European Journal of Public Health, Vol. 15, No. 5, 580–586 Ó The Author 2005. Published by Oxford University Press on behalf of the European Public Health Association. All rights reserved. doi:10.1093/eurpub/cki031 Advanced Access published on July 21, 2005 ...... Alcohol and drugs ...... Recreational drug consumers: who seeks treatment?
R. Siliquini1,2, A. Morra1, E. Versino1, G. Renga1
Background: Recreational drug consumption represents a complex issue, because of the lack of a shared definition, settings and patterns of consumptions, and poorness of evidence-based treatments. In spite of the great number of users, just few seek specific treatment, probably representing those at major risk of
continuing and problematic use. The general objective of this study was to report the characteristics and Downloaded from https://academic.oup.com/eurpub/article/15/6/580/440048 by guest on 24 September 2021 main consumption patterns of recreational drug consumers treated in Regione Piemonte (Italy), in order to formulate hypotheses suitable for further research aimed at establishing more effective preventive intervention and treatment. Methods: All addiction treatment services in the region were required to fill in, for each user, a questionnaire reporting: contact of the user with the service, socio-demoghaphic data, drugs consumption and interventions/treatments. Results: Among 441 users, 70.3% were new users, 85.5% were males and the average age of consumption onset was 22 years. Psychiatric and traumatics events were present in 13.3% and in 17.9% of cases, respectively. The most frequent primary substances were cocaine (76.9%) and ecstasy (13.8%). Substances taken in association with primary drug are quoted in 75% of cases. Conclusions: The users that get in touch with services are those showing greater problems, representing, therefore, the main target for preventive public health interventions. Some interesting points can be noted: among patients treated, cocaine represents the main issue; females seem to be more sensitive to recreational drug effects; social class (education), settings and use habits are similar for recreational drugs users and heroin users.
Keywords: pattern of consumption, recreational drug consumers, treatment ......
ealth and social problems related to ‘recreational drug’ In Italy, <5% of Drug Services patients are treated for other H consumption are a relevant and complex field of research. drugs than heroin and alcohol.14 This complexity can be easily demonstrated by the lack of Nevertheless, the few consumers seeking treatment are likely a shared definition: designer drugs, disco drugs, recreational to represent those at major risk for continuing and proble- drugs, psychoactive drugs, synthetic drugs, etc.1–3 matic use and misuse; their description can supply data that What brings all these definitions together is the relatively will help to formulate hypotheses suitable for further research ‘new’ pattern of consumption4,5 and, on this issue, research aimed at establishing more effective preventive interventions presently offers poor and fragmentary evidence.4,6,7 and treatments. For these reasons, the European Monitoring Centre for Drugs The ‘recreational drugs’ working group of the Italian National and Drug Addiction (OEDT) set up a project aimed at monit- Institute of Health, Ministry of Health promoted a national oring typology and doses of market substances (Early Warning survey in order to gather data on recreational drug consumers System),8,9 and data collected showed, in 2001, a population treated by Drug Services in 2000. The aim of the project was to consumption prevalence varying from 0.5% to 3% for cocaine, describe patients’ characteristics and the treatments proposed. from 0.5% to 6% for amphetamine and from 4% to 18% for In Regione Piemonte, responsibility has been given to the legal psychoactive drugs sold with medical prescription.6 Regional Observatory on Addiction (OED), which performed Recreational drug consumption is a more problematic if we the survey in collaboration with the Department of consider the amount of substances used by young.3,10–13 A survey Public Health of Torino University. carried out to estimate consumption among 18-year-old users in The general objectives of this paper are: to describe the socio- our region showed a prevalence of 36.6% once-in-life drug demographic variables and the reasons that lead patients to seek consumption. Most of them used multiple drugs in association:7 treatment; and to outline the characteristics and the main con- the average number of substances used was 3.5. sumption patterns of recreational drug consumers treated in Moreover, even if recreational drug consumption has often Regione Piemonte and the delivered interventions. been described as not influenced by the risk factors usually associated with addiction, Italian data show a worrying inverse Methods correlation between social class and continuing use of ecstasy, similar to heroin addictives.7 Regione Piemonte is an area in north-western Italy ( 5 million Another limit in recreational drug research is the lack of inhabitants). All 63 addiction treatment services in the region current informative systems, because consumers very seldom were required to fill in a card/questionnaire for each recreational seek help or treatment from the National Health System. drug user. Every subject treated whose primary substance of con- ...... sumption was not opiates, cannabis or alcohol was defined as 1 Department of Public Health, University of Torino, Torino, Italy a ‘recreational drug user’. 