Anna Maria Bargagli

Retention in treatment of heroin users in Italy: the role of treatment type and of methadone maintenance dosage.

Retention in treatment among 1503 heroin users attending public treatment centres in 1995 was studied. Three different treatments were considered: methadone maintenance, drug-free program and naltrexone. The retention rate after 1 year was 40% for patients in methadone maintenance, 18% in naltrexone and 15% in drug-free program. For patients in maintenance, methadone dosage and clinic policy were the most important factors for retention. Patients taking > or = 60 mg/day and 30-59 mg/day were respectively 70 and 50% more likely to remain in treatment than those receiving a < 30 mg daily dose. Patients in maintenance-oriented clinics were 30% more likely to remain in treatment than those in abstinence-oriented centres.

A persistent rise in mortality among injection drug users in Rome, 1980 through 1992.

OBJECTIVES The purpose of the study was to analyze overall and cause-specific mortality among injection drug users in Rome. METHODS A cohort of 4200 injection drug users was enrolled in drug treatment centers from 1980 through 1988 and followed up until December 1992. RESULTS The age-adjusted mortality rate from all causes increased from 7.8/1000 person-years in 1985/86 to 27.7/1000 in 1991/92. The rise was mainly attributable to acquired immunodeficiency syndrome (AIDS), but mortality from overdose and other causes increased as well. The cumulative risk of death by the age of 40 was 29.3%. CONCLUSIONS The impact of AIDS deaths appears to be additional to a persistent increase of mortality for all other causes.

Changes in the effects of heat on mortality among the elderly from 1998–2010: results from a multicenter time series study in Italy

BackgroundThis multicenter study is aimed at estimating changes in the effect of high temperatures on elderly mortality before and after the 2003 heat waves and following the introduction of heat prevention activities.MethodsA total of sixteen cities were included in the study. City-specific relationships between maximum apparent temperature (MAT) and elderly daily mortality before (1998–2002) and after (2006–2010) intervention were modelled through non-linear distributed lag models and estimates were combined using a random effect meta-analysis. We estimated the percentage change in daily mortality for 3°C variations in MAT above the 25th percentile of the June city-specific 1998–2002 distribution.A time-varying analysis was carried out to describe intra-seasonal variations in the two periods.ResultsWe observed a reduction in high temperatures’ effect post intervention; the greatest reduction was for increases in temperature from 9°C to 12°C above the 25th percentile, with a decrease from +36.7% to +13.3%. A weak effect was observed for temperatures up to 3°C above the 25th percentile only after. Changes were month-specific with a reduction in August and an increase in May, June and September in 2006–2010.ConclusionsA change in the temperature-mortality relationship was observed, attributable to variations in temperature distributions during summer and to the introduction of adaptation measures. The reduction in the effect of high temperature suggests that prevention programs can mitigate the impact. An effect of lower temperature remains, indicating a relevant impact of temperature at the beginning of summer when the population has not yet adapted and intervention activities are not fully operational.

Susceptibility to heat wave-related mortality: a follow-up study of a cohort of elderly in Rome

BackgroundFew studies have identified specific factors that increase mortality during heat waves. This study investigated socio-demographic characteristics and pre-existing medical conditions as effect modifiers of the risk of dying during heat waves in a cohort of elderly residents in Rome.MethodsA cohort of 651,195 residents aged 65 yrs or older was followed from 2005 to 2007. During summer, heat wave days were defined according to month-specific thresholds of maximum apparent temperature. The adjusted relative risk of dying during heat waves was estimated using a Poisson regression model including all the considered covariates. Risk differences were also calculated. All analyses were run separately for the 65-74 and 75+ age groups.ResultsIn the 65-74 age group the risk of dying during heat waves was higher among unmarried subjects and those with a previous hospitalization for chronic pulmonary disease or psychiatric disorders. In the 75+ age group, women, and unmarried subjects were more susceptible to heat. Furthermore, a higher susceptibility to heat among those with previous hospitalization for diabetes, diseases of the central nervous system (CNS), psychiatric disorders and cerebrovascular diseases resulted from risk differences.DiscussionResults showed a higher susceptibility to heat among those older than seventy-five years, females and unmarried. Pre-existing health conditions play a different role among the two considered age groups. Moreover, compared with previous studies the pattern of susceptibility factors have slightly changed over time. For the purposes of public health programmes, susceptibility should be considered as time, space and population specific.

