Prospective associations between adolescent risky substance use and school dropout and the role of externalising and internalising problems

Background: The aim of the present study was to assess to what extent risky substance use (RSU) acts as an important risk factor for school dropout from upper secondary school in a prospective study of Norwegian adolescents, and how externalising and internalising mental health problems influenced this association. Methods: We used data from a large population-based survey (the youth@hordaland-survey), which included adolescents aged 16-19 years. The predictor variables were self-reported RSU. The survey was linked with prospective data from the Norwegian Education Database, following the adolescents to 21-23 years of age. The outcome variable was registry-based school dropout within five years after starting upper secondary school. The analyses were adjusted for sex, age, socioeconomic status, and externalising and internalising problems. Results: After adjustment for sociodemographic variables, all indicators of RSU were prospectively associated with school dropout (adjusted odds ratios 1.26-2.25; all p values <.01). While internalising problems only slightly changed these estimates, the associations were substantially attenuated by externalising problems. Still, all measures of RSU, except frequent alcohol intoxication, remained positively associated with school dropout in the fully adjusted models. For the youngest students, all associations between RSU and school dropout were significant. Conclusions: Adolescent RSU is a strong predictor for school dropout, and externalising problems explained a considerable proportion of this effect. Prevention efforts to reduce student substance could improve academic outcomes among upper secondary school students, and such efforts may benefit from also targeting co-occurring externalising problems.

Which illicit drugs are injected in Oslo? A study based on analysis of drug residues in used injection equipment and self-reported information

BACKGROUND

People who inject drugs (PWID) have a high risk of premature death due to fatal overdoses. Newly emerged fentanyls, much more potent than heroin and other opioids, may increase this risk further. Therefore, precise information on injected drugs is critical to improving prevention strategies.

AIMS

This study aimed to analyse drug residues in used injection equipment in order to determine drug and drug combinations and compare and complement findings with self-reported information.

METHODS

Used syringes and needles (n=766) were collected at the supervised drug consumption facilities, the needle exchange service and two low-threshold health services for problem drug users in Oslo, Norway. The material was collected every third month from June 2019 to June 2020 and analysed for 64 substances using highly specific analytical methods (ultra-high performance liquid chromatography tandem mass spectrometry). Additionally, a street-recruited sample of PWID was interviewed from 2017 to 2019 regarding their drug injection habits (n=572).

RESULTS

Heroin (65.5%) or amphetamines (59.8%), often in combination (30.5%), were commonly detected in drug residues. Other opioids, stimulants or benzodiazepines were rarely detected (6.1%). Fentanyl was detected in only one syringe. Heroin was the most reported drug (77.6% during the past four weeks, 48.3% daily/almost daily), followed by amphetamines (57.5% during the past four weeks, 23.1% daily or almost daily). Injection of methadone, buprenorphine and dissolved tablets was self-reported more frequently than determined in drug residue findings.

CONCLUSIONS

Analysis of the injection equipment proved useful as a non-invasive, rapid and accurate means to obtain detailed information on injected drugs in Oslo and supplement traditional PWID survey information.

Attitudes Toward Cannabis Use Legalization and Openness to Legal Use Among Young Partygoers in Norway

OBJECTIVE

The purpose of this study was to examine attitudes toward legalization of cannabis use and openness to legal use among Norwegian partygoers.

METHOD

We examined a combined sample (N = 4,790; 46.2% female) of young partygoers (M age = 23.7, SD = 7.3) from three Norwegian studies on substance use in various settings: music festivals (n = 1,312), nightlife (n = 2,005), and high school graduation (n = 1,473). Through onsite surveys, the participants were asked if they thought cannabis use should be legal in Norway and whether they themselves would use the drug if legalized. These responses (yes/no/don't know) were examined in relation to participants' characteristics and cannabis use history using summary statistics and multinomial regression models.

RESULTS

Although 46.1% of participants reported having used cannabis at least once, only 1/3 (32.6%) favored legalization and 1/4 (25.6%) stated they would themselves use cannabis if legalized. Yet, even among never-users, we observed non-opposition to legalization (16.4% in favor; 14.9% don't know) and openness to legal use (8.2% would use; 12.4% don't know). Histories of cannabis, tobacco, or any other drug use, sex (male), and age younger than 21 years (vs. 30 or older) were consistently associated with affirmative responses to both questions. Openness to legal use was strongly associated with favorable legalization attitudes and age younger than 21, even after accounting for lifetime cannabis use history.

CONCLUSIONS

Favoring cannabis legalization and openness to legal use were relatively low in this sample of young Norwegian partygoers. Yet, prevalence of cannabis use may increase after legalization among its supporters and among those younger than 21, especially if "don't know" responses are considered.

Patients admitted to treatment for substance use disorder in Norway: a population-based case-control study of socio-demographic correlates and comparative analyses across substance use disorders

Background

Improved knowledge regarding socio-demographic correlates of people with substance use disorders (SUDs) is essential to better plan and provide adequate services for SUD patients and their families, and to improve our understanding of the complex mechanisms underlying progression into and development of various SUDs. This study aimed to: i) describe demographic, economic, and social correlates of people with SUDs in comparison with those of the general population and ii) compare these correlates across SUDs from licit versus illicit substances, as well as across specific SUDs.

Methods

A national population-based case–control study included all SUD patients enrolled in specialized drug treatment in Norway in 2009–2010 (N = 31 245) and a population control sample, frequency-matched on age and gender (N = 31 275). Data on education level, labour market participation, income level and sources, and family/living arrangement were obtained by linkages to national registers.

Results

Demographic, economic, and social correlates of SUD patients differed substantially from those of the general population, and across specific SUDs. Among SUD patients, those with illicit – as compared to licit – SUDs were younger (mean quotient = 0.72 [0.71–0.72]), more often had low education level (RR = 1.68 [1.63–1.73]), were less often in paid work (RR = 0.74 [0.72–0.76]) and had lower income (mean quotient = 0.61 [0.60–0.62]). Comparison of patients with different SUD diagnoses revealed substantial demographic differences, including the relatively low mean age among cannabis patients and the high share of females among sedatives/hypnotics patients. Opioid patients stood out by being older, and more often out of work, receiving social security benefits, and living alone. Cocaine and alcohol patients were more often better educated, included in the work force, and had a better financial situation.

