Assessment of risky cannabis use and related consequences Chair: Hugo López Pelayo, Spain − Definitions of risky and problematic cannabis use: a systematic review. Cristina Casajuana, Spain − Assessment of cannabis use disorders: a systematic review of screening and diagnostic instruments. Hugo López-Pelayo, Spain − Standard Joint Unit as a tool for assessing risky cannabis use. Antoni Gual, Spain − Weighting the evidence: a systematic review on long-term neurocognitive effects of cannabis use in abstinent adolescents and adults. Florian Ganzer, Germany − Discussant: Mercè Balcells, Spain

López-Pelayo H, Batalla A, Balcells MM, Colom J, Gual A Assessment of cannabis use disorders: a systematic review of screening and diagnostic instruments López-Pelayo H, Batalla A, Balcells MM, Colom J, Gual A

There is no conflict of interest related to this presentation

Menu Introduction Method: systematic review Results Conclusions & Next Steps

Menu Introduction Method: systematic review Results Conclusions & Next Steps

Cannabis related problems are not just Cannabis Dependence or Addiction Addiction: “A set of physiological, behavioral and cognitive manifestations in which the consumption of cannabis acquires the highest priority for the individual, even greater than any other type of behavior of those which had the highest value in the past ” (WHO ICD-10)

Cannabis related problems are not just Cannabis Dependence or Addiction Hazardous Use: “A pattern of substance use that increases the risk of harmful consequences for the user. Some would limit the consequences to physical and mental health (as in harmful use); some would also include social consequences. In contrast to harmful use, hazardous use refers to patterns of use that are of public health significance despite the absence of any current disorder in the individual user” (WHO)” e.g. Hazardous alcohol use: 60 g of alcohol/day for a man and 40 g/day for a woman http://www.who.int/substance_abuse/terminology/definition3/en/ Gual A, López-Pelayo H, Reynolds J and Anderson P (2016) Editorial: Brief Interventions for Risky Drinkers. Front. Psychiatry 7:42. doi: 10.3389/fpsyt.2016.00042

Cannabis related problems are not just Cannabis Dependence or Addiction Cardiovascular disorders including myocardial infarction Educational attainment Cognitive impairment and psychiatric disorders: psychosis, anxiety and affective Chronic Bronchitis & Respiratory Cancers The adverse health effects of chronic cannabis use. Wayne Hall and Louisa Degenhardt Drug Test. Analysis 2014, 6, 39–45

Why should we use screening and diagnostic instruments? Early identification allows early intervention in early stage of the problem = Identify hazardous users

Which characteristics are important for a screening and diagnostic instrument? Reliability Validity Adaptability to different consumption patterns Applicability to daily practice Shortness Clarity Usability in different settings and population Reliability in statistics and psychometrics is the overall consistency of a measure.[1] A measure is said to have a high reliability if it produces similar results under consistent conditions. "It is the characteristic of a set of test scores that relates to the amount of random error from the measurement process that might be embedded in the scores. Scores that are highly reliable are accurate, reproducible, and consistent from one testing occasion to another. That is, if the testing process were repeated with a group of test takers, essentially the same results would be obtained. Various kinds of reliability coefficients, with values ranging between 0.00 (much error) and 1.00 (no error), are usually used to indicate the amount of error in the scores.“ Inter-rater reliability assesses the degree of agreement between two or more raters in their appraisals. Test-retest reliability assesses the degree to which test scores are consistent from one test administration to the next. Measurements are gathered from a single rater who uses the same methods or instruments and the same testing conditions.[4] This includes intra-rater reliability. Inter-method reliability assesses the degree to which test scores are consistent when there is a variation in the methods or instruments used. This allows inter-rater reliability to be ruled out. When dealing with forms, it may be termed parallel-forms reliability.[5] Internal consistency reliability, assesses the consistency of results across items within a test.[5] the degree to which evidence and theory support the interpretations of test scores" ("as entailed by proposed uses of tests").[2] It is generally accepted that the concept of scientific validity addresses the nature of reality and as such is an epistemological and philosophical issue as well as a question of measurement. The use of the term in logic is narrower, relating to the truth of inferences made from premises. Validity is important because it can help determine what types of tests to use, and help to make sure researchers are using methods that are not only ethical, and cost-effective, but also a method that truly measures the idea or construct in question. Piontek D, Kraus L, Klempova D (2008). Short scales to assess cannabis-related problems: a review of psychometric properties. Substance Abuse Treatment Prevention and Policy 3, 25. Tiet QQ, Finney JW, Moos RH (2008). Screening psychiatric patients for illicit drug use disorders and problems. Clinical Psychology Review 28, 578–591.