An overview of systematic reviews on cannabis and psychosis: discussing apparently conflicting results.

ISSUES Cross-sectional surveys have revealed that cannabis is the most widely used illicit substance in Western countries. Cannabis intoxication can lead to acute, transient psychotic symptoms and the short-term exacerbation of pre-existing psychotic symptoms. However, controversy exists about whether cannabis can actually cause long-term psychosis. APPROACH We summarised the findings of systematic reviews on the association between cannabis use and psychosis, searching MEDLINE, EMBASE and CINAHL up to August 2007. We assessed the methodological quality, selected the better quality reviews and analysed reasons for discordant results. KEY FINDINGS We included five systematic reviews. Four of the reviews performed a meta-analysis and showed a consistent association between cannabis use and psychosis; the fifth review considered psychological problems more broadly, did not perform a meta-analysis and reported an inconsistent association. The reasons for discordance were: different outcomes (psychosis vs. psychological problems), different inclusion criteria for primary studies and different methods for summarising the results. IMPLICATIONS This overview shows a consistent association between cannabis use and psychotic symptoms, though it is not possible to draw firm conclusions about a causal relationship. Reverse causality and residual confounding cannot be excluded. An interaction with other environmental and genetic factors is difficult to ascertain. CONCLUSION We conclude that there is insufficient knowledge to determine the level of risk associated with cannabis use in relation to psychotic symptoms and that more information is needed on both the risks of cannabis use and the benefits of preventive interventions to support evidence-based approaches in this area.

Effectiveness of Therapies for Heroin Addiction in Retaining Patients in Treatment: Results From the VEdeTTE Study

Treatment is effective in reducing heroin use and clinical and social problems among heroin addicts. The effectiveness is related to the duration of treatment. “VEdeTTE” is an Italian longitudinal study funded by the Ministry of Health to evaluate the effectiveness of treatments provided by the National Health Services. The study involved 115 drug treatment centers and 10,454 heroin users. Clinical and personal information were collected at intake through a structured interview. Treatments were recorded using a standardized form. Survival analysis and Cox Proportional Hazard model were used to evaluate treatment retention. Five thousand four hundred and fifty-seven patients who started a treatment in the 18 months of the study were included in the analysis: 43.2% received methadone maintenance therapy (MMT), 10.5% therapeutic community, and 46.3% abstinence-oriented therapy (AOT). The likelihood of remaining in treatment was 0.5 at 179 days. The median daily dose of methadone was 37 mg. Psychotherapy was provided in 7.6% of patients receiving methadone and 4.9% of those in therapeutic community. Type of therapy was the strongest predictor of retention, with AOT showing the lowest retention. In MMT patients, retention improved according to dose. Living alone, psychiatric comorbidity and cocaine use increased the risk of dropout. Psychotherapy associated halved the risk of dropout.

Surveillance of Summer Mortality and Preparedness to Reduce the Health Impact of Heat Waves in Italy

Since 2004, the Italian Department for Civil Protection and the Ministry of Health have implemented a national program for the prevention of heat-health effects during summer, which to-date includes 34 major cities and 93% of the residents aged 65 years and over. The Italian program represents an important example of an integrated approach to prevent the impact of heat on health, comprising Heat Health Watch Warning Systems, a mortality surveillance system and prevention activities targeted to susceptible subgroups. City-specific warning systems are based on the relationship between temperature and mortality and serve as basis for the modulation of prevention measures. Local prevention activities, based on the guidelines defined by the Ministry of Health, are constructed around the infrastructures and services available. A key component of the prevention program is the identification of susceptible individuals and the active surveillance by General Practitioners, medical personnel and social workers. The mortality surveillance system enables the timely estimation of the impact of heat, and heat waves, on mortality during summer as well as to the evaluation of warning systems and prevention programs. Considering future predictions of climate change, the implementation of effective prevention programs, targeted to high risk subjects, become a priority in the public health agenda.

