Barcelona snapshots

Prof. Antoni Gual

Antoni Gual psychiatrist Controversies Psiquiatry Barcelona
Institute of Neuroscience, Hospital Clinic Barcelona, Spain
Talk Prevention of substance abuse in mental health settings
Date Thursday, September 16th, 2021
Time 18:15 - 19:00
Round Table 2. Addictions


Dr Antoni Gual is a psychiatrist, Emeritus Researcher at IDIBAPS, and former Head of the Addictions Unit at the Neurosciences Institute, Clinic Hospital, University of Barcelona, Spain, and also acts as Alcohol Consultant at the Health Department of Catalonia. He has coordinated several EU funded projects in the field of addictions and has also been PI of several pharmacological clinical trials. He has published more than 150 articles in peer reviewed journals and edited several books.

He is Vicepresident of the International Network on Brief Interventions for Alcohol Problems (INEBRIA), past-President of the European Federation of Addiction Scientific Societies (EUFAS) and past-President of the Spanish Scientific Society for the Study of Alcohol and Alcoholism.

Over the years he has been involved in several clinical trials for the treatment of addictions. Amongst them, he was PI in the pivotal spanish study on acamprosate, and researcher in RCT trials conducted with naltrexone, tiapride, bromocriptine, sertraline and mavoglurant. He was PI in the spanish sodium oxibate RCT, and in one of the pivotal trials of nalmefene (Esense 2).

In the field of brief interventions, Dr Gual has been involved in the development of the Catalan program on brief interventions in PHC since its creation in 1995, and has developed also brief motivational interventions in the Emergency Room. He has participated in several EU funded studies focusing on Brief Interventions (Smart, Bistairs, EWA, Scala), being project coordinator in some of them (Phepa, Amphora, Odhin, Deep Seas).


Drugs of abuse are an important public health problem worldwide. The most recent data show that alcohol, tobacco and cannabis continue to be the most widely abused drugs in western countries. In 2019, tobacco accounted for 7.69 million deaths and 200 million disability-adjusted life-years (DALYs) lost worldwide. The global burden of disease study reports alcohol use disorders as the most prevalent of all substance use disorders, with 100.4 million cases estimated in 2016, and 99.2 million DALYs attributable to alcohol. Cannabis use disorders account for 22.1 million cases and opioid use disorders 26.8 million cases. All illicit drugs taken together (excluding alcohol and tobacco) are responsible of 31,8 million DALYs.

It is widely documented that health settings offer unique opportunities for early identification of risky drug use, and a wealth of literature has shown the efficacy and effectiveness of brief interventions in the prevention of drug-related problems.

Mental health centers and visits, in particular, are settings where prevention of drug abuse is even more important, since drug use is more prevalent among this group of patients, and the risks associated with drug use are also higher than in the general population. The concept of risky use is especially relevant in psychiatric populations, given that, for some drugs (e.g., cocaine), any risk should be considered risky, and for others (e.g., cannabis) the threshold for risky use should be lower than for general populations. Drugs can have a deleterious impact on the evolution of psychiatric disorders, and pharmacological interactions between drugs and prescribed pharmacological treatments are relevant.

To prevent drug problems in mental health settings requires the availability of validated tools, both for early identification and intervention. For early identification the basic options are screening tools and quantity & frequency questionnaires. Among the former, the most widely used are AUDIT and AUDIT C (alcohol), Fagerström (nicotine), CAST and CUDIT (cannabis) and ASSIST and DAST (covering a wide range of drugs). All of them have been validated in psychiatric populations and the WHO-developed ASSIST is probably the first option to be recommended in psychiatric settings. When it comes to quantity & frequency questionnaires, a major issue is the comparable measurement of quantity consumed, which requires the development of standard units, as it has been done in alcohol (standard drink), cannabis (standard joint unit) and tobacco (cigarette).

Biological markers of drug use have improved notably in recent years, becoming also widely available. In the case of alcohol, new techniques to detect metabolites such as ethyl glucuronide and phosphatidylethanol, have enlarged the detection window markedly. For most drugs, urinalysis or hair analysis can help to reliably identify drug use.

Risky drug users can benefit from brief interventions. Classically, those interventions include feed-back on the results of the screening, non-judgmental advice to reduce or stop drug use, monitorization of the evolution, and referral options when needed.

Unfortunately, patterns of drug use are seldom screened in psychiatric settings. In many countries patients with addiction problems have commonly been rejected by traditional psychiatric services. This has changed consistently in the 21st century and the need for integrated treatment for patients with dual diagnosis is well established. Nevertheless, drug use remains an area that is often under-explored in many psychiatric settings. There are scientific, ethical and clinical reasons to advocate for a routine screening of drug use patterns in psychiatric patients, leading to brief interventions, specific treatments or referral, if needed.


Madero S, Oliveras C, Pons MT, Sague M, López-Pelayo H, Gual A, Balcells M. (2020). Cannabis use the week before admission to psychiatric in-patient service as a marker of severity. J Psychiatr Res. 2020 Oct;129:40-46. doi: 10.1016/j.jpsychires.2020.05.028. Epub 2020 May 29. PMID: 32563776.

Bruguera P et al. (2020). Detección y registro del consumo de alcohol en Urgencias. Rev. Esp. Salud Publica [online]. 2020, vol.94, 202004019. Epub 02-Nov-2020. ISSN 2173-9110.

Barrio P et al. (2018). Filling the gap between lab and clinical impact: An open randomized diagnostic trial comparing urinary ethylglucuronide and ethanol in alcohol dependent outpatients. Drug Alcohol Depend. 2018 Feb 1;183:225-230. doi: 10.1016/j.drugalcdep.2017.11.015. Epub 2017 Dec 27. PMID: 29291550.

López-Pelayo H et al. (2021). Standard units for cannabis dose: Why is it important to standardize cannabis dose for drug policy and how can we enhance its place on the public health agenda? Int J Drug Policy. 2021 Jul 7;97:103350. doi: 10.1016/j.drugpo.2021.103350. Epub ahead of print. PMID: 34246016.

GBD 2016 Alcohol and Drug Use Collaborators. (2018). The global burden of disease attributable to alcohol and drug use in 195 countries and territories, 1990-2016: a systematic analysis for the Global Burden of Disease Study 2016. Lancet Psychiatry. 2018 Dec;5(12):987-1012. doi: 10.1016/S2215-0366(18)30337-7. Epub 2018 Nov 1.