Conclusion

Findings revealed substantial and important differences in socio-demographic correlates between SUD patients and the general population, between SUD patients with illicit and with licit substance use, and across specific SUD patient groups.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-13199-5.

Poor correlation between alcohol concentration in oral fluid and breath in subjects consuming beverages immediately before testing

Introduction

In previous research projects and clinical settings, alcohol analysis in oral fluid (saliva) has been used as an alternative to breath or blood alcohol testing. In this study we examined whether it is possible to obtain clinically relevant data regarding alcohol consumption in individuals who recently consumed alcohol by analysing oral fluid samples when the recommended rinsing of the mouth is impossible before sample collection.

Materials and methods

We conducted a study of 89 nightclub patrons in Norway. Before collecting oral fluid samples and performing breath alcohol testing, participants were required to drink a glass of water to remove residual alcohol from the mouth. Oral fluid samples were collected with the Quantisal oral fluid collection device and analysed using an enzymatic method for alcohol. The alcohol concentration in the neat (undiluted) oral fluid was then calculated. Breath alcohol testing was performed using Lion Alcolmeter 500 instruments.

Results

No false-negative or false-positive results for alcohol were detected in the oral fluid when compared with those in the breath. The Intraclass Correlation Coefficient of 0.40 indicated a poor correlation between alcohol concentrations in the two sample types.

Conclusions

The procedure for collecting oral fluid was suitable for the qualitative determination of alcohol intake but not for quantitative assessment. We recommend that oral fluid samples should not be used for estimating blood or breath alcohol concentrations in people who have recently consumed alcohol or non-alcoholic beverages, as recommended in the instructions for use.

Key Interpretation Challenges for Wastewater-Based Epidemiology of Illicit Drugs: A Norwegian Three-City Case Study

INTRODUCTION

Wastewater-based epidemiology (WBE) has emerged as a timely, non-invasive, and cost-effective indicator of illicit drug consumption. It is increasingly used by international organizations as a proxy measure for estimates of drug prevalence and related trends. Nevertheless, the literature exploring the limitations of WBE remains limited. This paper aims to shed further light on important shortcomings of WBE with recommendations on moving forward.

METHOD

Utilizing case study and statistical analysis, the paper critically reviews methodological challenges associated with WBE results related to (i) levels, (ii) trends, and (iii) between-city comparisons of drug use. Data from raw influent wastewater samples from wastewater plants in the cities of Oslo, Bergen and Stavanger/Sandnes were analysed for amphetamine, methamphetamine, MDMA, and cocaine (benzoylecgonine) over a 3-year period. Normalized population loads were calculated and variation in daily loads analysed with plots and estimation of means, confidence intervals, and coefficient of variation. Linear regression models examined trends and between-city differences.

RESULTS

Plots and statistical analyses revealed extensive variation in daily loads, with min/max values of 6.1/453.9 mg/day per 1,000 inhabitants 15-64 years for amphetamine and correspondingly 9.4/675.9 mg for methamphetamine. Substantial differences in load levels and patterns across time and plants were also observed. A carefully designed sampling procedure and a relatively large number of daily samples are required to obtain estimates of sufficient precision for determining trends in space or time. Cross-referencing with alternative trend variables can improve the interpretation of WBE trend indicators. Finally, when using mean load levels for different wastewater-treatment plants to assess spatial variation in drug use, the representativeness of the catchment area should be evaluated before interpreting observed changes as city differences.

CONCLUSION

Although WBE is a useful supplementary indicator of illicit drug consumption, important methodological issues and potential shortcomings should be taken into account when designing sampling procedures and interpreting the analytical results.

Characteristics and risk of incarceration among "hard-to-reach" people who use drugs: A five-year prospective cohort study combining self-reports and registry data

BACKGROUND

Incarcerations are associated with an increased risk of morbidity and mortality among people who use drugs (PWUD). In a sample of 884 PWUD, we examine and estimate the risk of incarcerations (i.e., number, duration, and most serious offense).

METHODS

In this prospective cohort study, PWUD were recruited from street- and low-threshold services in seven Norwegian cities in 2013 (Sept-Nov), and followed through the Correctional Service Registry until 20.12.2018. The risk of incarceration during follow-up was examined with multivariable logistic (no incarceration vs. at least one) and multinomial regression models ("no incarcerations", vs. "1″, "≥2″), while accounting for gender, age, homelessness/shelter use, opioid substitution treatment, illegal income sources, injecting behaviours, previous incarcerations, and recruitment city.

RESULTS

During follow-up, there were in total 662 incarceration episodes, and 44.7% of the participants were incarcerated at least once. Overall, 37.5% of those incarcerated had at least one episode due to a drug offense. The average incarceration duration was 65.2 days with 3.5% of the episodes lasting ≥one year. Gender (male), homelessness/shelter use, illegal income sources, injecting stimulants, and previous incarcerations increased the odds of incarceration, while older age decreased the odds. Gender (male), younger age, self-reported theft or theft and dealing, injecting stimulants or heroin and stimulants and previous incarcerations increased the risk of multiple incarcerations.

CONCLUSION

In a five-year prospective study of PWUD, incarcerations were common, and short-term sentences and recidivism were the norm. This is of concern as incarcerations add to an already elevated morbidity and mortality risk in this population.

The Double Effect of COVID-19 Confinement Measures and Economic Recession on High-Risk Drug Users and Drug Services

The ongoing COVID-19 pandemic is likely to have a profound impact on the lives of high-risk drug users and on the services responding to their needs in at least two important ways: first, through the restrictive measures introduced to mitigate the spread of the virus and, second, as a result of extensive economic downturn. Currently there is great uncertainty as to the future intensity and duration of the pandemic. In addition, the lessons we have been able to learn from previous economic downturns may be of limited applicability to the current situation, which differs in a number of significant respects. Experience nevertheless suggests that the potential consequences for drug users' health and well-being may be severe. The ongoing uncertainty serves to underline the importance of close monitoring of the drug situation and preparing flexible and innovative solutions to be able to meet new challenges which may arise.

Illegal substance use among 1,309 music festival attendees: An investigation using oral fluid sample drug tests, breathalysers and questionnaires

AIMS

Illegal substance use at music festivals is less documented than it is in nightlife and electronic dance music settings. This study investigated such use through questionnaires, breathalysers and oral fluid drug testing. We also examined the associations between testing positive for illegal substances and demographics, self-reported substance use and measured blood alcohol concentration levels.