VEdeTTE, a longitudinal study on effectiveness of treatments for heroin addiction in Italy: study protocol and characteristics of study population.

The aim of this study was to provide a methodological overview of the study design of the national evaluation large-scale study VEdeTTE and a description of the VEdeTTE study population and to compare enrollments with refusals and the study population with the overall clients at the National Health System (NHS) treatment centers. VEdeTTE is a longitudinal study of heroin addicts recruited in 115 NHS treatment centers in Italy, 1998–2001; 11,903 people were enrolled, 3876 refused to participate; data were analysed on 10,454. Information from refusals was compared to enrollments. The characteristics of the cohort were compared to those of all patients treated in 1999 in Italy. Refusals had a lower educational level and less regular occupational status than those enrolled. Fourteen percent of enrolled patients were women; heroin users in the VEdeTTE study were older than patients attending all NHS treatment centers in Italy; incident cases were less represented. The majority of participants had more than 8 years of education, 33.5% were regularly employed, and only 2% did not have a fixed address. Injectors were 72.3%; 40.6% had a previous overdose, and 14.3% had been imprisoned for life; 15.7% shared injection equipment during the previous 6 months. The proportion of participants reporting heroin use approximately halved from the beginning of the current treatment to the time of the interview. The VEdeTTE study is the biggest cohort of heroin addicts attending treatment centers in Europe. The Italian heroin-addicted population under treatment seems to have low level of education but good social integration. Compared with men, women show a higher severity. Participants show a beneficial effect of treatment.

Changing Pattern of Drug Abuse among Patients Entering Treatment in Lazio, Italy, between 1996 and 2003: Transition from Heroin to Cocaine Use

Aim: This study describes temporal changes of the pattern of substance abuse among drug users in treatment in Lazio, Italy. Methods: We used individual data from the surveillance system of drug users of the Lazio region. We measured temporal changes in: the number of drug users in treatment, main and any substance of abuse, and mode of referral to treatment. Results: Among new clients, the proportion of heroin use decreased from 78.2% in 1996 to 37.6% in 2003 (p < 0.0001), while cocaine use increased from 4.1% in 1996 to 30.1% in 2003 (p < 0.0001). In 2003, any use of cocaine was reported by 43.1% of new cases as compared to 38.9% taking heroin, 36.8% cannabis and 5.3% other substances, 41.9% using more than one substance. In 2003, 37.7% of new patients were referred to treatment by the police as compared to 10.4% in 1996. Conclusions: Heroin use has been replaced by cocaine among people coming to treatment centres for the first time. The main mode of access to treatment of new cocaine and cannabis users occurred through mandatory referral by the police. Routine surveillance systems of treatment demand are essential to monitor temporal trends of patterns of drug use in order to plan proper treatment strategies.

Methadone treatment in clinical practice in Italy: need for improvement

Background: Methadone at appropriate doses has been demonstrated to be the most effective means for retaining patients in treatment and suppressing heroin use. Aim: To describe the modalities of day-to-day provision of methadone maintenance treatments (MMT) in Italian public health centres and to analyze the duration of MMTs by dose and by association with psychosocial treatments. Patients and Methods: We analyzed 8,378 subjects, 18 years of age or over, enrolled between September 1998 and March 2001 in one of 115 public treatment centres for heroin dependence in Italy. Treatment data were collected for each subject from enrolment to the end of the study period (maximum of 18 months). Results: Of the total of 29,495 treatments delivered, 21.0% were methadone maintenance, and 34.4% were methadone detoxification. Fifty percent of MMTs offered had a mean dose less than or equal to 40 mg/day, and only 19% had doses higher than or equal to 60 mg/day; treatments with doses higher than 60 mg/day lasted longer than treatments with lower doses. Differences in treatment length were observed between MMTs associated with a psychosocial treatment and those offered alone, only for doses <60 mg/day. Conclusions: In Italy, MMTs are delivered at inappropriate doses in more than 80% of the cases. The increase of methadone doses to adequate levels as indicated by the literature is necessary to ensure proper and effective use of MMTs in public treatment centres for heroin users.