2 Regional Observatory on Addiction, Regione Piemonte, Italy The questionnaire was structured in four main sections, refer- Correspondence: Roberta Siliquini, Associate Professor of Public Health, Department of Public Health, University of Torino, ring to (a) details of the contact of the user with the addiction Via Santena 5/bis 10126 Torino, Italy, tel: þ39 011 6706552, service, (b) socio-demographic data, (c) drug consumption and fax: þ39 011 6706551, e-mail: [email protected] (d) interventions and treatments. Recreational drug consumers 581
Section (a) was directed towards identifying the user as a ‘new committed to prison (table 1). Some significant differences user (for the service)’ or as an ‘already known user’, and towards can be seen between genders: females were more often students understanding how and why a subject comes into contact with or occasional workers. The prevailing level of education was an addiction service (person or institution that referred the secondary school (69.5%); 9.9% of subjects had a primary user to the service, subject’s requests at the first contact with school qualification, 18.6% a high or professional school the service, eventual other services—different from addiction qualification and 0.5% a degree (table 1). services—of first contact). Furthermore, it also considered the Referring to what led users to seek treatment, 50.4% of sub- presence of traumatic or psychiatric post-consumption events jects went autonomously to the service or were sent by affected (eventually reporting a specific diagnosis). persons (relatives or friends), 40.4% were sent by ‘institutions’ Section (b) evaluated users socio-demographic characteristics (public authorities, police forces) and 9.2% by social or health (gender, age, working condition, marital status, education). professionals (hospital, private psychologist or physician, Section (c) aimed to describe substances and habits of con- departments of mental health, social support services, etc.) sumption. It also required the indication of: consumption onset (data not shown). Subject’s requests at the first contact with age; favourite consumption setting; and the most frequent use the service were consistent with this data; in fact, half of the
habits (alone, together with friends or partner, etc.). Moreover, subjects expressed requests regarding relatives or in the affective Downloaded from https://academic.oup.com/eurpub/article/15/6/580/440048 by guest on 24 September 2021 substances taken in association with the primary drug were sphere and 47% expresses requests ‘forced’ by the law sanction surveyed. system (table 2). Section (d) refered to interventions: place, duration, Psychiatric events were reported on 13.3% of cards; among intervention typology and outcomes. these, in 46.6% a specific diagnosis was quoted. The most Among the 650 cards sent to the services to be filled in (related frequent event was personality disorder (29.6%), followed by to cases known on the basis of ministerial cards), 441 were sent depression (18.5%), drug dependence delirium (14.7%), panic back to the OED of Region Piemonte (67.8% of cards returned). disorders (11.1%) and psychotic disorders (11.1%) (table 3). Cards were returned from 70% of the regional services. Traumatic events were present in 17.9% of cards: road accidents in 27.1%, followed by sudden illness (26.1%), attempt at suicide (18.5%), brawls (18.5%) and falls (6.5%) (table 3). Results
Socio-demographic characteristics Patterns of consumption Among all recreational drug users (n ¼ 441), the majority of The most frequent primary substance (the substance that led the subjects (70.3%) were new users (for the service); 85.5% were subject to the service) was cocaine (76.9%), followed by ecstasy males [average age 27.8 years; standard deviation (SD) 7.36], (13.8%), and considerably lower percentages for amphetamine, 14.5% were females (average age 25.8 years old, SD 8.21). The hallucinogens, LSD, benzodiazepines and poppers. Table 4 average age of consumption onset for the primary drug was shows the significant differences between genders in primary 22 years, and no significative differences are seen between for substance consumption: cocaine was prevailing substance in genders (figure 1). It should be pointed out that the consump- males (79.3%), while females were characterized by a higher tion onset age was rather homogeneous for different drugs, ecstasy (20.3%), amphetamines and benzodiazepines consump- except ecstasy and hallucinogens, for which the onset occured tion (15.6% in total). 4 years earlier compared with the average age. Among 441 users treated at the addiction services, the pres- In all 51.5% of subjects had a regular job, 41.7% an occasional ence of substances taken in association to primary drug was job or unemployed, 5.2% were students and 1.1% were quoted on 75% of the cards; among these, in 27% the were two