METHODS

A cross-sectional study of 1,309 festival attendees from six Norwegian music festivals taking place between July and August 2016. Logistic regression models estimated the likelihood of a positive oral fluid drug test. Covariates were male, age, education, employment, smoking status, early age for alcohol intoxication, alcohol intoxication ⩾2 times a week, past-month and past-year illegal substance use, blood alcohol concentration levels and festivals.

RESULTS

Overall, 12% reported illegal substance use in the past 30 days and 11% tested positive for illegal substances. Cannabis (6%), cocaine (3%) and MDMA/ecstasy (2%) were most commonly detected. One-third had a blood alcohol concentration ⩾0.10%. Of those with a positive test result ( n=146), 95% had detectable alcohol levels and 41% had a blood alcohol concentration above 0.10%. Those studying or working part-time were less likely to test positive compared to those who were not employed. Furthermore, those reporting daily smoking and past-year cannabis or MDMA/ecstasy use were more likely to test positive, compared to those not reporting such use.

CONCLUSIONS

Illegal substance use was less prevalent than in previous nightlife and electronic dance music studies. Almost all those testing positive for illegal substances had detectable alcohol levels and 41% had a blood alcohol concentration greater than 0.10%, possibly indicating combined use.

Drug Use by Music Festival Attendees: A Novel Triangulation Approach Using Self-Reported Data and Test Results of Oral Fluid and Pooled Urine Samples

Background: Self-reported data are commonly used when investigating illicit substance use. However, self-reports have well-known limitations such as limited recall and socially desirable responding. Mislabeling or adulteration of drugs on the illicit market may also cause incorrect reporting. Objectives: We aimed to examine what could be gained in terms of illicit drug use findings among music festival attendees when including biological sample test results in the assessment. Methods: We included 651 attendees at three music festivals in Norway from June to August 2016. Self-reported drug use was recorded using questionnaires, and samples of oral fluid were analyzed to detect use of illicit drugs. In addition, we analyzed samples of pooled urine from portable toilets at each festival. Results: All methods identified cannabis, MDMA, and cocaine as the most commonly used drugs. Overall, 6.6% of respondents reported use of illicit substances during the previous 48 hours. Oral fluid testing identified a larger number of drug users as 12.6% tested positive for illicit drugs. In oral fluid testing, we identified ketamine and three new psychoactive substances (NPS) that had not been reported on the questionnaire. In pooled urine testing, we identified amphetamine and three additional NPS that were neither reported used nor found in oral fluid samples. Conclusions/Importance: Drug testing of biological samples proved to be an important supplement to self-reports as a larger number of illicit substances could be detected.

Correspondence between Oral Fluid Drug Test Results and Self-Reported Illicit Drug Use among Music Festival Attendees

BACKGROUND

Use of illicit substances is often under-reported. Testing positive in oral fluid provides an objective confirmation of recent intake.

OBJECTIVES

To examine the agreement between oral fluid test results and self-reported substance use among music festival attendees, and factors associated with reporting past 48 h drug use among users identified by drug testing.

METHODS

One thousand three hundred nine participants were recruited from six music festivals in Norway (June-August 2016). They completed a questionnaire and provided oral fluid samples analyzed for amphetamines, MDMA, tetrahydrocannabinol (cannabis), and cocaine. Additionally, their blood alcohol levels were measured.

RESULTS

Overall, 5.5% reported use of amphetamines, cannabis, cocaine, and/or MDMA during past 48 h in the questionnaire, whereas 10.8% tested positive in oral fluid. Only 16.7% of identified cocaine users and 31.1% of identified MDMA users reported past 48 h cocaine or MDMA use, respectively. Higher proportions of identified cannabis and amphetamine users reported past 48 h use (53.8% and 55.6%, respectively). Multivariable logistic regression analysis showed that among participants who tested positive, those reporting weekly illicit substance use (Adjusted Odds Ratio [AOR] 30.6; 95% Confidence Interval [CI] 6.3-147.9), and using such substances when younger than 18 years (AOR 5.0; 95% CI 1.9-13.4) were more likely to report past 48 h use. Conclusions/Importance: Oral fluid testing appears to be an important tool when studying illicit substance use among music festival attendees, as significant under-reporting was observed. Among those testing positive, regular, and experienced users were more likely to report recent use, compared to less regular and experienced users.

Identification and Assessment of Drug-User Groups Among Nightlife Attendees: Self-Reports, Breathalyzer-Tests and Oral Fluid Drug Tests

BACKGROUND AND OBJECTIVES

Even though nightlife studies with potentially intoxicated participants provide the much needed information on drug use, they face additional methodological challenges. This study aimed to explore the utility of such studies by (i) classifying nightlife attendees based on their self-reported drug use and by (ii) examining whether these classifications were meaningful when assessed against other sources of data, including oral fluid drug tests.

METHODS

Self-reported questionnaires, oral fluid samples and blood alcohol concentration readings were collected in a sample of 1,085 nightlife patrons recruited outside 12 popular nightclubs in Oslo, Norway, in 2014. Patrons were classified using multiple approaches, including latent class analysis. Group differences were examined by logistic regression models.

RESULTS

Participants were classified into 5 mutually exclusive groups: 2 among current non-users ("Never-users"; "Previous users"), 2 among current users ("Multiple drugs"; "Cannabis mainly") and one "Incomplete information" group. Meaningful differences across these groups were observed. For instance, positive tests for any illicit drug were more common in "Multiple drugs" group than in "Cannabis mainly" (62.7 vs. 29.1%, adjusted OR [aOR] 3.77 [2.42-5.84]) or "Incomplete information" groups (62.7 vs. 34.4%, aOR 2.46 [1.26-4.79]). Despite their self-declared non-use, illicit substances were detected in oral fluids of "Never-users" (13.1%; 95% CI 9.9-17.2) and "Previous users" (7.9%; 95% CI 5.1-12.1).

CONCLUSIONS

Despite some discrepancies between self-reports and biological tests, self-reports proved both suitable and useful in identification of substantively different drug-user typologies, potentially informing targeted policy responses. Still, methodological challenges associated with onsite studies of illicit drug use should be further explored.