One example of a good instrument for AUD From Hazardous Use through Quantity and Frequency To Dependence or Abuse through signs and symptoms

Menu Introduction Method: systematic review Results Conclusions & Next Steps

PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) flowchart detailing study selection

Menu Introduction Method: systematic review Results Conclusions & Next Steps

Good psychometric properties Many instruments reliability and validity Good psychometric properties Many instruments 6 specified scales for CUD 4 scales for SUD (including cannabis) 7 structured interviews 8 tools to quantify consumption and other methods López-Pelayo H, Batalla A, Balcells MM, Colom J, Gual A, (2014). Assessment of cannabis use disorders: a systematic review of screening and diagnostic instruments. Psychol. Med. 1–13.

Good psychometric properties Many instruments 6 specified scales for CUD 4 scales for SUD (including cannabis) 7 structured interviews 8 tools to quantify consumption and other methods Cannabis Problem Questionnaire (CPQ) Cannabis Abuse Screening Test (CAST) Cannabis Use Disorder Identification Test (CUDIT) Marijuana Screening Inventory (MSI-X) Marijuana Problem Scale (MPS) Risk and Consequences Questionnaire-Marijuana (RCQ-M) López-Pelayo H, Batalla A, Balcells MM, Colom J, Gual A, (2014). Assessment of cannabis use disorders: a systematic review of screening and diagnostic instruments. Psychol. Med. 1–13.

Good psychometric properties Many instruments 6 specified scales for CUD 4 scales for SUD (including cannabis) 7 structured interviews 8 tools to quantify consumption and other methods Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) Severity Dependence Scale (SDS) Drug Use Disorder Identification Test (DUDIT) Car, Relax, Alone, Forget, Friends, Trouble (CRAFFT) López-Pelayo H, Batalla A, Balcells MM, Colom J, Gual A, (2014). Assessment of cannabis use disorders: a systematic review of screening and diagnostic instruments. Psychol. Med. 1–13.

Good psychometric properties Many instruments 6 specified scales for CUD 4 scales for SUD (including cannabis) 7 structured interviews 8 tools to quantify consumption and other methods Child and Adolescent Psychiatric Assessment (CAPA-C) Minnesota Multiphasic Personality Inventory-Adolescent (MMPI-A) Drug Use History Form (DUHF) Psychiatric Research Interview for Substance and Mental Disorders (PRISM) MINI AUDADIS SCID López-Pelayo H, Batalla A, Balcells MM, Colom J, Gual A, (2014). Assessment of cannabis use disorders: a systematic review of screening and diagnostic instruments. Psychol. Med. 1–13.

Good psychometric properties Many instruments 6 specified scales for CUD 4 scales for SUD (including cannabis) 7 structured interviews 8 tools to quantify consumption and other methods TLFB López-Pelayo H, Batalla A, Balcells MM, Colom J, Gual A, (2014). Assessment of cannabis use disorders: a systematic review of screening and diagnostic instruments. Psychol. Med. 1–13.

Limitations Too long e.g. MSI-X 31 items or CPQ-A 21 items Not appropriate timeframe e.g. too short < 12 months Limited data for different population: Gender Age (adolescents/elderly) Psychiatric patients Partial data about validity sometimes only internal validity sometimes only external validity In scientific research, internal validity is the extent to which a causal conclusion based on a study is warranted, which is determined by the degree to which a study minimizes systematic error (or 'bias'). It contrasts with external validity, the degree to which it is warranted to generalize results to other contexts.

Limitations Gold standard: abuse or dependence. No data for at-risk or low validity in this population. Regular, risky and hazardous use worked as synonyms Do not consider quantity (dose and potency) and frequency

Menu Introduction Method: systematic review Results Conclusions & Next Steps

Conclusions Current instruments are not useful for early identification of hazardous users (quantity/frequency are lacking) Several dimensions of cannabis related problems are not assessed: Cognitive impairment Social/Educational impairment Respiratory or cardiovascular consequences

Next Steps for early identification & intervention We need instruments also based on hazardous cannabis use Hazardous cannabis use should be based on frequency and quantity and related to the consequences of the consumption pattern in all dimensions (physical, psychological and social)