30 males
females 25 total
20
15 age
10
5
0
s Z sy D ta ine B s m drugs cocaine ec ta luc/LSD e ho al h c h p sy m p a
Figure 1 Average age of onset for primary substance of use in the subjects treated in Regione Piemonte (Italy) Addiction Services (n ¼ 441) 582 European Journal of Public Health
Table 1 Recreational drug users treated in Regione Piemonte Addiction Services: working condition (n ¼ 439) and educational level (n ¼ 436)
Males Females Total
n % n % n %
Working condition ...... Regular job 203 54.1 23 35.9 226 51.5 ...... Unemployed 101 26.9 15 23.5 116 26.4 ...... Occasional job 49 13.1 18 28.1 67 15.3 ...... Student 15 4.0 8 12.5 23 5.2 ...... Other 7 1.9 – – 7 1.6 ...... Downloaded from https://academic.oup.com/eurpub/article/15/6/580/440048 by guest on 24 September 2021 P ¼ 0.0004 ...... Total 375 100 64 100 439 100 ...... Educational level ...... None 1 0.3 – – 1 0.2 ...... Primary school 37 9.7 6 9.4 43 9.9 ...... Secondary school 258 69.6 45 70.3 303 69.5 ...... Professional school 24 6.5 5 7.8 29 6.7 ...... High school 44 11.8 8 12.5 52 11.9 ...... Degree 2 0.5 – – 2 0.5 ...... No answer 6 1.6 – – 6 1.3 ...... P ¼ 0.9 ...... Total 372 100 64 100 436 100
Table 2 Subject’s requests at the first contact with the service in the recreational drug population treated in Regione Piemonte Addiction Services (n ¼ 441)
Category Request n % Assembled (%)
Affective/relational To end use 122 28.0 ...... To control anxiety 47 10.8 ...... To calm down parents 30 6.8 50.2 ...... To be admitted in a treatment centre 11 2.5 ...... To solve health problems 9 2.1 ...... Sent by institutions Sent by police forces 98 22.5 ...... Instead of prisona 82 18.8 46.6 ...... Instead of sanctionsa 23 5.3 ...... None/no answers None/no answers 19 3.2 3.2 ...... Total 441 100 100 a: Possibility provided by Italian law or three associated substances, while in 1% there were four Amphetamines were almost always used in association with or five drugs besides the primary one. The average number of other drugs (as an only substance in just 7.7%), mostly cocaine substances consumed was 1.99 for males and 1.89 for females. (33.3%), hallucinogens and LSD (33.3%), alcohol (25.0%) and Cocaine was taken as the only substance in 27.1% of cases; the cannabis (25.0%). most frequent substances taken in association were opiates The favourite consumption settings were, for all substances, (46.2%), cannabis (42.5%) and alcohol (28.7%). Ecstasy was private domiciles (30.4%), discos (25.3%), other public places taken in association with cocaine in 8.1% of cases. such as pubs, bars, etc. (21.8%), and open air places such as Ecstasy was taken as the only substance less frequently streets or parks (20.7%). Schools and stadiums were indicated as than cocaine (19.7%), and was mainly associated with cannabis favourite consumption settings in <1%. With regard to con- (59.2%), alcohol (26.5%) and cocaine (22.5%). Opiate drugs sumption habits, it was frequently declared that consumption were associated with ecstasy in just 18.3% of cases. takes place together with friends (58.7%); 34.7% declared using Recreational drug consumers 583
Table 3 Indication of psychiatric (n ¼ 58) or traumatic events (n ¼ 78) occurring after consumption in recreational drug consumers treated by Region Piemonte Addiction Services
Presence % Indication of diagnosis % Specific diagnosis %
Psychiatric event No 86.7 ...... Yes 13.3 ...... No diagnosis 53.4 ...... With diagnosis 46.6 ...... Personality disorders 29.6 ...... Depression 18.5 ...... Drug-dependence delirium 14.7
...... Downloaded from https://academic.oup.com/eurpub/article/15/6/580/440048 by guest on 24 September 2021 Panic disorders 11.1 ...... Psychotic disorders 11.1 ...... Dysthymic disorders 7.4 ...... Cognitive deficit 3.8 ...... Appraisal disorders 3.8 ...... Traumatic event ...... No 82.1 ...... Yes 17.9 ...... Road accident 27.1 ...... Sudden illness 26.1 ...... Attempt at suicide 18.5 ...... Brawl 18.5 ...... Falls 6.5 ...... Labour accident 3.3
Table 4 Frequency of consumption of primary substance (n ¼ 441) in recreation drug consumers treated by Regione Piemonte Addiction Services
Males Females Total
n % n % n %
Cocaine 299 79.3 40 62.5 339 76.9 ...... Ecstasy 48 12.7 13 20.3 61 13.8 ...... Amphetamines 10 2.7 3 4.7 13 2.9 ...... Psychoactive drugs 8 2.1 5 7.8 13 2.9 ...... Hallucinogens/LSD 5 1.3 1 1.6 6 1.4 ...... BDZ 4 1.1 2 3.1 6 1.4 ...... Gambling 2 0.5 – – 2 0.5 ...... Poppers 1 0.3 – – 1 0.2 ...... P ¼ 0.04 ...... Total 377 100 64 100 441 100
the substance alone and 6.6% together with the partner (data occurred outside of addiction treatment services, mostly in not shown). prison (data not shown). The interventions carried out and their frequencies are shown in table 5. Urinary controls represented the most frequent inter- Interventions vention (53.3%), followed by psychological colloquies (46.3%), In 92.7% of cases interventions were completely developed socio-educational help (44.7%) and medical intervention within the addiction service; in the remaining 7.3%, treatments (39.9%); 26.1% of subjects were treated pharmacologically. 584 European Journal of Public Health