Who seeks treatment for cannabis use? Registered characteristics and physical, psychological and psychosocial problem indicators among cannabis patients and matched controls

BACKGROUND

There has been an absolute and relative increase in the number of patients with cannabis-related disorders as the principal diagnosis in many countries in recent years. Cannabis is now the most frequently mentioned problem drug reported by new patients in Europe, and cannabis patients constituted one third of all drug treatment patients in 2015. There is limited knowledge with regard to patient characteristics, the extent and types of health and psychosocial problems, as well as their association with long-term outcomes.

METHODS

We analysed indicators of physical, psychological and psychosocial problems of all patients admitted to treatment for cannabis use in Norway in 2009 and 2010 using register data and observed them to the end of 2013. Patient characteristics and outcomes were compared to a randomly drawn control group with corresponding age and gender distribution. Using logistic regression of prospective data, we studied associations between baseline characteristics and work and study status in 2013.

RESULTS

Cannabis patients tended to be relatively young and the large majority were male. They had parents who were less highly educated compared to controls, while there was no difference in migration background. In addition to an increased risk of premature death, nearly half of the patients received a secondary psychological diagnosis and a similar proportion received an additional substance use diagnosis during the 4-5 years of study follow-up. The cannabis patients were less educated than the control group and also less likely to be studying or working at the end of the study period. Entering treatment at a young age, having completed more than secondary education, having a highly-educated mother and not having a secondary diagnosis were factors that were positively associated with being in education or employment at the end of follow-up.

CONCLUSIONS

Data covering the entire Norwegian population of patients admitted primarily for cannabis-related problems showed comprehensive and complex patterns of physical, psychological and psychosocial problems. The prevalence and extent of these problems varied markedly from those of the general population. Work and study outcomes following treatment depended on the seriousness of the condition including co-morbidity as well as social capital.

Patterns of substance use and mortality risk in a cohort of 'hard-to-reach' polysubstance users

AIMS

To examine the mortality risk in a cohort of 'hard-to-reach' polysubstance users and its putative associations with substance use. Specifically, we estimated all-cause mortality risk as a function of individual substance use indicators, and then as a function of their complex, 'real-life' patterns as identified through latent class analysis (LCA).

DESIGN

Prospective cohort study among street- and low-threshold service-recruited polysubstance users included between September and November 2013 and followed through the National Cause of Death Registry until 31 October 2015.

SETTING

Seven Norwegian cities.

PARTICIPANTS

A total of 884 users of illegal opioids and/or stimulants. Of these, 357 were in opioid substitution treatment (OST) at the time of inclusion. Forty-four participants died during follow-up.

MEASUREMENTS

Primary outcome: all-cause mortality risk. Unadjusted and adjusted Cox proportional hazard (PH) regression models (covariates: male, age, homelessness/shelter use, overdose experience, OST status, years of injecting, individual substance use indicators, city, use patterns). LCA models estimated separately for those in and those not in OST due to measurement invariance.

FINDINGS

The crude mortality rate was 2.52 per 100 person-years. Standardized mortality ratio was 26.11 [95% confidence interval (CI) = 10.06-54.87] for women and 10.71 (95% CI = 6.39-16.81) for men. No single drug use indicator, such as 'heroin injection' or 'number of drugs used', was associated with the mortality risk. However, meaningful use patterns were identified; three OST and non-OST patterns each. The non-OST patterns 'polysubstance injectors' [hazard ratio (HR) = 3.45, 95% CI = 0.98-12.14] and 'low frequent injectors' (HR = 3.17, CI = 1.05-9.56) were associated significantly with the mortality risk even when adjusted for other known risk factors.

CONCLUSIONS

In a Norwegian prospective cohort study, 'hard-to-reach' polysubstance users had a more than 10 times higher mortality risk than the general population. Mortality risk was not a function of any single drug use indicator, but two distinct combinations of substances, frequencies and routes of administration were associated with the mortality risk.

Ready, willing, and able: the role of cannabis use opportunities in understanding adolescent cannabis use

AIMS

To examine adolescent cannabis use-both at national and individual levels-by deconstructing it into its necessary conditions of realistic use opportunities and willingness to use the drug given such opportunities.

DESIGN

Nationally representative, repeated cross-sectional survey.

SETTING

Norway.

PARTICIPANTS

A total of 8818 16-year-olds who participated in the European School Survey Project on Alcohol and Other Drugs (ESPAD) in 2007, 2011, and 2015.

MEASUREMENTS

Adolescent reports concerning their life-time 'cannabis use' and 'possibilities to use cannabis' were used to assess: (a) overall cannabis use, (b) exposure to realistic cannabis use opportunities, and (c) cannabis use among those exposed to use opportunities. Logistic regression models were used to estimate national trends since 2007 in these indicators, and to identify individual-level factors associated with cannabis use versus non-use among youth exposed to concrete use opportunities.

FINDINGS

Prevalence of life-time cannabis use remained stably low, averaging 6.4% across the three surveys. Life-time exposure to cannabis use opportunities decreased [odds ratio (OR)_{ESPAD assessment}  = 0.90, 95% confidence interval (CI) = 0.84-0.97, P = 0.006], yet cannabis use among adolescents with such opportunities increased significantly (OR_{ESPAD assessment}  = 1.17, 95% CI = 1.03-1.34, P = 0.02) since 2007. After controlling for a range of other risk factors, abstinence from alcohol intoxication and cigarette use, as well as the perceptions of even minimal cannabis use as risky remained the factors most robustly associated with lower likelihood of cannabis use among youth with realistic use opportunities.

CONCLUSIONS

Approaches accounting for realistic use opportunities proved critical in our understanding of underage cannabis use, both at the national and individual level, and may be informative for development of prevention strategies in the era of cannabis liberalization. In addition, delineation of realistic opportunities from behaviours conditioned upon such opportunities is generalizable to a range of public health issues.

Article

Einar Ødegård & Anne Line Bretteville-Jensen & Astrid Skretting: The development of drug abuse in Norway in the 1990s

This article aims to shed light on the development of drug abuse in Norway during the 1990s. The data come from various different sources, including questionnaire studies as well as other data sets describing the extent of drug abuse in the country.

There has been a marked increase in drug abuse during the 1990s. Data from annual youth surveys in 1990 to 1995 indicate that between 8 and 10 per cent of youths aged 15–20 had ever used cannabis, whereas the figure during the latter half of the decade was substantially higher at 18–19 per cent. Surveys in the whole population also point at an increase from 1991 through to 1999: in 1991 the proportion indicating they had ever used cannabis was 8.2%, by 1999 the figure had risen to 12.5%.

