Benedetta Pajusco

Factors Associated with Hepatitis C Virus Infection in Injection and Noninjection Drug Users in Italy

We describe the prevalence of hepatitis C virus (HCV) infection among noninjection users of heroin in Italy and compare the prevalence of HCV infection among noninjection drug users (NIDUs) and injection drug users (IDUs). Multiple logistic regression analysis of data from NIDUs showed that hepatitis B virus (HBV) infection status was the only independent predictor of HCV seroprevalence. Among IDUs, the number of years of drug use and HBV and human immunodeficiency virus infection status were independent predictors of HCV seropositivity. We found an HCV infection prevalence of 20% among NIDUs. This rate was much lower than that for IDUs, who are 11 times more likely to have antibodies against HCV. The prevalence of HCV infection was much higher than that of HBV infection among the IDUs. In contrast, the prevalence of HBV infection was slightly higher than that of HCV infection among unvaccinated NIDUs. The prevalence of HCV infection among long-term IDUs approached true population saturation; among long-term NIDUs, however, it appeared to plateau at approximately 40%. Additional research on HCV infection among NIDUs is needed to develop a strategic prevention program for this patient subgroup.

Tobacco Addiction and Smoking Status in Heroin Addicts under Methadone vs. Buprenorphine Therapy

Aims of the present investigation were: (i) to assess the prevalence of current smokers and relative smoking status among a large number of heroin addicts attending opioid-substitution therapy prevalence; (ii) to evaluate the relationship between the type (methadone, buprenorphine) and dosage of opioid substitution therapy and nicotine dependence. Three hundred and five (305) heroin addicts under opioid-substitution therapy were recruited at five Addiction Units. All participants completed a questionnaire assessing sociodemographic information, type and dose of opioid-substitution therapy, smoking history and status, Fagerström Test for Nicotine Dependence (FTND), and the Zung Self-Rating Depression scale (SDS). 298 subjects, out of 305 (97.2%) were smokers, with an average of 20.5 cigarette/day and a median FTND of 6. Our data confirmed the high prevalence of smokers among heroin addicts, the highest described in the literature to date among heroin addicts under substitution therapies, without any significant difference between methadone vs. buprenorphine therapy groups. There was no correlation between dose of methadone or buprenorphine and average number of cigarettes/day. Patients in substance abuse treatment very frequently smoke cigarettes and often die of tobacco-related diseases. Substance abuse treatment programs too often ignore tobacco use. We hope that these findings will help to incorporate smoking cessation in substance abuse treatments.

Hepatitis C virus infection: prevalence, predictor variables and prevention opportunities among drug users in Italy

Summary. The study assessed rates and predictor variables of hepatitis C virus (HCV) infection among drug users receiving pharmacological treatment for opiates addiction.

Progressive decrease of hepatitis B in a cohort of drug users followed over a period of 15 years: The impact of anti-HBV vaccination

In the Western world, the population at the highest risk of HBV infection is probably that of illicit drug users (DUs). Since 1985, 1 Public Health Centre for Drug Users (PHCDU), in north-eastern Italy, has been asking all heroin DUs, whether in treatment or not, to undergo screening for HIV, HBV and, since 1989, for HCV infection. Since 1988 the Centre has proposed HBV vaccination to all patients who were negative for all HBV markers. From 1985 to 2001 895 heroin DUs were screened, 726 males and 169 females. 442 (49.4%) were negative to HBV markers at the first control and 72.4% received at least 1 dose of the vaccine. 320 DUs were vaccinated and a total of 995 doses of recombinant vaccine were administered. The anti-HBc antibody appeared in 2 vaccinated patients out of 258 DUs undergoing controls, while 13 seroconversions for anti-HBc occurred in 45 DUs who had refused to be vaccinated. On the basis of these results, HBV vaccination of DUs can be strongly recommended. Vaccination showed a good adherence in a population difficult to treat and can have a leading role in reducing HBV infection in DUs and their contacts.

Risk factors of peptic ulcer in 4943 inpatients.

Background Over the past few years, major changes have taken place in the treatment of gastroduodenal peptic ulcer. Aim To evaluate risk factors associated with the incidence of peptic ulcer in inpatients. Methods From 2001 to 2004, the number of prescriptions of H2-antagonists and proton pump inhibitors (PPIs) in each department of Verona University Hospital was monitored. Over the same period we prospectively recorded the number of upper endoscopies per department for inpatients with a diagnosis of peptic ulcer. Results We analyzed 4943 inpatients. A significantly decreasing trend in H2-antagonist prescriptions (r=−0,88; P<0.001) and an increasing trend in PPI prescriptions (r=0.97; P<0.001) were observed. The endoscopic incidence of duodenal ulcers decreased linearly from 2001 to 2004 as follows: 6.5% (94/1439) in 2001, 5.6% (82/1473) in 2002, 4.5% (63/1411) in 2003, and 3.1% (22/702) (P<0.001) in 2004. Gastric ulcer incidence, sex, age, indication for endoscopy, use of nonsteroidal anti-inflammatory drugs (NSAIDs), presence of Helicobacter pylori (32%), and smoking and drinking habits showed no significant changes over the study period. Considering time-dependent variables, multivariate regression analysis identified only PPI use and NSAID use as factors predictive of duodenal ulcer but not of gastric ulcer. Conclusions In inpatients, PPIs are associated with a reduced risk of duodenal ulcer, whereas NSAIDs are associated with an increased risk. Gastric ulcer was not associated with any increased or degreased risk with the 2 above-mentioned variables.

