Suicide Attempts in an Italian Population with Cannabis Use Disorders: Results of a Follow-Up Study.

The relationship between cannabis use and suicidal behavior is complex, with no consensus in the literature. We used electronic health records of national health services to identify individuals who received a diagnosis of Cannabis Use Disorder in the Metropolitan area of Bologna from 2009 to 2019. In this cohort we identified accesses to Emergency Departments for suicide attempts from 2009 to 2019. The Crude Suicide Rate for 1,000 Person Years was 2.5, higher in females, in patients with Alcohol Use Disorders, with any psychiatric diagnosis, within one year from the first visit, and during the COVID-19 period. The risk was over 22 times higher than in the general population. Considering the high prevalence of cannabis use in the general population and the consequent risk of Cannabis Use Disorders, these data suggest the importance of a clinical evaluation for suicidal risk.

COVID-19-Related Death in Patients with Alcohol or Substance Use Disorders.

BACKGROUND: People with substance or alcohol use disorders (SUDs/AUDs) are likely to be more vulnerable to COVID-19 infection than the general population, but the evidence of COVID-19-related mortality in these patients is unclear. OBJECTIVES: The aim of the study was to verify whether patients with AUD and SUD have a higher mortality rate for COVID-19-related mortality compared to the general population. METHOD: We performed a follow-up study to assess mortality in 2020 in a cohort of patients diagnosed for the first time with AUDs or SUDs at the Public Health Services in the metropolitan area of Bologna (Northern Italy) from 2009 to 2019. RESULTS: SUDs/AUDs patients present an excess mortality with respect to the general population for all causes of death and for COVID-19-related mortality. CONCLUSIONS: Our data support the need for prevention strategies in SUDs/AUDs patients such as vaccinations.

Epidemiology and Clinical-Demographic Characteristics of Suicide Attempts in Alcohol Use Disorders in an Italian Population.

Suicide is a leading cause of morbidity worldwide. Among the known risk factors, alcohol use disorders (AUDs) are particularly relevant, but data on the epidemiology and characteristics of suicide attempts (SA) in this group are lacking. We used electronic health records of national health services to identify individuals who received a diagnosis of AUD in the Metropolitan area of Bologna from 2009 to 2019. In this cohort we identified accesses to Emergency Departments for SA from 2009 to 2020. The Crude Suicide Rate (CSR) for 1,000 Person Years was 2.93, higher than the general population. The CSR was higher in females, within one year from receiving the diagnosis of AUD, in patients with psychiatric comorbidities, concomitant abuse of cannabis or benzodiazepines. As for Covid-19 pandemic, the risk ratio of SA was significantly higher in 2020 compared to 2019 in females. Our results are relevant to identify clinical risk factors for SA in patients with AUDs, which are strongly associated with suicide risk but with scarce data in the previous literature and paucity of evidence-based therapeutic interventions.

Mortality risk for individuals with cannabis use disorders in relation to alcohol use disorders: Results of a follow-up study.

BACKGROUND: There are few studies on mortality on individuals entering treatment for cannabis use disorders. OBJECTIVES: To estimate mortality risk for individuals treated for cannabis use disorders comparing patients with concomitant alcohol use disorders to those with only cannabis use disorders. METHODS: Follow-up study on 1136 residents in Northern Italy who turned to health services following problems caused by cannabis use disorders between 2009 and 2019. Individuals with concomitant use of opioids, amphetamines, cocaine, or injecting drugs were excluded. Crude mortality rates per 1000 Person Years (CMR), and standardized mortality ratios adjusted for age, sex and calendar year (SMR) were calculated. RESULTS: Elevated CMRs (CMR 4.4, 3-6.4), higher among patients with concomitant alcohol use disorders (CMR 10.2, 6.6-15.6) compared to those with only cannabis use disorders (CMR 1.8, 0.9-3.6) were found. Regarding excess mortality with respect to the general population, SMRs were higher and statistically significant (SMR 5.4, 3.7-7.8), both among patients with concomitant alcohol use disorders (SMR 10.2, 6.6-15.6) and among those with only cannabis use disorders (SMR 2.3, 1.1-4.5). CONCLUSIONS: The results of this study show that individuals with only cannabis use disorders have a lower mortality risk compared to those with both cannabis and alcohol use disorders.