Furthermore, a simple cohort analysis clearly indicates that large numbers are continuing to use cannabis: the figures are also rising in older age groups. With the growing prevalence of cannabis use in younger age groups we may therefore expect to see increasing numbers of regular and frequent cannabis users in the whole population as well.

Drug seizures by the police and customs have increased sharply during the latter half of the 1990s: this applies not only to amphetamine and ecstasy but also cocaine and LSD. This is supported by the results of annual questionnaire surveys among youths, who are reporting a marked increase in the use of these types of drugs. In the early 1990s around 1% of youths in the age group 15–20 said they had ever used amphetamine. This figure remained more or less unchanged through to the mid-1990s. However by the end of the decade around 4% said they had used amphetamine.

The data from youth surveys furthermore indicate that there is considerable overlap in the use of amphetamine and ecstasy. In this material the sharpest increase is recorded in the proportion of those indicating they have used both amphetamine and ecstasy.

There are several indicators which describe the extent of heroin abuse. All these indicators show that there has been a sharp increase in heroin abuse during the 1990s. A simple mortality analysis suggests that the number of heroin abusers has doubled over the past decade.

Drug abuse has also spread markedly both in relation to age groups and geographically: today the problem is by no means limited to any specific age group, nor just to a few major cities.

Risky substance use among young adults in the nightlife arena: An underused setting for risk-reducing interventions?

AIMS

Alcohol and illicit substance use among young adults carries the risk of adverse consequences like violence, injuries, risky sexual behaviour and, ultimately, the development of possible addiction. The nightlife arena is a high-risk setting for excessive substance use and the aims of this study were to examine prevalence rates and identify high-risk subgroups in this context.

METHODS

Patrons ( n = 1099, response rate 76%) entering or exiting 12 popular licensed premises in downtown Oslo, Norway, completed an anonymous self-administered questionnaire and their blood alcohol concentration (BAC) levels were measured using a Breathalyzer.

RESULTS

The average BAC levels were similar ( t = 1.67, degrees of freedom (df)= 936, non-significant (ns)) and high both for males (1.03‰) and females (0.97‰). A total of 67% reported ever using illicit drugs, 43% reported last-year use, 25% last-month use and 14% use during the last 48 hours. High-risk groups included the youngest patrons (16-20 years) where 50% reported illicit drug use in the last year. Males reported more use of illicit drugs than females, whereas females had equally high alcohol consumption frequency and intoxication levels as males. Young age, male gender, frequent alcohol intoxications and age < 15 for first alcohol intoxication experience were associated with increased risk of illegal substance use in multivariate analyses.

CONCLUSIONS

The high levels of alcohol and illicit drug use, particularly among patrons younger than 21 years, should be of concern to the community, policymakers and the nightlife industry. The nightlife arena may be an under-utilized setting for the implementation of risk-reducing interventions.

Who are the adolescents saying "No" to cannabis offers

BACKGROUND AND AIMS

Adolescents who refuse direct cannabis offers and remain non-users represent a potentially very informative, yet surprisingly understudied group. We examined a range of risk and protective factors putatively associated with this poorly understood "cannabis-resilient" profile.

METHODS

Paper-and-pencil questionnaires assessing substance use, peer and family relations, and behavioral and personality characteristics were completed by 19,303 middle- and high-school students from 82 schools in Norway (response rate 84%)

RESULTS

The lifetime prevalence of cannabis use was 7.6%. Another 10.4% reported no use of the drug despite having received recent cannabis offers. Results from the multinomial logistic regression revealed a set of characteristics differentiating adolescents who resisted such offers from those who: (a) neither received the offers nor used, and, more importantly, (b) used the drug. Specifically, parent-child relationship quality, negative drug-related beliefs, absence of close relationships with cannabis-users, low delinquency, no regular tobacco use, and infrequent alcohol intoxication were all associated with increased odds of being in the cannabis-resilient vs. cannabis-user group. This pattern of results was comparable across middle- and high-school cohorts, but the parent-child relationship quality and delinquency were significantly associated with cannabis-resilient vs. cannabis-use outcome only among younger and older adolescents, respectively.

CONCLUSIONS

Among other low-risk characteristics, better relationships with parents and beliefs that drug use is problematic were associated with adolescents' refusals to accept cannabis offers. These results may have implications for novel preventive strategies targeting cannabis-exposed adolescents.

Recreational drug use in the Oslo nightlife setting: study protocol for a cross-sectional time series using biological markers, self-reported and qualitative data

INTRODUCTION

Recreational drug use in the nightlife setting carries the risk of many negative consequences, such as violence, injuries, aberrant driving and sexual risk-taking. The aim of this study is to investigate recreational drug use and user characteristics among people visiting licensed premises, for example, nightclubs and bars, by using self-reports and biological markers. Staff of licensed premises will be asked to report drug use observations. Further, by using qualitative data, we will examine the motives, consequences and culture associated with recreational drug use. An additional aim is to compare self-reported drug use with oral fluid test (OFT) results in order to validate the different measurement methods in this context.

METHODS AND ANALYSES

Data collection will be conducted among patrons (n=1000) outside licensed premises. On consent, patrons will be asked to anonymously complete a questionnaire, a breath alcohol concentration test and an OFT. Patrons who report use of recreational drugs in the previous 12 months will be asked to leave their contact information for a subsequent qualitative in-depth interview (n=30-40). Staff from licensed premises (n=500) will be invited during Responsible Beverage Service Training to participate in an anonymous survey. Survey data will be analysed by univariate and multivariate statistical methods and the oral fluids will be analysed for a large number of drugs using biochemical methods. Cohen's κ will be used as a measure of agreement between self-reported drug use and OFT. In-depth interviews will be coded in HyperRESEARCH and analysed using an inductive approach. Data collection will be repeated on a biannual basis until at least 2020, allowing for examination of trends in recreational drug use.

ETHICS AND DISSEMINATION

This study has been approved by the Regional Committee for Medical and Health Research Ethics. Results will be disseminated in research journals, conferences and the media.

Are overdoses treated by ambulance services an opportunity for additional interventions? A prospective cohort study

AIMS

To assess whether people who inject drugs (PWID) and who are treated for overdose by ambulance services have a greater mortality risk compared with other PWID, and to compare mortality risk within potentially critical time-periods (1 week, 1 month, 3 months, 6 months, 1 year, 5 years) after an overdose attendance with the mortality risk within potentially non-critical time-periods (time before and/or after critical periods).

