for people with heart problems.
Smoking cannabis causes the lungs a severe risk that probably increases with duration of use. The custom of mixing cannabis smoking increases this risk. Indeed, smoke cannabis and tobacco have virtually the same composition and they thus contain the same chemicals harmful to the lung tissue. After several years of regular use, we can already see changes in the airway tissue. To date, there is no convincing evidence of a possible causal link with asthma, chronic bronchitis, pulmonary emphysema or lung cancer (7). The mixture of cannabis and tobacco causes a severe risk of seeing the user addicted to tobacco.
If cannabis is smoked with a hookah or a humidifier, the smoke is cooler and therefore less harmful to the lungs. However, given the smaller amount of THC absorbed, the subject will tend to consume more. Ultimately, he will inhale more tar.
Other organic effects
Cannabis use has an influence on fine motor skills and mobility. This effect is dose-dependent and can be stimulating or inhibiting.
THC interferes to some extent with the reproductive system. At Short-term cannabis use can cause a transient and reversible fertility. Pregnant women should not use cannabis, let alone in combination with tobacco.
In adults, studies have failed to demonstrate that cannabis use could cause permanent changes in brain structure. For teenagers, the reality is much less certain.
Briefly
psychologically vulnerable patients, marijuana can accelerate the development of psychotic disorders. A relationship between cannabis and decreased motivation and performance, as well as depression and suicide. In vulnerable patients, cannabis can induce schizophrenia. Cannabis affects the short-term memory. There is no evidence in favor of a lasting impairment of memory.
Mental effects
As mentioned above, the use of cannabis leads to increased sensitivity to auditory and visual stimuli and a change in perception of time.
In some exceptional cases, the use (oral) of a large dose of cannabis can cause acute psychotic symptoms. They usually disappear by themselves after a few hours. Nothing indicates that cannabis use causes psychotic chronic.
By cons, cannabis can accelerate the development of psychotic disorders in people with a predisposition. Cannabis use can also accelerate the evolution of an existing psychotic disorder.
The decrease in motivation and benefits that are occasionally seen in heavy users of cannabis is a complex psychosocial phenomenon. This may not always be attributed to cannabis, the problem may be related to underlying depression or be part of a broader psychological dysfunction. A link between the problematic use of cannabis and depression and suicide. However, the mechanisms underlying this link are unknown.
cannabis induces schizophrenia-it?
Recently, both the general press in the scientific press have focused on a few longitudinal cohort studies, these studies argued that chronic cannabis use leading to schizophrenia. If the association between cannabis use and the onset of schizophrenia has been established, evidence of a causal link is lacking. It seems that in a population not vulnerable, cannabis use does not result in schizophrenia. Indeed, the incidence of schizophrenia is not increased, despite the endemic form that makes use of cannabis.
In people vulnerable cons, cannabis can trigger schizophrenia. It also increases the risk of recurrence in patients with schizophrenia. In addition, schizophrenic patients would switch more rapidly to cannabis.
Cognitive effects
Cannabis can affect memory in the short term. There is no scientific evidence that drinking significant affects memory permanently. Youth of school age, the deterioration of the short-term memory and other mental functions may lead to poorer school performance immediately after consumption. Among regular users of cannabis, poor school performance are often linked to other behavioral problems. Cannabis use does not cause severe disturbances of other cognitive functions.
Driving
Driving under the influence of cannabis is dangerous. The ability to perform complicated tasks is reduced for at least eight hours after a single dose. For safety, it is best not to drive or operate dangerous machinery for 24 hours after consumption. Measures should be even stricter for those whose profession requires absolute security, such as train drivers and bus drivers, etc.. Furthermore, alcohol increases the negative influence of cannabis on driving behavior.
Briefly
The risk of physical and psychological dependence on cannabis is relatively low. Some groups become addicted faster than others; this is particularly true of young people under 16 who use cannabis every week. There is a clear relationship entrel'utilisation cannabis and that of other drugs. It is possible that cannabis acts as a gateway to other drugs.
Dependence
Comparing cannabis with other drugs, it is found that the risk of physical and psychological dependence are limited. About 8% of adult users of cannabis and 15% of teenage consumers show signs of addiction. Epidemiological studies indicate that a minority of people with cannabis in the past continue to donate regularly and over a long period.
The risk of dependence is not identical for everyone, perhaps it is partially determined by genetics. In all cases, the risk of dependence increases as you consume larger amounts over a longer period and particularly more regularly. The very young people who start using cannabis become addicted faster. Use before the age of sixteen years increases the risk of dependence, especially when the young consumes cannabis at least once a week. In addition, the following groups are particularly susceptible: young men, the concurrent users of other stimulants, particularly tobacco and alcohol, and persons with a history of behavioral disorders, violence and other psychological problems.
