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.

The impact of precarious employment on mental health: The case of Italy.

Although there has been a sizeable empirical literature measuring the effect of job precariousness on the mental health of workers the debate is still open, and understanding the true nature of such relationship has important policy implications. In this paper, we investigate the impact of precarious employment on mental health using a unique, very large data set that matches information on job contracts for over 2.7 million employees in Italy followed over the years 2007-2011, with their psychotropic medication prescription. We examine the causal effects of temporary contracts, their duration and the number of contract changes during the year on the probability of having one or more prescriptions for medication to treat mental health problems. To this end, we estimate a dynamic Probit model, and deal with the potential endogeneity of regressors by adopting an instrumental variables approach. As instruments, we use firm-level probabilities of being a temporary worker as well as other firm-level variables that do not depend on the mental illness status of the workers. Our results show that the probability of psychotropic medication prescription is higher for workers under temporary job contracts. More days of work under temporary contract as well as frequent changes in temporary contract significantly increase the probability of developing mental health problems that need to be medically treated. We also find that moving from permanent to temporary employment increases mental illness; symmetrically, although with a smaller effect in absolute value, moving from temporary to permanent employment tends to reduce it. Policy interventions aimed at increasing the flexibility of the labour market through an increase of temporary contracts should also take into account the social and economic cost of these reforms, in terms of psychological wellbeing of employees.

[Alcohol-addiction inpatient: characteristics of patients and rehabilitation program]. / La residenzialità alcologica ospedaliera: caratteristiche dei pazienti e dei percorsi terapeutici/riabilitativi.

AIM: The treatment of alcohol addiction in Italy has had a progressive evolution of therapeutic structures for in-and outpatients. During the last 20 years there had been a crescent presence of short residential treatment facilities (1-6 months) characterized by a high level of medical and psychotherapeutic intervention. About two years ago 12 of them jointed together in an association called CORRAL (COordinamento of Residenzialità Riabilitive Alcologiche). The aim of this study was to describe the socio-demographic medical and other characteristics of the patients coming for this type of treatment and to describe the characteristics of the residential treatment itself including referring and aftercare. METHODS: Two thousand sixty-one hospitalized patients of the 12 rehabilitative alcohol units were examined by using a questionnaire and collecting various sociodemographic variables and clinical diagnosis of the patients. Even it was asked who had referred the patients, the characteristics of the residential treatment and of the planned aftercare. RESULTS: The present residential facilities are mainly distributed in the North of Italy. The typical patient is male, with a high school instruction and with a comorbidity regarding psychiatric and liver disorders. The majority of the patients were referred by the public ambulatory services for addictions (SerT/SerD). The characteristics of the residential treatment were medical, pharmacological and psychotherapeutic interventions with a high intensity and the presence of a general-purpose staff. CONCLUSIONS: This study outlined a model of residential rehabilitation of alcohol disorders characterized by short duration and a complex, intense therapeutic intervention mainly addressed to patients with a severe clinical condition and a low level of social problems. Further research should be useful to understand better which sort of patient characteristics obtain a better clinical result and for that even economically a major effectiveness from this type of residential treatment.

[Alcohol and drug addiction in the work place]. / Alcolismo e tossicodipendenza in ambiente lavorativo.

Alcohol and drug addiction in the work place have always been an important but little known problem. These behaviours represent today one of the principal causes of work mishaps in Italy and are responsible for the marginalization of many subjects from the working world. Recently some laws (DPR 309/90 and Legge Quadro 125/2001) and their subsequent decrees have affronted this problem, highlighting its extreme complexity (diverse aspects in fact still remain to be solved from the organizational and legal-medical points of view). In the last few decades, Medicine and Occupational Psychology have focused on the relationship between employees' professional activity and private life, analyzing the problem of psychoactive substance abuse. In Anglo-Saxon countries, for example, Employee Assistance Programs (EAPs) have been implemented--a key element of which is the support to alcohol and drug abusers--in order to offer employees and their families help in coping with problems that could adversely impact their work and personal lives. After examining these laws, including their contradictory aspects, we propose two main modes of intervention: prevention focused on the identification of alternative behaviour and the promotion of self-help groups.

