1. Definitions of risky and problematic cannabis use: a systematic review
Casajuana C, López-Pelayo H, Miquel L, Balcells MM, Colom J, Gual A

2. There is no conflict of interest related to this presentation

3. Introduction Cannabis the most used illicit drug worldwide
Increasing evidence on organic, psychiatric and social consequences of consuming cannabis
Early interventions in potential at-risk cannabis users are needed
… but how can we identify this users?
Cannabis is the third most consumed illicit drug worldwide and evidence for the negative consequences of cannabis consumption is increasing.
Although cannabis is one of the oldest drugs used, little is known about which consumption patterns may lead to negative consequences. Cannabis dependence has been well documented, but pre-dependent stages remain unexplored

4. Knowledge gap Official definitions are lacking
Risky cannabis use: pattern increasing the probability of future negative consequences
Problematic cannabis use: pattern already causing negative consequences, with or without fullfilling dependence criteria
Defintitionssitua les dificultats per definir el consum de risc i perjudicial per falta d'eines de freqüència i quantitat

5. Objective Conduct a systematic review to:
1) Identify and analyze current definitions and criteria used in scientific literature and by official organizations or institutions
2) To identify if there exists a consensus
3) Give recommendations for further studies

6. Methodology
1582 unique entries by title/abstract
73 fulfilling inclusion criteria
43 not fulfilling exclusion criteria + 3 references
46 articles finally included
25 definitions using screening tools
17 definitions for problematic cannabis use
8 definitions for risky cannabis use
21 definitions
using frequency of cannabis use
7 definitions for problematic cannabis use
14 definitions for risky cannabis use
19 fulfilling exclusion criteria:
-Imprecise definition (N=12)
-Personal characteristics (N=7)
1508 not fulfilling inclusion criteria
Flowchart resulting from the systematic literature review following PRISMA guidelines

7. Results
Identified criteria used to define risky and problematic cannabis use:
a) Screening tools (N=25)
Specific for cannabis
Cannabis Abuse Screening Test (CAST)
Cannabis Use Disorder Identification Test (CUDIT)
Cannabis Use Problems Identification Test (CUPIT)
Not specific for cannabis
Alcohol, Smoking and Substance Involvement Screening Test (ASSIST)
CRAFFT Test
b) Frequency of consumption (N=21)

8. Specific screening tools
Term used
Author
Proposed cut- off score
Screened population
CAST
Screens for cannabis abuse
6 items
Lifetime use
Risky cannabis use
Guitart (2012)
Score ≥ 4
Adolescents
Problematic cannabis use
Gálera (2013)
Score ≥ 2
Gheorghiev (2009)
Score ≥ 3
Military sample
Redonnet (2012)
Young adults
CUDIT
Screens for cannabis abuse and dependence
10 items
Past 6 months
Lyvers (2013)
Score≥ 8
Young adult users
Adamson (2010)
Score ≥ 13
Mental health patients
Adamson (2003)
Scores ≥ 8
Alcohol-dependent out-patients
Annaheim (2008)
Score 6-8
Adolescents and young adults
Thake (2011)
Scores ≥ 6
Scores≥ 8
General population
Health care settings
Annaheim (2007)
General population 
CUPIT
Screens problematic cannabis use and risk of developing CUD after 12 months.
13 items
Considers frequency & times cannabis is used in a typical occasion
Past 3 and 12 months
Bashford (2010)
Score ≥ 12
Cannabis users recruited from different settings , including patients and general population)
Tools used to identify both risky and problematic, but more often problematic use
Variabilty in scores:
+ confusion as scores overlap
are higher than for problematic use
Depend on diferent populations, versions of the screening tools
Screening tools consider a timeframe, but just one screening tool includes information on quantity to define risky use, although using as a proxy the hours stoned after consumig

9. Proposed frequency pattern
Author (year)
 Proposed frequency pattern
Justification
Risky cannabis use
Caldeira (2008)
5 or more times in the past year
Empirically decided
Coffey (2003)
Weekly cannabis use
Cohort study
Degenhardt (2008)
At least weekly
Díaz (2011)
Almost weekly
Fischer (2012)
Gmel et al (2010)
At least twice a week during the past 6 months, or more than once per week during the past month
Ogborne (2000)
At least weekly during the year of the survey
Survey result
Patton (2003, 2007)
Weekly (moderate risk) or daily (high risk)
Van Ours (2013)
Several consumptions per week
Problematic cannabis use
Kay- Lambkin (2009 y 2011)
At least weekly use
Kelly (2014)
More than 2 days of marijuana use in the past 12 months
Survey result (children)
Steinhausen (2007)
More than 3 times in the past month
More definitions for risky use
Problematic cannabis use less frequent than risky use
We observe more heterogenity in definitions
Can be explained as more than 50% frequencies proposed are not evidence-based
Incomplete definitions:
No time-frames included
No quantites included
Shouldn’t there be specific considerations for high risk groups?

10. Institutional web-pages
Only three included a definition related to risky or problematic cannabis use
EMCDDA
High risk users are frequent cannabis users, defined as consuming 20 days or more a month.
Canadian Centre on Substance Abuse
“At risk” cannabis users are individuals consuming less than 1 gram, a few times a week, at night and especially at weekends during several years with periods of high intensity usage
PNSD
Binary CAST scores of 2-3 are indicative of a low risk and scores above 4 suggest a high risk to develop problems related to cannabis use.
Variability within institutional definitions
One definition uses quantity but is actual based on medical marihuana use

11. Limitations of current criteria
No consensus = high variability
Incomplete criteria
Mostly not evidence based
Quantities not considered
No timeframes
Specific at risk groups are not reflected

12. Recommendation Clearly differentiate both concepts
Work for evidence based and complete definitions
Quantity & frequency
Timeframes
Specific considerations for high-risk groups
Risky use  Quantity and frequency
Problematic use  Screening tool

13. Conclusions
To promote early interventions we need to be able to identify at risk and problematic cannabis users
Consensus on definitions is decisive
Need to homogenize and complete definitions
Recommendations to the public

14. Thank you for your attention