COVID-19 hospitalization rates in individuals with substance or alcohol use disorders.

People with Substance or Alcohol Use Disorders (SUDs/AUDs) are likely to be more vulnerable to COVID-19 infection than the general population. We performed a cross-sectional study to compare the hospitalization rate (CHR) for COVID-19 in 2020 in patients diagnosed with SUDs or AUDs in the previous 10 years vs the population without these disorders (NAS). We included individuals who were resident in the Metropolitan Area of Bologna (Northern Italy). People with SUDs or AUDs have a greater probability of being hospitalized for COVID-19 infection compared to the general population NAS, suggesting that they suffer from worse physical symptoms/conditions than the general population. Furthermore, we found higher mortality rates during hospitalization for COVID-19 in patients with AUDs or SUDs than the general population NAS. These findings highlight the importance of a careful monitoring and early intervention measures in these patients.

Comparison of Mortality Rates between Italian and Foreign-born Patients with Alcohol Use Disorders.

In Italy, although the number of foreign-born residents has grown exponentially, there are no data on mortality risk among migrants who have alcohol use disorders (AUDs). We examined the mortality risk and causes of death for natives and non-natives in a cohort of individuals treated for AUDs in Northern Italy in the period from 01/01/1975 to 31/12/2016. We highlight important characteristics of non-natives compared to Italians: 1) a younger age and a higher proportion of females; 2) a better health status; 3) a better social capital 4) a lower risk of death. We found differences in mortality between the various areas of origin, with a higher risk among participants born in Asia and African countries other than Mediterranean. The excess mortality compared to the reference population (SMRs) was at least three times for Italians and two times for migrants. While the non-native patients with AUDs have in general better health than Italians with AUDs, our results highlighted higher percentage of dropouts from treatment and lower access to Mental Health Services, suggesting that barriers to the access and completion of therapeutic programs still exist.

Gambling Disorder in an Italian Population: Risk of Suicide Attempts and Associated Demographic-Clinical Factors using Electronic Health Records.

To identify the demographic and clinical characteristics associated with access to Emergency Departments for Suicide Attempt in a cohort of patients with Gambling disorders. We used electronic health records of inpatient and outpatient services to identify individuals who received a diagnosis of gambling disorder (ICD-9 or ICD-10 codes) in the Metropolitan area of Bologna from 2009 to 2019. In this cohort we identified accesses to Emergency Departments for suicide attempt through cross-matching with electronic records. We calculated Crude Suicide Attempt Rates; we also included the demographic-clinical variables in a multivariate Poisson regression. We identified 692 patients with a diagnosis of gambling disorder and a total of 2733 Person Years. The Crude Suicide Attempt Rate per 1000 Person Years was 9.17 (95% CI 6.20-13.58), higher for females and much higher than the general population (incidence rate ratio = 93.72). The multivariate analysis showed a higher risk of suicide attempt in the year following the first contact with a clinical service, in patients younger than 45 years, with alcohol use disorders and personality disorders. This study evidenced a high risk of access to Emergency Departments for suicide attempt in individuals with a diagnosis of gambling disorder and highlighted important demographic and clinical factors that should be considered when evaluating suicide risk in this population.

Mortality risk in a population of patients treated for gambling disorders: results of a follow-up study.