[Alcohol and work: remaining sober and return to work]. / Alcol e lavoro: mantenimento della sobrietà e reinserimento lavorativo.

BACKGROUND: One of the most complex alcohol-driven problems is the job loss and the subsequent attempts to return to a professional activity. METHODS: In order to better understand the issue, an epidemiologic investigation was carried out on a group of 162 alcoholics whilst hospitalised in a specialised clinic. RESULTS: The outcome shows the importance of remaining sober to keep or to be returned to one's own job. Unfortunately, local resources at hand, first of all joining an auto-mutual-help group, re still too little known and thus clearly underemployed. Therefore, an informative action within companies is highly desirable. Those alcoholics suffering from serious illnesses, especially mental ones represent a different issue. CONCLUSIONS: For these people a higher involvement of public authorities is desirable in creating protected job openings.

A functional assessment methodology for alcohol dependent patients undergoing rehabilitative treatments.

PURPOSE: We propose a functional assessment approach for patients with alcoholic dependence of working age undergoing aerobic training. The background is the WHO indication (ICIDH-2) to use measurable 'activities' as a means to assess the individual 'participation' in social life which also implies work capacity. Defining sustainable energetic levels for the individual is an important issue for both the quantification of an effective training and the evaluation of possible improvements following training. METHODS: Fifty-six 'alcohol dependent' patients, as defined by DSM IV (Diagnostic and Statistical Manual of Mental Disorders), admitted to our Unit in a 16 month-period participated in the study. Eighteen healthy subjects served as controls (Group C). Out of all the 56 patients, 33 (Group A) underwent an aerobic training and 23 subjects (Group N) underwent the same pharmacological and psychological therapy but without aerobic training. Patients were assigned to the treatment (A) or no treatment (N) group according to a 'quasi-experimental' design (i.e. temporal selection criteria). The evaluation protocol consisted of submaximal symptom-limited tests. The tests consisted of bouts of 'basic' activities (walking, lifting, arm-work) to be performed at different intensities. We estimated the total energetic work (TW) performed in the tests by means of formulas available in the literature. The maximal energetic intensity (EI) reached during the tests was also estimated and expressed in MET (multiple of the basal metabolism). RESULTS: Significant differences in work capacity were observed between patients and healthy subjects at baseline. Group A significantly increased TW after rehabilitation, while Group N did not increment their performance at the re-test. CONCLUSIONS: The proposed approach could be useful in the functional assessment of deconditioned subjects with alcohol dependence in working age, and could monitor the changes in work capacity following training.

Alcoholic polyneuropathy: a clinical and epidemiological study.

In the present study, we investigated the frequency of polyneuropathy in a sample of 296 alcoholics who were admitted to the 'S. Maugeri' Medical Centre for detoxification from October 1997 to November 1999. Results revealed a high frequency of polyneuropathy in the sample under study. The disorder was often clinically asymptomatic and demonstrable only on electroneurographic investigation. Significant correlations were found between polyneuropathy, the duration of alcoholism, the type of alcoholic beverage consumed (wine) and the presence of liver disease and macrocytosis.

Capture-recapture methods to size alcohol related problems in a population.