Table 5 Frequency of different kinds of interventions account, with reference to its possible causes; in fact, even offered to recreational drug consumers treated in though it is probably true that recreational drug users seldom Regione Piemonte Addiction Services (n ¼ 1099) express their own treatment needs ( 40% of subjects are sent to an addicition service by public authorities or police forces), it n % should be pointed out that most addiction treatment services Urinary tests 235 53.3 were set up to provide support to another user typology ...... (primarily heroin users). Psychological colloquy 204 46.3 The gender distribution of recreational drug users is similar ...... 15 Socio-educational support 197 44.7 to that of heroin users; however, the age distribution is dif- ...... ferent. Recreational drug users are younger than heroin users Medical intervention 176 39.9 ...... by 10 years. However, it should be stressed that the average age Pharmacological treatment 115 26.1 at the first contact with addiction services in recreational drug ...... users, although lower than that for heroin users, is >19 years, the Socio-psychological support 77 17.5 ...... age at which people usually achieve a secondary school degree. Psychiatric intervention 32 7.3 These data, together with the fact that 80% of the subjects Downloaded from https://academic.oup.com/eurpub/article/15/6/580/440048 by guest on 24 September 2021 ...... do not have a secondary school degree and that 30% are unem- Admission to a specific treatment centre 27 6.1 7 ...... ployed, confirm that, as stated in previous publications, the Socio-medical treatment 21 4.8 problematic consumption does not involve all social classes, but ...... is more frequent in lower socio-economic classes, in accordance Group treatment 15 3.4 with the known model for heroin users. Regarding the age of first consumption, it should be pointed The total of percentages is higher than 100 because of the possibility of each subject receiving more than one out that ecstasy and hallucinogen consumption are among the intervention earliest (average age 18 years), in particular among females, while psychoactive legal drug use is considerably later for females, although the average age is low for both genders. It In just 6.1% of cases the subject was sent to a specific treatment therefore emerges that, among the subjects which, for behavi- centre; the least frequent intervention was represented by group oural or health reasons, get in touch with the services, illegal treatment (3.4%). Usually (30%) two combined interventions synthetic substances are used earliest (41% of the users between were received; in general, 80.5% of users received one to three 12 and 16 years old), while psychoactive legal drugs and cocaine kinds of treatments. are often used for the first time in post-teenage age groups. Referring to treatment outcomes, 22.7% gave up the treatment These data confirm a preference among teenagers for the and 1.2% of subjects died (data not shown). drugs that are easiest to find on the market and the most suitable to be taken in social contexts; this information should be taken Discussion into account by services since, obviously, the planning of pre- ventive or treatment interventions should not overlook the age The discrepancy between the clear perception of a phenomenon classes they are addressing. of great social relevance, such as that of recreational drug con- Subjects contact services for affective reasons (50.2%), or are sumption, and the difficulty in getting an accurate description sent by institutions, public authorities and police forces of it is becoming more and more evident; the elements of com- (46.6%). So, it is clear how, while a considerable percentage plexity have been mentioned above. Therefore, it is extremely show an expressed need (be it of physical, psychic or social difficult to cope with health needs deriving from recreational health), the other 50% come into contact with services only drug use, not only because in most cases the needs are not in order to avoid administrative sanctions. expressed, but, above all, because users often reject interventions Seldom (4.1%) are patients referred to services by other and supports provided by social and health-care systems. health-care services (hospitals, emergency departments, mental The aim of this study was to describe a very limited aspect health services or general practitioner): this could suggest that of the problem (among recreational drugs users, only a small recreational drugs represent a hidden medical issue. Relevant minority comes into contact with addiction treatment services), psychiatric or traumatic post-consumption events are recorded analysing crucial aspects, such as users’ typology and consump- in anamnesis, and a large percentage of subjects undergo a tion patterns. It is most probable that the recreational drug users