AIMS: To examine mortality risk and causes of death in a cohort of a population of patients treated for gambling disorders in northern Italy from 1992 to 2019. METHODS: Cohort study. RESULTS: Half of the patients were diagnosed with psychiatric disorders, substance use disorder or alcohol dependence. The excess mortality compared to the general population (SMR) was 1.16 (0.85-1.58), more elevated among females aged 40 to 59 and males aged 20 to 29. Females had higher SMRs for all cancers and suicide; males for malignant neoplasm of liver, of lung, of prostate, and of bladder. CONCLUSIONS: Despite patients increasing, subjects who most turn to the services are the most serious ones, in older age, with comorbid mental disorders and with a compromised health status. This is reflected in the high risk of death for all cancers.

Suicide mortality risk in a cohort of individuals treated for alcohol, heroin or cocaine abuse: Results of a follow-up study.

Cohort study. This follow-up study (from 1975 to 2016) was aimed to estimate the mortality risk for suicide in a cohort of patients presenting to a public treatment centre for addiction (SERD) with Alcohol Use Disorder (AUD), Heroin Use Disorder - HUD or Cocaine Use Disorder (CUD), also relating to their access to a Mental Heath Service. Crude Mortality Rates for suicide were higher for patients with AUDs, for men and subjects 45-64 years old. Hanging was the main cause of suicide death. We highlight an increase in mortality in the period 2009-2012, which coincides with the economic recession, and in the year of first contact with a SERD. The Standardized Mortality Ratios (SMRs) were 4.9, higher among females than males. From the multivariate analysis, a higher risk for patients that were separated or divorced was observed. The results of our study provide some guidance on the features of subjects at greatest risk of death from suicide, which may be useful in reducing and preventing suicide and gaining a better clinical management of patients with SUDs.

Mortality Risk among Cocaine Users before and after the Economic Recession: Results of a Longitudinal Study.

BACKGROUND: Studies have highlighted 2 different groups of cocaine users (CUs): "socially integrated" (stable living conditions, regular employment, use cocaine alone or in combination with other psychoactive substances) and "socially marginalized" (socioeconomic and health problems, former or current heroin users, many injecting cocaine). These differences are also found in the elevated mortality risk for CUs, higher among subjects with cocaine and heroin use. This study targeted residents in Northern Italy who turned to a public treatment center for drug addiction following problems caused by primary cocaine use between 1982 and 2016. OBJECTIVES: To estimate mortality risk for subjects who have never used heroin (CUs) compared to that of subjects who have used heroin (HCUs). METHOD: Retrospective cohort study. We selected 1,993 subjects; 18,015 Person Years (PY). RESULTS: Over time, the quota of subjects injecting cocaine and using heroin decreased, while patients not using heroin increased. Both new patients and crude mortality rates (CMR) decreased during the years 2009-2012 and increased in the following period. CMRs were 5.55 per 1,000 PY, higher for HCUs, men and subjects aged over 44 years. Standardized mortality rates were 3.49, higher for women, injecting cocaine and HCUS. Among CUs, most of the deaths were from injury excluding drug related and tumors; among HCUs, from drug-related causes and diseases of the cardiovascular system. CONCLUSION: The study results show a change in the characteristics of SERD clients being treated for primary cocaine use, which are reflected both in mortality risk and causes of death. After a long period of a decrease, mortality risk increased in the period after the economic recession. Aspects concerning the effects of the economic recession on the problematic consumption of cocaine and on the risk of death are discussed.

Mortality Risk among Heroin Users Accessing Treatment: Natives and Non-Natives Patients Results of a Longitudinal Study.

The aim of this study was to examine mortality risk and causes of death for natives and non-natives in a cohort of heroin population of treated in Northern Italy. Crude Mortality Rates (CMRs) were 12.78 per 1,000 Person Years (PY), Standardized Mortality Rate (SMR) was 9.93. Mortality has been decreasing over time, was higher for patients who accessed the treatment services before 2001 and has been increasing with age. CMRs and SMRs were higher among natives, while non-natives were distinguished by higher CMRs and SMRs for suicide. The natives were at greater risk of death than non-natives both injecting and non-injecting, but the mortality risk was not statistically significant in the different periods of first admission. Among non-native patients, older on average, there was a lower proportion of injecting, and a higher quota of people unemployed than among Italian natives. We highlight differences between the various areas of origin concerning consumption patterns and risk of death. The results of the study highlight a particular sub-population of heroin users, the non-natives, who as compared with the Italians, have less invasive consumption styles, reach the health services later but benefit from fewer medical controls.