STUDY OBJECTIVE: To investigate the utility of capture-recapture methods to estimate prevalence of subjects with alcohol related disorders using multiple incomplete lists. DESIGN: This was a cross sectional study of alcohol related disorders in a large community. SETTING: During 1997 identified cases with known alcohol related disorders were independently flagged by four sources (self help volunteering groups; psychiatric ambulatory; public alcohology service; hospital discharges). PATIENTS: 381 records were flagged, corresponding to 349 individual cases from a target population resident in a northern Italy area. MAIN RESULTS: The two sample capture-recapture estimates were clearly biased because of dependencies among sources. Estimates based on log-linear models showed prevalent counts ranged from 2297 (95% confidence intervals: 1524, 3794) to 2523 (95% confidence intervals: 1623, 4627) after adjustment for dependence among sources only or also for heterogeneity in catchability among age categories (< 50 and >/= 50 years), respectively. CONCLUSIONS: The study suggests that capture-recapture is an appropriate approach for estimating prevalence of subjects with alcohol related problems who seek or need treatment and assistance when different lists of alcoholics can be obtained from different types of agencies involved with problematic use of alcohol. Critical factors are the complexity in case definition and the analysis of heterogeneity among people. Accurate estimates are needed to plan and evaluate public health interventions.

[Alcoholism at the work setting]. / Alcolismo in ambito lavorativo.

Alcoholism is a nation-wide problem because of the variability and severity of its associated phenomena. In Western European countries, according to the WHO, the use of alcohol is the direct or indirect cause of approximately 20% of hospital admissions of male adults of working age. In Italy, the number of lost working days due to sickness is four times greater in drinkers, as is the risk of serious accidents. In addition, alcohol accounts for 5% of disability payments. In the authors' experience, alcohol abuse is a widespread problem in the work setting, however its social and medical impact is still underestimated.

[Work and alcohol: considerations on a caseload of patients undergoing treatment]. / Lavoro e alcol: considerazioni su una casistica di pazienti in trattamento.

An enquiry into alcohol dependent subjects admitted to the clinical wards of the first section of Occupational Medicine belonging to Medicina Preventiva Occupazionale e di Comunità of University of Pavia for an alcohol disaddiction treatment has been performed through a phone interview. 289 patients have been contacted and time elapsed from admission to interview was one to three years. The questions focused alcohol abstinence, occupational position before and after admission, any improvement in the work sphere (relationship with the collegues), any feeling of empowerment of the work abilities and any increase in the responsibilities load. From our results we can conclude that alcohol disaddiction carried on during admission has positively contributed to the reinstatement of alcoholics patients.

[High resolution computerized tomography in the diagnosis of asbestosis]. / La tomografia computerizzata ad alta risoluzione nella diagnosi di asbestosi.

The clinical observation, the work history, the analysis of pulmonary function tests and, mainly, the conventional x-ray chest radiograms have represented, til now, the diagnostic basis for pneumoconiosis (silicosis, mixed dust pneumoconiosis, asbestosis). Recently, the high resolution chest tomography (HRCT) has been introduced into the diagnostic procedures: such method seems to have its main application in the assessment of incipient clinical pictures of pneumoconiosis, particularly when characterized by normal pulmonary function tests. Asbestos fibers exposed workers were submitted to both radiologic methods. The great majority of them had already been recognized to be affected by asbestosis. A considerable statistical agreement (Cohen K) was observed between radiographic and tomographic I.L.O. classes. In conclusion, high resolution chest tomography doesn't appear to be an indispensable test for the diagnosis in admitted subjects, but we underline its importance in the evaluation of pleural thickenings.

[High resolution computerized tomography in the diagnosis of silicosis and mixed dust pneumoconiosis]. / La tomografia computerizzata ad alta risoluzione nella diagnosi di silicosi e di pneumoconiosi da rischio misto.

The clinical observation, the work history, the analysis of pulmonary function tests and, mainly, the conventional x-ray chest radiograms have represented, til now, the diagnostic basis for pneumoconiosis (silicosis, mixed dust pneumoconiosis, asbestosis). Recently, the high resolution chest tomography (HRCT) has been introduced into the diagnostic procedures: such method seems to have its main application in the assessment of incipient clinical pictures of pneumoconiosis, particularly when characterized by normal pulmonary function tests. 75 silica- and mixed dust exposed workers were submitted to both radiologic methods. The great majority of them had already been recognized to be affected by asbestosis. The statistical analysis (Cohen K) showed a satisfactory agreement between radiographic and tomographic I.L.O. classes. However, high resolution tomography appeared to be more accurate in the assessment of less severe clinical pictures. In conclusion, we underline the importance of high resolution chest tomography in the evaluation of individual clinical cases, particularly when forensic problems are involved.

