The Standard Joint Unit as a tool for assessing risky cannabis use. Antoni Gual, Cristina Casajuana, Hugo López, Joan Colom, Mercé Balcells Grup de Recerca en Addiccions Clínic Hospital Clínic i Universitari de Barcelona IDIBAPS Red de Trastornos Adictivos

Conflicts of Interest Funding for this study: Name of organisation Current roles and affiliations Addictions Unit, Psychiatry Department, Neurosciences Institute, Hospital Clinic, University of Barcelona; IDIBAPS; Vice President of INEBRIA; President of EUFAS Grants Lundbeck, D&A Pharma, FP7, SANCO, FIS, PND. Honoraria Lundbeck, D&A Pharma Advisory board/consultant Funding for this study: Plan Nacional sobre Drogas 2013 PI: Antoni Gual Solé Nº: 2013I082

¿Is it possible to define a meaningful standard drink?

Standard drink in Spain (UBE) The content of a UBE is 10 g d’alcohol Una copa de vino o cava Una cerveza Un chupito. Una copa de brandy Un whisky, un gin-tonic Un combinado (cubata) 1 UBE 2 UBE

The Standard Joint Unit (SJU): is it unrealistic? Variety of potencies Multiple psychoactive principles Variety of forms: hachís, marihuana, etc Home made preparation Variety of patterns of use, including shared use.

The SJU: a need Third most prevalent drug in the world Risky use criteria based just on frequency Screening tools (CAST) do not consider quantities used National surveys (Estudes, Edades) just focus on frequency, not in quantity. Need for a simple, reliable and standardized tool.

The SJU: a reality

Aim To define a SJU based on the amount of Δ9-THC and make it a reliable and usable tool: SJU ¿? Joints ¿? Grams cannabis ¿? Euros ¿? Mg of Δ 9 THC

Methods Before we start the field work we needed: Cannabis active compounds to be considered when defining a SJU Factors that may interfer with our study Patterns of use in our territory Systematic review Pilot study

Most psychoactive compound Delta-9-Tetrahidrocannabinol (Δ9-THC) Systematic review Most psychoactive compound Delta-9-Tetrahidrocannabinol (Δ9-THC) 2. Secondary compounds Delta-8-Tetrahidrocannabinol (Δ8-THC) Cannabinol (CBN) 3. Modulators Cannabidiol (CBD)

Pilot study Predisposition to donate a joint: incentives are required How is cannabis used: smoked and mixed with tobacco Cannabis presentations used: marihuana and hashis Optimization of methods (transport of samples, recruitment hours, etc)

Methods Four complementary samples in Barcelona: Selection criteria Leisure (100 subjects) Cannabis clubs (100 subjects) Mental Health outpatients (100 subjects) University students (100 subjects) Selection criteria 18 years old Cannabis users (last 60 days) Informed consent No cognitive deficits No language barrier

Methods Protocol  Aim: 328 samples A) Questionnaire (15 questions; annonimous) Sociodemographic data Patterns of cannabis use SJU questions (€/gr, joints/gr, etc) Subjective motivations for cannabis use Cannabis Abuse Screening Test (CAST) B) Donation of a joint Joint rolled by the participant  Aim: 328 samples

Methods Incentive 8GB USB uploaded with preventive information on cannabis

Methods Recruitment Naturalistic convenience sample Specific two steps procedure in Mental Health 2) Legal difficulties Work in areas of high use of cannabis Management of joints (from the user to the lab)

Methods Analytics Samples analyzed at a external lab Method: HPLC- UV Compounds analysed: Δ9-THC per joint CBD per joint Manual for use by national drug analysis laboratories

Results Marihuana joints (N=232) Valid donations (N=315) Questionnaires Questionnaires with donation (N=323) Valid donations (N=315) Marihuana joints (N=232) Hashish joints (N=83) Non valid donations (N=8) Questionnaires without donation (N=169) Non detectable cannabis (N=5) Excluded cannabis compounds (N=3)

Characteristics of donnors Results Characteristics of donnors 77% men 63% working 29 years (DE 10) 72% at least high school 75 % single

Patterns of cannabis use Results Patterns of cannabis use More than 20 days in the last month: 82% 4 or more times per week: 84% 4,2 (SD 3,7) joints per day of use Type of cannabis used Marihuana (74%): Club (51%) Black market (30%) Self-grown (19%) Hashish (24%) Two thirds prepare joints always in the same way 55% do not share joints Percentage of tobacco in each joint: 55%

Results Risky use based on CAST Risk categories No problem Moderate risk High risk Total sample 9,4 % 23,7 % 66,9 %

Conversion factors for the SJU Results Conversion factors for the SJU   Marihuana (N=232) Hachís (N=83) Euros per gram P25 4,00 3,14 Median 5,00 P75 6,00 Grams per joint 0,20 0,22 0,26 0,25 0,33 0,32 Euros per joint 0,99 0,80 1,26 1,00 1,77 1,43

Miligrams of Δ9-THC per joint Results Miligrams of Δ9-THC per joint Δ9-THC per joint Marihuana Hashish

Results Lab results Marihuana (N=232) Hashish (N=83) 9-THC P25 2,18 Miligrams 9-THC P25 2,18 3,50 Mediana 6,56 7,94 P75 12,79 13,72 CBD 0,02 1,49 3,24 0,04 4,70 Outliers 15 5

Miligrams of Δ9-THC per joint Results Miligrams of Δ9-THC per joint Δ9-THC per joint 7 mg Δ9-THC Marihuana Hashish

Results Lab results Less than 10% of extreme values: Marihuana N=15 Hashish N=5 Non parametric distribution of Δ9-THC and CBD in hashish and marihuana  MEDIAN

Values close to 7 mg Δ9-THC Results Similar results in marihuana and hashish in Δ9-THC Relevant differences in CBD Marihuana (N=232) Hashish (N=83) Median Gr cannabis per joint 0,26 0,25 € per joint 1,26 1,00 CBD (mg) 0,02 3,24 Δ9-THC (mg) 6,56 7,94 Values close to 7 mg Δ9-THC

1 UPE  1 joint  0,25g  1 €  7mg Δ9-THC Resultados By consensus it was decided to count hashish and marihuana with the same contents: 1 UPE  1 joint  0,25g  1 €  7mg Δ9-THC

Resultados Concerning CBD: Its modulator effect is still not well known and it was decided not to include it as a main variable to calculate the SJU We recommend it should be taken into account in: research Heavy hashish users

1 UPE  1 joint  0,25g  1 €  7mg Δ9-THC Information from the user A practical example 1 UPE  1 joint  0,25g  1 €  7mg Δ9-THC Information from the user Health assessment 1 Gr marihuana 5 SJUs 35 Mg 9-THC/ day 4 joints/day 5 € spent

1 SJU 1 Joint 0,25 Grams of cannabis 5 Euros 7 Mg of Δ 9 THC

Thanks for your attention Obrigado Antoni Gual, Cristina Casajuana, Hugo López, Joan Colom, Mercé Balcells Grup de Recerca en Addiccions Clínic Hospital Clínic i Universitari de Barcelona IDIBAPS Red de Trastornos Adictivos