Prevalence of Polysubstance Abuse and Dual Diagnosis in Patients Admitted to Alcohol Rehabilitation Units for Alcohol-Related Problems in Italy: Changes in 15 Years — A. Zambon, C. Airoldi, G. Corrao, M. Cibin, D. Agostini, F. Aliotta, M. Movalli, F. Biondini, P. Bizzi, G. Zucchi, G. Cerizza, A. Dattola, A. Marmora, G. Vittadini, F. Girardi, L. Liberto, I.M. Hinnenthal, A. Jaretti Sodano, P. Vizzuso, E. Majolino, D. Mioni, L. Pedretti, P. Ranaletti, M. Forghieri, G. Spolaor, I. Giorgi centroSoranzo Alcohol and Alcoholism, 2017, 1–7 doi: 10.1093/alcalc/agx061 Article Article Prevalence of Polysubstance Abuse and Dual Diagnosis in Patients Admitted to Alcohol Rehabilitation Units for Alcohol-Related Problems in Italy: Changes in 15 Years A. Zambon1,*, C. Airoldi1, G. Corrao1, M. Cibin2, D. Agostini3, F. Aliotta3, M. Movalli4, F. Biondini4, P. Bizzi5, G. Zucchi5, G. Cerizza6, A. Dattola7, A. Marmora7, G. Vittadini8, F. Girardi9, L. Liberto9, I.M. Hinnenthal10, A. Jaretti Sodano11, P. Vizzuso11, E. Majolino12, D. Mioni13, L. Pedretti14, P. Ranaletti6, M. Forghieri14, G. Spolaor15, and I. Giorgi16 1Department of Statistics and Quantitative Methods, University of Milano-Bicocca, Via Bicocca degli Arcimboldi, 8, 20126 Milano (Milano), Italy, 2Dipartimento per le Dipendenze, Az. Ulss 13 del Veneto, Via Don Giacobbe Sartor, 4, 30035 Mirano (Venezia), Italy, 3Casa di Cura Villa Silvia, Viale Anita Garibaldi, 64, 60019, Senigallia (Ancona), Italy, 4Servizio per le Alcoldipendenze, Ospedale San Raffaele Turro, Via Stamira D’Ancona, 20, 20127 Milano (Milano), Italy, 5Ospedale Privato Accreditato Villa Maria Luigia, Via Montepelato nord, 41, 43022 Monticelli Terme (Parma), Italy, 6U.O. Riabilitazione Alcologica, Ospedale S. Marta, A.O. Ospedale Maggiore, Via Montegrappa, 15, 26027 Rivolta d’Adda (Crema), Italy, 7Centro di Riabilitazione Alcologica—Fondazione Stella Maris Mediterraneo— Chiaromonte (Potenza), Italy, 8Servizio di Psicologia, Istituti Clinici Scientifici Maugeri, IRCCS, Via S. Maugeri, 10, 27100, Pavia (Pavia), Italy, 9U.O. Ospedale San Pancrazio, Istituto di Riabilitazione S. Stefano, Via D. Chiesa, 38062 Arco (Trento), Italy, 10Economia e Gestione Aziende Sanitarie, Università Cattolica del Sacro Cuore, Largo Francesco Vito, 1, 00161, Rome (Roma), Italy; ASL 1, Regione Liguria, Via Giovanni borea, 56, 18038 Sanremo (Imperia), Italy, 11U.O. Alcolfarmacodipendenze Presidio Ospedaliero, Fatebenefratelli, Via Fetebenefratelli, 70, 10077 San maurizio Canavese (Torino), Italy, 12Centro Terapeutico Dipendenze, Ospedale Bad Bachgart Comprensorio Sanitario, Bressanone, Italy, 13Casa di Cura Parco dei Tigli, Via Monticello, 1, 35037 Villa di teolo (Padova), Italy, 14Centro di Riabilitazione Alcologica Villa Rosa, Via F.lli Rosselli, 83, 41125 Modena (Modena), Italy, 15Centro Soranzo (www.centrosoranzo.it), Via Pezzana, 1, 30173 Tessera (Venezia), Italy, and 16U.O. Riabilitazione Alcologica, Istituti Clinici Scientifici Maugeri, IRCCS, Via S. Maugeri, 10, 27100, Pavia (Pavia), Italy *Corresponding author: Department of Statistics and Quantitative Methods, University of Milano-Bicocca, Via Bicocca degli Arcimboldi, 8, 20126 Milan, Italy. E-mail: [email protected] Received 5 July 2016; Revised 11 August 2017; Editorial Decision 11 August 2017; Accepted 21 August 2017 ABSTRACT Aims: Alcohol abuse has long been known as a disease with social and economic burden to soci- ety. 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 hav- ing a dual diagnosis. The association estimates were reported as adjusted odds ratios and relative 95% confidence intervals. © The Author 2017. Medical Council on Alcohol and Oxford University Press. All rights reserved. 