DESIGN

A prospective cohort study.

SETTING

Oslo, Norway.

PARTICIPANTS

A total of 172 PWID street-recruited in 1997 and followed-up until the end of 2004.

MEASUREMENTS

Interview data linked to data from ambulance records, Norwegian Correctional Services, Opioid Substitution Treatment records and National Cause of Death Registry. Separate Cox regression models (one for each critical time-period) were estimated.

FINDINGS

Ambulance services treated 54% of the participants for an overdose during follow-up. The mortality rate was 2.8 per 100 person-years for those with an overdose and 3.3 for those without; the adjusted hazard ratio (HR) was 1.3 (95% CI = 0.6, 2.6, P = 0.482). Mortality risk was greater in all but the shortest critical time-period following ambulance attendance than in the non-critical periods. The mortality risk remained significantly elevated during critical periods, even when adjusted for total time spent in prison and substitution treatment. The HR ranged from 9.4 (95% CI = 3.5, 25.4) in the month after an overdose to 13.9 (95% CI = 6.4, 30.2) in the 5-year period.

CONCLUSIONS

Mortality risk among people who inject drugs is significantly greater in time-periods after an overdose attendance than outside these time-periods.

Public opinion and medical cannabis policies: examining the role of underlying beliefs and national medical cannabis policies

Background

Debate about medical cannabis legalization are typically informed by three beliefs: (1) cannabis has medical effects, (2) medical cannabis is addictive and (3) medical cannabis legalization leads to increased used of cannabis for recreational purposes (spillover effects). We examined how strongly these beliefs are associated with public support for medical cannabis legalization and whether this association differs across divergent medical cannabis policy regimes.

Methods

Robust regression analysis was used to analyse data derived from two nationally representative samples of adults participating in comparable cross-sectional online surveys in one country where medical cannabis smoking is illegal (Norway, n = 2175, 51 % male) and in one country where medical cannabis smoking is legal (Israel, n = 648, 49 % male).

Results

The belief that cannabis has medical benefits was more strongly related to support for medical cannabis legalization than were beliefs about addiction and spillover effects. While the support for medical cannabis legalization was stronger in Israel than in Norway (78 vs. 51 %, p < 0.01), the belief variables had, in general, more impact on the policy stand in Norway.

Conclusion

The belief that cannabis has medical benefits is particularly salient for support for medical cannabis legalization. It is possible that the recent surge in evidence supporting the medical benefits of cannabis will increase the belief about medical benefits of cannabis in the general population which may in turn increase public support for medical cannabis legalization. Results also suggest that once medical cannabis is legalized, factors beyond cannabis-specific beliefs will increasingly influence medical cannabis legalization support. These conclusions are, however, only suggestive as the current study is based on cross-sectional data. Hopefully, future research will be able to capitalize on changes in medical cannabis policies and conduct longitudinal studies that enable an examination of the causal relation between public opinion and medical cannabis policy changes.

Illicit use of opioid substitution drugs: prevalence, user characteristics, and the association with non-fatal overdoses

BACKGROUND AND AIMS

Diversion of opioid substitution drugs (OSD) is of public concern. This study examined the prevalence, frequency, and predictors of illicit OSD use in a group of injecting drug users (IDUs) and assessed if such use was associated with non-fatal overdoses.

METHODS

Semi-annual cross-sectional interviews conducted in Oslo, Norway (2006-2013), from 1355 street-recruited IDUs. Hurdle, logistic, and multinomial regression models were employed.

RESULTS

Overall, 27% reported illicit OSD use in the past four weeks; 16.8% methadone, 12.5% buprenorphine, and 2.9% both drugs. Almost 1/10 reported at least one non-fatal overdose in the past four weeks, and roughly 1/3 reported such experience in the past year. Use of additional drugs tended to be equally, or more prevalent among illicit OSD users than other IDUs. In terms of illicit OSD use being a risk factor for non-lethal overdoses, our results showed significant associations only for infrequent buprenorphine use (using once or less than once per week). Other factors associated with non-fatal overdoses included age, education, homelessness, as well as the benzodiazepines, stimulants, and heroin use.

CONCLUSIONS

Users of diverted OSD may represent a high-risk population, as they used more additional drugs and used them more frequently than other IDUs. However, illicit OSD use may be less harmful than previously assumed. After accounting for an extensive set of covariates, only infrequent illicit buprenorphine use, but not methadone use, was associated with non-fatal overdoses.

Does liberalizing cannabis laws increase cannabis use?

A key question in the ongoing policy debate over cannabis' legal status is whether liberalizing cannabis laws leads to an increase in cannabis use. This paper provides new evidence on the impact of a specific type of liberalization, decriminalization, on initiation into cannabis use. Our identification strategy exploits variation in the timing of cannabis policy reforms and our estimation framework marries a difference-in-difference approach with a discrete time duration model. Our results reveal evidence of both heterogeneity and dynamics in the response of cannabis uptake to decriminalization. Overall, we find that the impact of decriminalization is concentrated amongst minors, who have a higher rate of uptake in the first five years following its introduction.

Gender differences in mortality and risk factors in a 13-year cohort study of street-recruited injecting drug users

BACKGROUND

Injecting drug users (IDUs) are at risk of premature mortality. This study examined gender differences in mortality, risk factors, and causes of death among IDUs.

METHODS

In a 13-year cohort study including 172 street-recruited IDUs from Oslo, Norway in 1997, interview data was merged with the National Cause of Death Registry. Crude mortality rate (CMR) and indirect standardized mortality ratio (SMR) were estimated with 95% confidence intervals (CI). A log-logistic multivariate survival analysis model was estimated for the full sample. For a smaller data set (1.1.1998-31.12.2004) the influence of substitution treatment and prison were assessed using cox regression survival analysis.

RESULTS

Eight females and 37 males died. Acute intoxications were the most common cause of death. Women were more at risk in the short-term, but more protected in the long-term. CMR was 16.0 [95% CI 8.0, 31.9] for women and 26.0 [95% CI 18.0, 35.8]) for men. SMR was 39.4 [95% CI 0.2, 220.8]) for women and 21.3 [95% CI 5.7, 54.1] for men. More women injected heroin (98% vs. 88% [x2 = 3.5, p = 0.063]), used prescription drugs (73% vs. 52% [x2 = 5.6, p = 0.018]) and combined these to inject (45% vs. 26% [x2 = 5.9, p = 0.015]). Mixing prescription drugs in heroin injections, and sex work (only women) were associated with decreased survival time. There were no gender differences in access to substitution treatment, while significantly more men had been in prison (74% vs. 51% [x2 = 7.5, p = 0.006]). The instance of substitution treatment and prison significantly decreased the mortality risk. Prison release increased the risk, but not statistically significantly.