medical/psychiatric intervention (47%) and/or a pharmacolo- that do get in touch with services are those showing greater gical treatment (26%). These data illustrate how the recreational post-consumption health problems, therefore representing the drug phenomenon, besides being ‘underground’ in relation to main target for preventive public health interventions. the consciousness of its spreading, needs to be analysed in The degree of representativeness of the data collected in this depth, with a focus on its effects.5 region can be considered good, because of the percentage of It should be also underlined that cocaine consumption is the described cases and by reason of a further analysis of the cases most problematic among non-opiate drugs, for both frequency for which the services did not provide data: missing data were and trend, characterized by a continuous increase in its use,15,16 not due to systematic errors, but to a failure of compliance of while meta-amphetaminic synthetic substances interest a low some services, the patients from which are not different from the percentage of subjects. rest of the region.15 Moreover, although literature17 displays a male:female ratio Furthermore, the results presented in this study can be of 2–3:1 for ecstasy consumption, females receiving treatment regarded as representative also at a national level, not only for amphetamine and meta-amphetamine consumption in our because Regione Piemonte patients represent 25% of the popu- region as in Italy, represent >50% of patients; even though the lation covered by national research, but also because results do total number is very low, this could mean that females are more not differ from Italian ones.16 sensitive to the issue (and consequently more open to the treat- Recreational drug users represent, in Regione Piemonte, 5% ment), or more exposed to problematic use. of total addiction services patients (7.3% in Italy),16 notwith- Recreational drug use is characterized by a high frequency of standing the large diffusion of consumption shown by other polyconsumption: just 25% of subjects use only one substance, scientific studies carried out on the same population.7 This but when cocaine is excluded, this percentage drops to 16%. limited use of services is an element that should be taken into Polyconsumption seems to be much higher in subjects who Recreational drug consumers 585
come into contact with services because of problematic use Piemonte. The study was made possible thanks to the of amphetamines, meta-amphetamines and legal psychoactive cooperation of Regione Piemonte Drug Addiction Services. drugs (probably used not only as curative self-prescription but also as substance abuse). On this basis, it is necessary to identify related health out- Key points comes and to set survey activities based on hospital admissions and mortality able to quote all substances taken by the subject. In spite of a large number of recreational drugs users, Private domiciles and open air places represent >50% of use only few of them require treatments. In order to for- settings; these data, which are quite similar to the national mulate hypotheses we study the characteristics of users ones,16 should bring attention to use habits, which seem to treated in our Region Piemonte. no longer be limited to traditional social transgression settings, Educational level of recreational users under treatment like discos and raves, and to have turned from group consump- is quite similar to heroin addictive one; among patients tion to private or alone consumption. This evidence, in particu- treated for non-opiate substances, cocaine represents lar if pointed out in higher risk groups (such as persons treated the main issue. There are no evidence-based treatments for the prob- at addiction services), introduce alarming new elements in rela- Downloaded from https://academic.oup.com/eurpub/article/15/6/580/440048 by guest on 24 September 2021 tion to the low possibility of controlling use when it occurs in lematic consumption of recreational drugs. private settings,18 and the practice of taking substances alone or The synthesis of the different variables can give useful in small groups, very well-known among heroin users, intro- cues and ideas for the definition of primary prevention duces new risk factors such as users’ marginalization from their programmes directed at populations at higher risk contemporaries. for a problematic use and the future research about As regards interventions, we are dealing with a certain homo- treatments. geneity: while urinary tests constitute a law obligation for sub- jects sent to the services by public authorities and police forces, psycho-social/educational and medical/pharmacological References interventions occur with the same frequency. 1 Geninatti S, Bellavia F, Chieppa G. 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This work was funded by internal funds Dipendenze e dei comportamenti di abuso/Quaderni; Franco Angeli of Osservatorio Epidemiologico delle Dipendenze-Regione Editore, 2003. 586 European Journal of Public Health
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