[A group therapy model in the rehabilitation fo alcoholism]. / Un modello di terapia di gruppo nella riabilitazione dell'alcolismo.

At present group psychotherapy is one of the most important resources in the treatment of alcoholism. Among the various theoretical orientations present in this setting, the systemic approach has always favoured interventions designed to improve interpersonal relationships. More recently, the concepts of constructivism and "narrative" therapy have laid greater emphasis upon the relational and linguistic aspect of any individual problem. Starting from these premises, a systemic-constructivistic therapy group was created for persons with problems associated with alcohol, as part of an inpatient rehabilitation programme. Given the novelty of this initiative and the particular context, several solutions were adopted that may represent a proposal for the extension of the method. The characteristics and ways in which this particular group might evolve are discussed under four headings: 1) the characteristics of the group, 2) techniques for guiding the group, 3) the role and problems facing the therapist, and 4) the recurrent problems in the life of the group.

[Evaluation of trends in occupational pathology in clinical cases]. / Valutazione della tendenza della patologia occupazionale in una casistica clinica.

The study considered all patients admitted to the 1st Division of Occupational Medicine, Department of Preventive, Occupational and Community Medicine of the University of Pavia between January 1st 1989 and December 31st 1995 with a diagnosis of occupational disease. It was useful in illustrating the evolution of occupational disease as regards both changes in etiology and in the symptoms and systems involved. A decrease in the number of occupational diseases diagnosed from 1993 to 1995 was revealed, but it is difficult to draw any significant conclusions from these data since the need for hospitalization when diagnosing this type of disease has diminished greatly. Changes in legislation which have obliged employers to take precise preventive measures could also be partly responsible for this downward trend. The patients were, in almost all cases, at an initial stage of their disease. This is reassuring as far as the therapeutic and legal need for an early diagnosis is concerned. However, it remains unknown how often the causal relationship between work and disease was not suspected and therefore how many cases did not arrive to observation. Finally, the study confirmed the disappearance of some occupational diseases, such as benzene intoxication, common in the past, and the increase in "emerging" pathologies like allergies.

Occupational asthma, rhinitis and urticaria due to piperacillin sodium in a pharmaceutical worker.

A 28 year old man with no history of atopy was referred to our hospital for possible work-related asthma. He had been employed in the production section of a pharmaceutical company for 2 yrs, and in the last 2 months he had complained of dyspnoea, wheezing, chest tightness, symptoms of rhinitis and a cutaneous rash when exposed to powdered antibiotics. Symptoms disappeared after being transferred to the packaging section. When the subject was admitted to our department he was asymptomatic. Basal lung function tests were in the normal range. Bronchial challenges with methacholine and with ultrasonically-nebulized distilled water were negative. Skin-prick test with piperacillin sodium gave a strong positive response at a very low concentration. Specific inhalation challenge with piperacillin sodium resulted in an immediate asthmatic reaction, and also reproduced rhinitis symptoms and the cutaneous rash. A control challenge with lactose, and the specific challenge test with cefuroxime sodium (another antibiotic to which the patient was exposed at the workplace) were negative. We conclude that piperacillin sodium is an agent that can cause occupational asthma.

[Employment and alcohol: analysis of a clinical casuistic]. / Lavoro e alcol: analisi di una casistica clinica.