CONCLUSIONS

There were gender differences in mortality and risk factors; sex work and prison were gender specific risk factors. These factors should be investigated further to better design future preventive measures.

Is opioid substitution treatment beneficial if injecting behaviour continues?

BACKGROUND

Opioid substitution treatment (OST) is recognised as an effective treatment for opioid dependence. Still, a subgroup of OST users continues to inject drugs. This study examines health risks and criminal activity in a population of needle exchange programme (NEP) participants by comparing those identified as current OST users to (i) those identified as former OST users and (ii) those with no OST experience.

METHODS

This was a semi-annual cross-sectional study conducted from 2002 to 2011. NEP participants were interviewed in Oslo, Norway (n=1760); 341 were identified as current OST users, 356 as former OST users and 1063 had no OST experience. The associations between OST status and health risk and criminal activity were assessed through univariate and multiple logistic regression analyses.

RESULTS

Among NEP participants, those currently in OST had fewer non-fatal overdoses (OR=0.5 [95% CI 0.3, 0.9]) compared to former OST users and those never in OST. Additionally, they were less likely to have injected frequently (OR=0.4 [95% CI 0.3, 06]), to have used heroin daily or almost daily (OR=0.3 [95% CI 0.2, 0.4]), and to have committed theft (OR=0.6 [95% CI 0.4, 1.0]) and engaged in drug dealing (OR=0.7 [95% CI 0.5, 0.9]) in the past month. Overall, there was a high level of polysubstance use and no group differences on this measure.

CONCLUSIONS

NEP participants who are currently in OST have substantially reduced health risks and criminal activity than other NEP participants. The high level of polysubstance use nevertheless poses a public health challenge.

Synthetic Cannabinoids and Cathinones: Prevalence and Markets

Over the past few years, the phenomenon of new designer drugs has attracted much attention. Synthetic cannabinoids and cathinones are the two main classes of these drugs. Both are potent drugs of abuse, and several cases of severe toxicity and deaths are reported. The present work is based on a systematic review of studies that have assessed the market and prevalence of synthetic cannabinoids and cathinones, and integrates pharmacological, sociological, and epidemiological aspects of these two groups of emerging synthetic drugs. The review reflects that the Internet has made synthetic cannabinoids and cathinones widely available. Furthermore, aggressive and widespread marketing, as well as the low price level of these drugs, their juridical status and their lack of detection on standard drug tests may serve as major motivations for drug use. The number of prevalence studies is small and derived from a limited number of countries. In spite of the many methodological shortcomings, some conclusions may be cautiously drawn. Taken together, the results point toward higher prevalence of use for synthetic cathinones than for synthetic cannabinoids. In the general population, the prevalence of use of synthetic cathinones is reported to be around 4% compared to figures lower than 1% for synthetic cannabinoids. Among students, the prevalence varies from 1-20% for synthetic cathinones and 2-10% for synthetic cannabinoids. Among groups with high rates of drug use, the prevalence varies between 4% to more than 60% for synthetic cathinones and around 10% for synthetic cannabinoids.

A method to estimate total entry to hard drug use: the case of intravenous drug use in Norway

BACKGROUND/AIMS

Epidemiological measures such as the prevalence and incidence of hard drug use are important tools for evaluating drug situations and drug policies. Models for drug use trajectories illustrate how temporary and lasting cessation of and relapse into hard drug use are other important elements in the overall picture of change in hard drug use over time. Estimating the total entry to hard drug use broadens the knowledge of the change in such use.

METHODS

The entry rate for hard drug use is defined as the sum of incident cases and relapses and estimated based on successive prevalence estimates and cessation rates.

RESULTS

The entry rate, as applied to the Norwegian case of intravenous drug use, increased from the mid-1980s to a peak in 2000, decreased up to 2003 and stabilized thereafter. The peak in Oslo appeared earlier (1998). The estimated level of the entry rate is sensitive to the rate of cessation.

CONCLUSION

We conclude that it is possible to expand the description of hard drug use epidemics beyond estimates of prevalence and incidence. The entry rate supplies a useful tool for our understanding of drug situations and decision making regarding drug policies.

Hard drug use in Norway

E.J. Amundsen & A. Bretteville-Jensen: Hard drug use in Norway

Background

Hard drug use has a variety of heavy personal, social and economic costs. Knowing the size of the hard drug use population, the types of drugs consumed and modes of consumption can help policy makers design better policies and facilitate decision making. Intravenous drug users constitute one subgroup of hard drug users. The aim of this article is to describe 1) how the prevalence of intravenous drug use is estimated in Norway and 2) how available data sources give insight about other types of hard drug use even though we can not estimate the true extent of such use. Some policy consequences are outlined.

Methods/Materials

Overdose deaths and the mortality multiplier method were used to estimate the prevalence of intravenous drug users. Other materials were used to supply the picture of hard drug use in Norway.

Results/Findings

The prevalence of intravenous drug users in Norway increased steadily from the early 1980s, peaked in 2001, decreased until 2003 and then stabilized. Heroin is the substance of choice of most hard drug users in Norway and injection is the preferred means of intake. Amphetamines are also injected or consumed in other ways, while heavy use of cocaine in the treatment population is low. The use of more than one substance is common.

Conclusion

Preventing and reducing heroin injection is the main challenge facing Norwegian policy makers. Other drugs pose a problem as well. Wide availability of substitution treatment has a successful record of helping many former heroin users avoid heroin. The risk of relapsing remains high, however, and of dying after drop out or completion. Current knowledge of hard drug use is fragmented and improved monitoring of this high risk group should be prioritized.