When stopping consumption, few withdrawal symptoms such as loss of appetite, anxiety, irritability, tension, sleep disturbance and depression. The reason is the long half-life of THC.
Path to other products
In the past, it was assumed that the pharmacological properties of cannabis induced a biological mechanism leading inevitably to the use of other illegal drugs more powerful. However, this hypothesis, known as the stepping-stone theory, is refuted long ago.
theory gateway (gateway) is more nuanced. It assumes that cannabis use puts users in touch with the world of illegal drugs, cannabis acts here as a gateway to other illegal drugs.
level support services, we see that this concept is the reality: cannabis can open the door to other drugs. The process is influenced by personal vulnerability, social pressure existing or abundance of supply.
Briefly
Among users of cannabis are for support services, there are four main groups: the novice user, the user long-term users of cannabis as a medicine and polydrug users.
For each of these types of consumers, the approach is different. In all cases it is preferable to focus on the functions and the consequences of using rather than product.
Opportunities assistance in cases of problematic use of cannabis
In a high proportion of users of cannabis consumption is either experimental or integrated, therefore, consumption is consistent with a lifestyle acceptable to the user and to society. However, a relatively small group ends up appealing to teams of aid through various channels.
During the last decade, the number of people who started using cannabis has increased. In the future we can expect an increase proportional to the number of people who will require specialized assistance. Figures Vlis-VVBV (Vlaams Informatiesysteem van de Vlaamse Vereniging voor Behandelingscentra Verslaafdenzorg) confirm that the number of help requests from users of cannabis showed an increasing trend since the nineties. However, we must guard against drawing hasty conclusions: people with problematic cannabis use lead in several different structures, for which we do not have similar data.
Based on experiences primarily from the outpatient practice, we can set different profiles users who come into contact with support services .6
The novice user. In the novice user, the request for help usually comes from family members, especially parents. The problems identified by them are tensions in the family, poor school performance and the exclusive contact with other users. For the consumer himself is responsible for the use of a positive connotation. The firm minimizes its potential problems. It consumes mostly with friends, hence the fact that consumption also has a social function.
User long term. If cannabis use has existed for several years, demand for help usually comes from the consumer himself. It is motivated by feelings of exhaustion, emptiness and loneliness, the patient suffers from insomnia, impaired concentration and memory and has a psychological dependence. Often, it consumes one and lives alone. Consumption persists because of psychological dependence. For the entourage, the main problems lie in social isolation, passivity and dependence of the consumer.
Selfmedication. People involved in support services described a group of patients using cannabis to manage their psychiatric symptoms. This practice complicates treatment because it negatively affects the pharmacological action of most prescription drugs and patient compliance. Psychotic patients, cannabis can trigger or exacerbate crises. The polydrug
. Generally, the consulted polydrug addiction for another. He does not consider the use of cannabis as a problem and wants to continue using this product.
General Approach support services
Caregivers argue for appropriate care the type of consumer, according to the profiles outlined above. Thus, young addicts feel attacked quickly, and with them, it is often difficult to talk about use and abuse. However, some changes seem to appear in recent years an increasing number of young people seeking information correctly and they are open to nuanced information, even if they are not positive. Among the group of older users, the use and abuse of cannabis are easier to address, and because it is perhaps in the fact that the request for assistance is usually the patient himself.
Anyway, it is unwise to focus solely on the product. It is better to consider the functions and consequences of cannabis use.
Briefly
Early detection of cannabis use is primarily the responsibility of the first line. The urine test can confirm the consumption. We may use questionnaires for the diagnosis of addiction. Generally, no medication is required for withdrawal.
It is not uncommon for parents or asking the general partner of inducing the drop in consumption. Early detection of problem or not cannabis is especially evident from the first line.
As with other products, the user typically has a different conception of the risks and problems related to use than its surroundings and the caregiver. However, we must start from the idea that this difference in definition of the problem is not a cons-indication. Instead, it forms the basis of a methodical process of motivation. We know that motivation to change behavior takes place in stages, they are described in the model Prochaska and Di Clemente.8 To influence the motivation, we can introduce the principles of motivational interviewing in the consultation (9).
Early detection of cannabis use
Somatic complications related to cannabis use is relatively rare, it should rather look for clues in the psychosocial context. We will be attentive to behavioral changes, relational conflicts, failures in various fields, negative experiences may be a consequence of experimental use, etc.. If the patient recognizes the use during a meeting open and non-threatening, it can conduct a more extensive history of substance abuse.
Urine test
To support a suspicion of cannabis, we can do a urinalysis. To this end, there are screening tests similar to pregnancy tests. However, the most reliable results are obtained with a chromatographic test in the laboratory. Preferably, it will oversee the sample collection to prevent tampering. Ingestion of large amounts of water may particularly affect the result. For suspected dilution of urine, serum creatinine may be useful.
urinalysis does not say everything on consumption, it offers even less a solution. This is only a snapshot weakly provided information about the type of use and consumption patterns. The use of urinalysis must be in compliance and patient confidentiality. Otherwise, it undermines the potential for open communication about use.
