Prevalence of Polysubstance Abuse and Dual Diagnosis in Patients Admitted to Alcohol Rehabilitation Units for Alcohol-Related Problems in Italy: Changes in 15 Years.

AIMS: Alcohol abuse has long been known as a disease with social and economic burden to society. Given the complex nature of alcohol treatment, it is worthwhile to examine the change over time of patients admitted to residential alcohol abuse rehabilitation units. METHODS: The data were collected from two Italian projects on alcoholics performed in the mid-1990s (ASSALT) and in 2009 (CORRAL), respectively. Categorical variables were considered in terms of absolute and relative frequencies. Comparisons of relative frequencies between groups were assessed by means of Fisher's exact test. Mixed logistic regression models were fitted to CORRAL data to identify the predictors of the probability of being a polysubstance abuser or having a dual diagnosis. The association estimates were reported as adjusted odds ratios and relative 95% confidence intervals. RESULTS: Compared to the mid-1990s, in 2009 patients were older (P= 0.0003), with a higher level of education (P= 0.0204), with fewer comorbidities (liver disease except cirrhosis, P < 0.0001; polyneuropathy, P= 0.0001), more frequently polysubstance abusers (P < 0.0001), affected by dual diagnosis (P < 0.0001). In 2009, the probability of being a polysubstance abuser was higher in younger and in patients with dual psychiatric diagnosis. Female gender and polysubstance abuse were positively associated to the probability of being affected by dual psychiatric diagnosis. CONCLUSIONS: The increment of patients admitted to residential programs for alcohol dependence with polysubstance abuse and/or dual psychiatric diagnoses suggests the need to pay more attention to both psychological/psychiatric interventions and internal medicine/physical rehabilitation. SHORT SUMMARY: The results of this study suggest that further research is needed to identify the best treatment strategy that is safe and effective for the new population of alcoholics.

Novel strategies to treat alcohol dependence with sodium oxybate according to clinical practice.

OBJECTIVE: The treatment of alcohol dependence (AD) with sodium oxybate (SMO) was introduced in Italy and Austria more than 20 years and 15 years ago respectively, and it is now widely employed. In addition to the data obtained from clinical trials, little information is available on specific clinical practices. Thus, the aim of this study was to present and discuss the results of a consensus meeting held after twenty years of using SMO in clinical practice in Italy. MATERIALS AND METHODS: A validated questionnaire study was conducted to investigate the modalities of treatment of AD with SMO currently used in Italy. A group of four referees first drew up the questionnaire which was distributed to fifty experts in the field of alcohol use disorders. The questionnaire consisted of 125 items with five different modalities of response and two or three answer possibilities. RESULTS: The results of this survey showed a broad consensus on some issues regarding, for example, the duration of treatment, and the dose regimen of the drug; however, some aspects of the treatment of AD with SMO still remain controversial. CONCLUSIONS: This is the first consensus study investigating the use of SMO for the treatment of AD through the opinions gained in over twenty years of clinical practice provided by fifty Italian expert clinicians. A consensus on good practice for the correct administration of SMO has clearly emerged; these opinions, along with those derived from previous clinical investigations, will help physicians to use SMO in a better way. However, some issues remain controversial, and others remain unresolved.

Relationship between pathological gambling, alcoholism and drug addiction.

The aim of this survey was to evaluate the distribution of pathological gamblers treated in an alcohol or drug addiction treatment program run by the Italian National Health Service providing assistance to alcohol and drug abusers in Venice (North east Italy) from September 1 to December 31, 2001. Each drug- or alcohol-dependent patient retained for treatment for at least one month was administrated an anonymous precoded questionnaire to collect personal and socio-demographic features. The South Oaks Gambling Screen (SOGS) was used to measure pathological gambling and the Symptom Checklist-90-Revised (SCL-90-R) to measure psychological distress levels and psychiatric symptoms. Among the 113 enrolled subjects we found a greater prevalence of pathological gamblers among drug users than among alcoholics and drug abusers were younger than alcoholics; moreover, there was a prevalence of single status, low schooling, and a low-medium income despite full-time occupation. Only pathological gamblers revealed a significant positive correlation with a family history of gambling and reached positive scores (>1.5) for some likely psychiatric symptoms. Abuse disorders and pathological gambling are frequently associated with multidependence personality traits. Preventing substance abuse may reduce the pathological gambling rates and better results can be obtained with educational campaigns beginning earlier in life.

Adrenal bilateral incidentaloma by reactivated histoplasmosis.

We report a case of bilateral adrenal incidentaloma caused by the capsulatum variety of Histoplasma capsulatum diagnosed in a 74 years old man born in and a life time resident of Treviso, Italy, with the exception of two years spent in Pakistan (1964-1966) as a well-driller. The patient was hospitalized in 1995 for alcoholic chronic hepatitis, chronic Helicobacter pylori gastritis and post-infarction ischemic cardiomyopathy. Abdominal ultrasound incidentally showed bilateral adrenal masses (the right one 6.3 cm in diameter) confirmed by computed tomography, with adrenal function within normal limits. After three months, the patient was again hospitalized due to evening fever, asthenia, anorexia, weight loss and occasional hyperhidrosis. Abdominal ultrasound showed an increase of the right adrenal lesion with normal adrenal function. Ultrasound-guided fine needle aspiration did not prove useful for diagnosis. Accordingly, a laparotomy with bilateral biopsy was performed; histology showed the presence of numerous tissue form cells of H. capsulatum variety capsulatum. Serum anti-H. capsulatum antibodies were negative. Since March, 1996, the patient was given itraconazole and his symptoms quickly regressed but the computed tomography findings, however, have not changed and the patient has adrenal hypofunction that is being treated with cortisone acetate.