Lormetazepam addiction: data analysis from an Italian medical unit for addiction

Background The purpose of this study was to determine, in the context of a hospital addiction unit, which benzodiazepines were abused and to look for correlations with the characteristics of detoxified patients. Methods A retrospective study was carried out using the database of hospital admissions to the addiction unit for detoxification from 2003 to 2010. Results Of 879 admissions to the addiction unit during the seven-year period, 281 were for benzodiazepines. The percentage of patients addicted only to benzodiazepines was higher among females than males. Benzodiazepine consumption had started as a drug addiction behavior in only 10% of cases. The main sources of prescription identified were general practitioners (52% of cases) or compliant pharmacists (25%). Overall, 15 different benzodiazepines were abused, with lormetazepam being the most commonly used (by 123 patients, 43.8% of the total). Conclusion Our data show that, outside the population of multidrug addicts, there is an underestimated group of chronic benzodiazepine consumers who are often not referred to medical institutions for treatment. Even in the group of patients addicted to one substance only, we observed an abnormal number of requests for detoxification from lormetazepam, which appears to be more “popular” than other benzodiazepines. This drug should be prescribed according to stricter criteria and submitted to closer control.

Hepatitis A Virus among Drug Users and the Role of Vaccination: A Review.

In countries with advanced economies better health and hygiene conditions, along with the introduction, in some cases, of global vaccination, have relegated most viral hepatitis to marginal social groups and, in particular, drug users (DUs). The availability of safe and effective vaccines for hepatitis A virus (HAV) and B (HBV) may play a major role in combating this phenomenon. Despite the availability of a safe and effective vaccine for over a decade and the recommendations of international health organizations, vaccinations against HAV among DUs are not as widely known and available as are HBV vaccinations. The purpose of this review article is to present the most significant data in the literature on the prevalence of HAV among DUs and the role of targeted vaccination. To our knowledge, the present article is the first to solely deal with vaccination against HAV in DUs. Immunization after the administration of anti-HAV vaccine has been demonstrated in DUs even if they have responded significantly less than either the general population or carriers of chronic liver disease. All the vaccines were well tolerated and adherence to the vaccine schedule was good. Further studies are needed to optimize the timing and doses of vaccine to be administered to DUs, especially to assess adherence and antibody persistence. Vaccination campaigns are feasible among DUs and have proven to be highly cost–effective.

AGONIST SUBSTITUTION FOR HIGH-DOSE BENZODIAZEPINE- DEPENDENT PATIENTS: LET US NOT FORGET THE IMPORTANCE OF FLUMAZENIL

We read with great attention the paper by Liebrenz et al. about the potential use of an agonist substitution with long-half-life benzodiazepines (BZD) in cases of high-dose BZD dependence [1]. We would like to contribute to this debate, because in our hospital in-patient unit, BZD represent the main reason for people seeking detoxification. We fully agree about the difference between the liability of BZD having a fastversus slower-onset of action. Lormetazepam, lorazepam and alprazolam (available world-wide, except for lormetazepam which is not approved for sale in the United States and Canada) represent 81% of the BZD abused by our patients, while clonazepam, clobazam and ketazolam (three drugs eligible as possible substitutes) represent fewer than 1% of the recovered cases. Liebrenz et al. did not discuss the slow infusion of flumazenil (FLU-I) [2–5] as one of the fastest and most effective treatments for BZD high abuse [4,5]. In our 8-year experience with FLU-I we have treated 294 severe BZDdependent patients (median daily BZD dose was 14-fold greater than the maximum recommended dose). Patients usually immediately stop using the abused BZD and move rapidly to low doses of clonazepam in 3 days and then no BZD on day 4. FLU-I (1–2 mg/24 h) starts on day 1 and lasts up to discharge at days 8–10. For patients eligible for an agonist substitution, the most suitable dose (usually about 1–2 mg of clonazepam) can be reached rapidly and stopped after patient discharge. Although we have not submitted our results to peer review, we are able to state that no patients have dropped out of treatment during hospitalization and preliminary data suggests promising results, although these will need to be confirmed through peer-reviewed research publications. One of the more critical aspects of Liebrenz et al. agonist substitution method resides, in our opinion, in the starting phase, when it is difficult to keep patients in treatment by proposing substitution with a slow-onset BZD (subjects are normally taking very high doses of BZD, mainly of the fast-onset action type, and many of the patients are also polydrug users). The receptor resensibilization obtained with 4–6 days of FLU-I allows patients to experience a good therapeutic effect with very small doses of low-power BZD, without significant withdrawal symptoms. Nevertheless, we should clarify that for the majority of patients being treated with FLU-I, the real aim is total abstinence from BZD.