1 Downloaded from https://academic.oup.com/alcalc/article-abstract/doi/10.1093/alcalc/agx061/4157313/Prevalence-of-Polysubstance-Abuse-and-Dual by Universita degli studi di Padova- Dipartimento di diritto Pubblico internazionale e Comunitario user on 14 September 2017 2 Alcohol and Alcoholism 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 atten- tion 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. INTRODUCTION Services in Northern Italy (Morandi et al.,2015) showed that 10.5% Alcohol abuse has long been known to be a significant disease, of patients had dual diagnosis (with a higher prevalence in women) representing a social and economic burden in societies. A recent and 10.6% used psychoactive substances other than alcohol (polysub- paper showed that in Italy ~5320 deaths (1530 female deaths and stance abuse). Similarly, a recent paper reported high proportions of 3790 male deaths) or 5.9% of all deaths of people aged 15–64 years alcohol users in patients affected by psychiatric diseases varying from were estimated to be alcohol-attributable (Shield et al., 2013). In 65.5% (patients with a diagnosis of schizophrenia) to 88.9% (patients 2001 the Italian Parliament approved a law aimed at the prevention, with a diagnosis of bipolar disorder) (Martinotti et al.,2014). These care and rehabilitation of alcoholics (Official Journal of the Italian patients are particularly problematic because, as suggested in litera- Republic, 2001). Since then, the Italian Ministry of Health has ture, they may be at greater risk of psychosocial and interpersonal issued an annual report on alcohol abuse treatment in Italy problems, treatment non-compliance, alcoholic relapse and attempted (Ministry of Health, 2014). These reports help to understand the and completed suicide (Fein, 2015). extent of these problems and their changing patterns. In 2000, Data from two Italian projects (ASSALT project and CORRAL 34,558 patients were referred to Public Alcoholism Services, com- project) conducted on patients admitted to RAARUs for AD or pared with 69,770 patients in 2012. The doubled number could be abuse was available and included information about both polyabuse the result of organizational improvements and increased sensitivity and psychiatric comorbidities. The first project was carried out in towards alcohol-related problems in these services. The number of the mid-1990s (Corrao et al., 1999) and the second in 2009 (Soares patients treated is nevertheless very small compared to the potential Pinto et al. 2013; Zambon et al., 2013). demand for treatment in the population: a recent survey (Rehm We analyzed the data from the ASSALT and CORRAL projects et al., 2015) found a prevalence of alcohol dependence (AD) of which referred to patients admitted to a RAARU for AD: (a) to ver- 3.4% in the Italian population between 18 and 64 years of age ify the change in the prevalence of polysubstance abusers and of (~37,600,000 people) (Istat, 2014). In other words, there are poten- patients with psychiatric comorbidities over this 15-year period; (b) tially ~1,300,000 people suffering from AD in Italy. In 2012, there to describe the changes in prevalence of other socio-demographical were 454 Public Alcoholism Services in Italy, Services for the treat- and clinical covariates in the same period; and (c) to identify the ment of alcohol problems encompass statutory facilities such as the determinants in recent years associated to the likelihood of admit- Public Ambulatory Services for addictions and Residential Alcohol ting a patient with dual diagnosis or polysubstance abuse to a Abuse Rehabilitation Units (RAARUs). Although they have different RAARU (CORRAL project). organizational structures, these services regard alcoholism as requir- ing a multidisciplinary approach which includes medical, psycho- logical and social aspects (Klingemann et al., 1992). MATERIALS AND METHODS The Italian Ministry of Health report from 2014 showed that the number of polysubstance abusers increased from 7.3 % of AD Data sources patients in 2000 to 9.0 % in 2013. In the same period, the percentage The data for the analysis was taken from two Italian projects carried of hospitalizations completely attributable to alcohol decreased from out on the treatment assessment of AD in Italy in RAARUs. 9.2 to 4.0%. These facts are particularly important