Defining the issue of addiction
For diagnosis, we may use two screening tools: the CUDIT * (Cannabis Use Disorders Identification Test) 10 for cannabis use and, for the problem of addiction in general, the Europ-ASI, which covers 7 areas of life different. In young
who score high on a test screening, one can use the CIDI (Comprehensive International Diagnostic Interview) to confirm or exclude a disorder of cannabis use and associated problems. CIDI allows for the systematic diagnosis by DSM-IV.10
Weaning
In general, withdrawal does not require drugs unless the patient has symptoms such as agitation intensity, anxiety and psychotic breakdown. In cases of anxiety or agitation, may be prescribed diazepam (a) for a short period. In case of intense agitation or psychotic decompensation, it is better establish a brief treatment with neuroleptics, such as risperidone (b). In case of psychotic decompensation during outpatient treatment, hospitalization will be considered (11).
Briefly
Besides substance abuse, we often find another mental disorder: psychosis, depression or anxiety for example. In all these disorders, it is advisable to stop or reduce the use of cannabis. Preferably, drug abuse and psychiatric disorder are treated simultaneously. Sometimes it is appropriate to refer the patient to a specialized center.
disorders associated
In the presence of a disorder related to cannabis use, the problem is often multiple. Therefore, it will often not sufficient to diagnose disorder of substance abuse. Other problems somatic, psychiatric and social complicate the clinical picture and make treatment difficult.
Ideally, the diagnosis of mental disorder is associated with raised after a period of abstinence from 3 to 4 weeks, in practice, however, such a delay is often not realistic. It is advisable to proceed with the history as complete as possible history of drug addiction, preferably, this history will be supplemented by urine and blood tests.
Treating comorbidity
Some recent reports suggest the latest evidence-based treatments and / or best practice of abuse and dependence substances, as well as psychiatric comorbidity (12-14).
When it comes to comorbidity, the two disorders (substance abuse and psychiatric disorder) are preferably treated simultaneously.
However, improvements of a disorder are not necessarily associated with improvements in another.
Psycho
For the treatment of problematic cannabis use and psychosis (schizophrenia and bipolar disorder), the Australian National Comorbidity Project has identified the following recommendations (14).
It is important to distinguish between an acute psychotic episode resulting from drug use, a first episode of psychotic disorder and an acute episode of an already diagnosed chronic psychotic disorder.
In the presence of an acute psychotic episode resulting from the use of drugs, curbing the consumption result in the disappearance of the episode. Sometimes, the use of antipsychotics or benzodiazepines is indicated for a few days.
In general, you should recommend to patients with psychotic disorders not to consume cannabis.
Depression
The ASC has also made some important recommendations about the treatment of depression, abuse or cannabis dependence.
Because of the sedative action of cannabis, it should be recommended for depressed patients to stop or reduce their consumption so that depressive symptoms can be better evaluated.
In association with cannabis, there is a risk - probably limited - that the SSRIs have side effects. Patients should be informed.
If SSRIs are administered while the patient consumes cannabis, it should inform the patient of symptoms of serotonin syndrome
Anxiety
Cannabis with a potential anxiogenic effect, it is advisable for people suffering from an anxiety disorder to stop or reduce their consumption so that symptoms can be better evaluated. Often, abstinence results in an overall decrease in anxiety symptoms.
When the patient uses cannabis as self medication, it is appropriate to offer him a drug therapy or cognitive behavioral therapy specifically focused on anxiety.
Help Centers
We have many support services for differentiated drug problem. However, few centers have an offer corresponding therapeutic specifically those who have a problem with cannabis.
In the specialized area, the most common treatment strategies are also those for which the literature offers more evidence of effectiveness: motivational interviewing, cognitive behavioral therapy and family support.
Some centers offer occasional group activities Youth whose entourage considers addiction problem. The group sessions take the form of a course or activity support. The aim is to encourage young people to think about consumption and risky behavior.
In addition, there are groups oriented towards the exchange between the parents. The aim of these groups is to give parents the feeling of having control over the situation. Currently, the supply of parent groups is much wider than that of groups for young people.
a. EG Diazepam, Diazepam Teva ratiopharm Diazepam, Valium
b. Risperdal
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Brussels: Scientific Institute of Public Health, 2006.
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released by order of the Netherlands within the Mental Health Project Scoring Results. Amersfoort, 2004.
12. JC van der Stel. Comorbidity: addiction and a mental disorder. ZonMW, Addiction Program, 2006.
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14. National comorbidity project. Canberra: Commonwealth Department of Health and Ageing, 2003.
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