Heroin smoking and heroin using trends in Norway

A.L. Bretteville & A. Skretting: Heroin smoking and heroin using trends in Norway

The aim is to ascertain whether new ways of administering heroin have gained ground in Norway by examining three series of cross-sectional surveys (D1–D3). D1–D2 are based on postal questionnaires for which D1 is a representative sample of 15–20 year olds in Oslo (1968–2006) and D2 is a corresponding sample of 21–30 year olds (1998, 2002, 2006). D3 is based on personal interviews and consists of users of a needle-exchange service in Oslo (1993–2008). Despite a substantial rise in illegal drug use over the study period, there is no indication of increased heroin use by young people. The prevalence rates are relatively low for all heroin use (1–2%). Routes of heroin administration seem to have changed, however, as more young people (21–30 years) now report having smoked heroin and fewer report having injected the drug. There also seem to be changes in drug use patterns among current injecting drug users (IDUs). Splitting the sample by year of injection debut, we find among those starting since year 2000; i) a rise in average injection debut age of 10 years (25.6 versus 15.5 years); ii) a higher proportion with heroin smoking experience (74% versus 53%); and iii) a higher proportion having smoked heroin before injecting the drug (73% versus 16%), compared to the IDUs debuting before 1980. Consequently, the data suggest changes in drug use patterns, particularly heroin use, among recreational users and heavy drug users. So, in addition to an increase in the number of IDUs, it seems likely that the number of heroin smokers has risen too.

To legalize or not to legalize? Economic approaches to the decriminalization of drugs

Drug legalization is gaining ever-widening support in most Western societies. A liberalization of current drug laws will most probably lead to a fall in drug prices. The present article focuses on recent economic studies examining the effects of a fall in prices on quantities consumed and recruitment. Estimates of price elasticities indicate that a substantial increase in consumption by current drug users should be expected if prices decrease, whereas estimates of participation elasticities suggest an increase in the number of users. Tests of the so-called gateway theory (i.e., whether the use of a less harmful drug increases the risk of future use of more harmful drugs) offers less unambiguous results.

Where have all the young girls gone or where do all the men come from? Change and lack of change in demographic characteristics of the norwegian heroin user population

A rough estimate indicates that women amount to one third of the heroin user population in Norway. However, among the youngest users females account and have accounted for a larger proportion. Given this greater representation of females in the younger age groups one would expect that the gender difference in the general population of users would be reduced over time due to a cohort effect. However, the ratio of male to female users has remained stable. The prevailing explanation for this stability is based on the claim that women are more likely to overcome their abuse. This paper addresses both the basis for the assumption of a missing cohort effect and examines an alternative explanation linked to the way into abuse rather than the way out. The study primarily draws upon two distinct data sources. The first body of material consists of interviews carried out in the period 1993-1997 with people attending the only needle exchange service in Oslo. The second data source consists of police records, which provide the number of persons arrested each year in the period 1984-1997 for using, possessing or selling heroin distributed by age and gender. We find that the age of injection debut has increased and that this is especially true for male users. Applying a simple quantitative model, the effect a change in recruitment may have on the male-to-female ratio is analysed. The results indicate that a higher debut age may have contributed to stabilizing the gender gap. The finding suggests that more research is needed on the conditions of recruitment in order to better predict the future population demographics and to avoid hasty and incorrect conclusions.

[Sex differences concerning the habit patterns and health among intravenous heroin addicts in Oslo]

The issue addressed below concerns sex differences in consumption patterns and ways of financing the drug habit among intravenous heroin users. The findings are linked to recorded differences in various health indicators. The article is based on data collected through 1,840 interviews with heroin abusers who contacted the "Needle-Exchange Bus" in Oslo during the years 1993-97. Analysis indicates the existence of substantial differences between women and men along a number of variables. Women report injecting more frequently than men and using on average more heroin per injection. Women also finance their drug habit differently, as more than half of them report some income from prostitution. The finding may seem paradoxical as women also appear to have a lower risk of dying from an overdose/poisoning and a lower risk of contracting hepatitis A and B than male injecting misusers. The risk of contracting HIV and other sexually transmitted diseases, on the other hand, appears to be greater among female injectors.

Addiction and discounting

In 1988, Becker and Murphy [Becker, G.S., Murphy, K.M., 1988. A theory of rational addiction. Journal of Political Economy, 96, 675-700.] launched a theory in which they proposed that the perspective of rational decision-making could be applied also to cases of addictive behaviour. This paper discusses the theory's assumptions of interpersonal variation and stability in time preferences on the basis of estimates derived from three groups of people with different consumption levels of illegal intoxicants. We find that active injectors of heroin and amphetamine have a higher discount rate than a group reporting that they have never used the substances. Of greater interest, though not in accordance with Becker and Murphy's assumption of stability, we also find that the discount rate among active and former users differs significantly. These findings raise the question of whether a high time-preference rate leads to addiction or whether the onset of an addiction itself alters people's inter-temporal equilibrium.

Gender, heroin consumption and economic behaviour

The study examines differences in consumption and economic behaviour among male and female heroin users. A sample of heroin injectors (n = 1834) was interviewed near the needle-exchange service in Oslo and information on consumption, prices, and income was recorded. The consumption pattern of the heroin addicts varies by gender, with females consuming relatively less alcohol and cannabis but significantly more heroin than their male counterparts. The finding of greater heroin consumption among women is surprising. By means of a switching regression model, price and income elasticities for heroin are estimated. Women appear to be more responsive than men to changes in prices. However, the elasticities also differ substantially by dealing status, and non-dealers are more price-responsive than dealers. Non-dealing males emerge with a higher income elasticity compared with their female counterparts, whereas female dealers seem to respond more to changes in income than do male dealers.

The income-generating behaviour of injecting drug-users in Oslo

Drug users' income-generating behaviours, such as prostitution, acquisitive crime and small-scale dealing, have a major influence on the harm caused to the non-using population. Using data on the drug use and income sources of 900 drug-injectors in Oslo, this paper has two aims: to present data on Oslo income-generating behaviours and compare these with those in the Netherlands and Scotland; and to explore conceptual issues in the comparison of self-reported dealing income with other sources. Eighty-three per cent of respondents reported income from social benefit, and 43% had sold drugs in the last month. Half the females reported income from prostitution. The income-generation differences found in the comparisons section do not seem to reflect variations in drug and other social policies, but may relate to differences in the profitability of dealing. Using self-reported dealing income to compare the contributions of different income sources may be misleading, however, since it does not reflect financial profit or the value of dealers' drug consumption. Adjusted figures show that theft accounts for 23% of total drugs expenditure, while the corresponding figures for dealing and prostitution are 42% and 21%, respectively.