Gamma-hydroxybutyric acid in the treatment of alcoholism: dosage fractioning utility in non-responder alcoholic patients.

Gamma-hydroxybutyric acid (GHB) has recently been introduced in clinical practice for alcoholism management, due to its utility in inducing abstinence from alcohol. In the present study we investigated the usefulness of greater dosage fractioning of GHB in non-responder alcoholics to the usual three administrations per day. A total of 154 alcoholics were admitted to the study and were treated with GHB (50 mg/Kg orally administered three times per day) for 8 weeks (phase 1); the patients who continued to drink alcohol in phase 1 were administered the same dose of GHB divided into six times per day for another 8 weeks (phase 2). Of the 154 patients, 115 completed phase 1; 78 (67.8%) of these began and maintained abstinence (group A) while 37 subjects (32.2%) continued to drink alcohol (group B) showing a craving significantly higher than group A at the end of phase 1 (P < 0.001); in these patients the major fractioning of the drug in phase 2 caused a significant reduction in craving (P < 0.005) and 26 (70.2%) began and maintained abstinence. Moreover no significant differences in final craving score between group A and B was observed. Within the limits of an open study, our data show that non-responder subjects to the conventional fractioning of GHB seem to benefit from the greater fractioning of the drug and seem to indicate the need for a slow-release form of GHB with a prolonged action.

Gamma-hydroxybutyric acid for treatment of opiate withdrawal syndrome.

In a double-blind placebo-controlled trial, gamma-hydroxybutyric acid (GHB) (25 mg/kg orally) suppressed most of the withdrawal symptomatology in 14 heroin addicts and 13 methadone-maintained subjects. The GHB effect was prompt (within 15 minutes) and persisted for between 2 and 3 hours. Subsequently, the same patients received GHB in an open study every 2 to 4 hours for the first 2 days and 4 to 6 hours for the following 6 days: most abstinence signs and symptoms remained suppressed and patients reported felling well. Urine analysis failed to detect any presence of opiate metabolites. No withdrawal symptomatology recurred after 8 days of treatment when GHB was suspended, and patients were challenged with an intravenous injection of 0.4 mg naloxone. The results indicate that GHB may be useful in the management of opiate withdrawal.

[The role of the nurse in services for drug dependents]. / Il ruolo dell'infermiere nei servizi per le tossicodipendenze.

Aim of the work is to take into account the role of nursing in Drug Dependence Units, on the bases of the experience acquired by the Authors at the Servizio di Neuropsicotossicologia in Dolo (Venice). Two working patterns are distinguished, which have to be integrated in daily practice: 1) the fulfillment of "technical" tasks, giving particular importance to drug administration and laboratory data control (for chemical and toxicological testing); 2) the relationship with patients, with reference to the distinction between diagnostic function. It is particularly stressed that the nurse is the first staff operator to be brought in contact with patients and to follow them during the therapeutic program. The relationship with psychologically disturbed patients can be very hard and often too much involving. It is therefore important for nurses working in this field to have a specific training.

Gamma-hydroxybutyric acid for treatment of alcohol withdrawal syndrome.

The effect of gamma-hydroxybutyric acid (GHB) on ethanol withdrawal syndrome in alcoholics was investigated in a randomised double-blind study. Patients with withdrawal symptoms were treated either with GHB (orally in a syrup preparation) (11 patients) or with the syrup alone (12). GHB treatment (50 mg/kg) led to a prompt reduction in withdrawal symptoms, such as tremors, sweating, nausea, depression, anxiety, and restlessness. The only side-effect was dizziness. GHB may be useful in the management of alcohol withdrawal syndrome in man.

[Naltrexone and prevention of opiate dependence relapse. An Italian experience]. / Naltrexone e prevenzione della recaduta nella dipendenza da oppiacei. Una esperienza italiana.

A group of 93 patients consecutively treated for Opiate Dependence (DSM) III) was examined and the relationship between detoxification outcome and treatment with an opiate antagonist (naltrexone), sociodemographic characteristics and clinical features was studied. The treatment with naltrexone followed detoxification in 46 cases (50%). Average retention is 16.7 weeks, much longer than reported in the literature. This outcome is ascribed to: 1) better social adjustment of the population considered, in terms of employment, relatives' involvement in the treatment and Opiate Dependence in partners; 2) introduction of naltrexone in a multimodal program, including psychological and social support.

Locus of control, life events and treatment outcome in alcohol dependent patients.

We investigated the relationship of locus of control and life events to outcome of treatment at 6 months in 67 patients with alcohol dependence. Outcome was less favourable in patients with pre-treatment scores indicating external locus of control than in those with internal locus of control. Furthermore, patients with relapse in the follow-up period experienced more independent life events with moderate to severe objective negative impact than those with more favourable outcome. These results suggest that locus of control may be of clinical use in formulating treatment and prognosis, and that the occurrence of life events may influence outcome. The results are discussed in relation to strategies for treatment and prevention of relapse.

Alcohol intake and withdrawal: effects on branched chain amino acids and alanine.

The effects of chronic alcohol consumption on plasma branched chain amino acids and alanine concentrations were evaluated, and basal blood concentrations of these amino acids were determined after chronic ethanol intake and following a withdrawal period in 30 admitted alcoholics. After ethanol intake, alcoholics showed increased branched chain amino acid concentrations; the blood alanine concentrations were depressed after the withdrawal period. To evaluate the effect of ethanol on diurnal variations of these amino acids in the blood, a group of these patients underwent two isocaloric diets with and without wine. The diet with alcohol induced a sustained increase of branched chain amino acids persisting even after the postprandial phase with a decrease of alanine as compared to the diet without.