The relationship between alcohol and work was studied in a group of 537 voluntary patients (393 male and 144 female) admitted to the department of Medicina del Lavoro, Pavia University for alcohol rehabilitation. The highest incidence of alcohol abuse was found in non-working subjects (pensioners, unemployed, housewives) although the start of excessive drinking takes place after beginning a working activity; a cause-effect relationship between these two factors can not be clearly determined, however. It is true that the stress provoked by this new condition (introduction to the work experience) can, in certain subjects, be a contributing factor in alcohol abuse. The increasingly lower age of initiation to alcohol reconfirms the need for prevention and instruction even at scholastic level. We can deduce how no working condition, low age and low education can constitute makers of risk for alcohol abuse.

[The personal and familial alcohol habits in groups of young men at their first military draft exam]. / Studio sulle abitudini alcoliche personali e familiari in gruppi di giovani alla prima visita di leva.

In order to evaluate alcoholic consumption in a group of young men from an area in northern Italy, 834 subjects (18 years old) were examined at their first military check up. They compiled a questionnaire dealing with their own and their fathers' alcoholic consumption, social status, cultural habits, tobacco and drug abuse. 14.3% of the group examined were teetotalers. The alcoholic consumption of the youths was 31.44 +/- 48.8 DS alcohol g/a day versus their fathers' consumption of 44.52 +/- 42.12 DS alcohol g/a day. This difference is statistically significant (t = -8.1 p less than 0.001). No difference in alcoholic consumption was found between employed and unemployed subjects. Artisans and traders evidenced the highest levels of alcohol consumption (F = 2.58, p less than 0.009). The youths changed their alcoholic habits with respect to their own parents, preferring beer to wine consumption, although no change was observed in their approach to the alcoholic problems. The beer, like alcohol, remains a sociable and reassuring drink with positive connotations, even tough it is not considered a traditional Italian drink.

[Evaluation of several neuropsychological parameters in subjects occupationally exposed to anesthetics]. / Valutazione di alcuni parametri neuropsicologici in soggetti professionalmente esposti ad anestetici.

51 workers, occupationally exposed to anaesthetic gases and vapours (nitrous oxide, halothane, and isoflurane), were studied monitoring their environmental and biological exposure. Moreover, they were tested for visual reaction times and neurobehavioural batteries. There was no evidence of important neurotoxic effects nor of neurobehavioural problems with low concentrations of anaesthetics.

[Changes in the blood rheology and an audiometric deficit in a group of patients exposed to occupational noise pollution]. / Modificazioni dell'assetto emoreologico e deficit audiometrico in un gruppo di pazienti sottoposti ad inquinamento acustico professionale.

Several hemorheologic and plasma proteic features were analyzed in workers exposed to acoustic defilement. Whole-blood viscosity was significantly increased (at every shear-rate considered) in patients with severe sensorineural hearing impairment; whereas plasma, serum and relative viscosity remained unchanged. These variations were independent of erythrocyte deformability and aggregation, and of plasma fibrinogen levels, resulted indeed in the normal range. On the contrary plasma fibronectin was significantly increased in patients with sensorineural hearing impairment, suggesting a microvascular endothelial damage in these subjects. The exposition to acoustic defilement during work activity may be considered as aetiological factor for the development and progression of sensorineural hearing impairment, and more extensively for the occurrence of cardiovascular complications.

[Alcohol and work: comments on a clinical case load]. / Alcol e lavoro: considerazioni su una casistica clinica.

The relationship between alcohol and work was studied in a group of 260 voluntary patients (186 male and 74 female) admitted to the unit of Medicina del Lavoro, Pavia University for alcohol rehabilitation. The highest incidence of alcohol abuse was found in non-working subjects (pensioners, unemployed, housewives) although the start of excessive drinking takes place after beginning a working activity; a cause-effect relationship between these two factors can not be clearly determined, however. It is true that the stress provoked by this new condition (introduction to the work experience) can, in certain subjects, be a contributing factor in alcohol abuse. The increasingly lower age of initiation to alcohol reconfirms the need for prevention and instruction even at scholastic level.