Ketamine abusers referring to emergency departments in northern Italy: a cross- sectional study.

INTRODUCTION: Ketamine is an essential medicine used as an anesthetic in low and middle-income countries and in veterinary medicine. Recreational use is widespread throughout the world, especially owing to its lower price compared to other substances. In Western countries its use has been mainly linked to subpopulations of young people who use drugs recreationally. Ketamine misuse is associated with amnesia, dependence, dissociation, lower urinary tract dysfunction and poor impulse control. Regular ketamine use is associated with abdominal pains. AIMS: The aims of this study are to analyze characteristics and main symptoms of ketamine abusers attending emergency departments (EDs) in the metropolitan area of Bologna, Emilia-Romagna Region, northern Italy. METHODS: We identified 74 records of ketamine-related visits: 30% female; 22% non-natives; mean age 25.6 years. Forty-two percent reported ketamine use alone, 46% reported the use of other illegal substance (cocaine 19%, heroin 18%), 26% alcohol misuse. RESULTS: The most common reported symptoms were neurological (soporous state 18%, agitation 14%, confusion 7%, panic attacks 7%, mydriasis 7%, tremors 7%), gastro-intestinal (abdominal pain 15%, vomiting 11%), urological (6.8%) and cardiac (palpitations 5%, chest pain 5%). Complications secondary to falls and cuts (7%) were the most frequent trauma complications. We highlight a significant number of visits regarding suicide attempts (10%) and overdose (4%). CONCLUSIONS: The results highlight a particular population of problematic ketamine users identified using the hospital's ICT system. In particular, poly-drug users who consume ketamine in combination with heroin or cocaine presenting to the ED represent a specific target for targeted prevention projects on non-lethal overdoses and suicide attempts.

Mortality Rates and Trends Among Bologna Community Mental Health Service Users: A 13-Year Cohort Study.

The present study aimed to determine mortality rates and trends among community mental health service users in Bologna (Italy) between 2001 and 2013. Standardized mortality ratios (SMRs) were calculated, and Poisson multiple regression analysis was performed. The cohort comprised 42,357 patients, of which 3556 died. The overall SMR was 1.62 (95% confidence interval = 1.57-1.67). SMRs for natural causes of death ranged from 1.25 to 2.30, whereas the SMR for violent deaths was 3.45. Both serious and common mental disorders showed a significant excess of mortality, although higher rates were found in severe mental disorders, especially in personality disorders. Different from most published studies, the overall SMR slightly decreased during the study period. The present study, though confirming that people with mental disorders present a higher risk of mortality, calls for prevention strategies oriented to all psychiatric diagnoses.

Who Are the Subjects with Gambling-Related Problems Requiring Treatment? A Study in Northern Italy.

BACKGROUND: This study analyzes data related to Hospital (HOS), Public Treatment Service Dedicated to Drug Addicts (SERD), or Community Mental Health Center (CMHC) clients with a first diagnosis of Pathological Gambling (PG) in the period 2000/2016 in Northern Italy. The aims were to describe trends and characteristics of pathological gamblers (PGs) and to estimate the prevalence of other diagnoses before or after the diagnosis of PG. METHODS: Participants aged over 17 years with an ICD-9 or ICD-10 PG diagnosis were selected. RESULTS: 680 PGs were identified, mean age 47.4 years, 20% female, 13% non-natives, 30% had other mental disorders diagnoses, 9% had alcohol dependence syndrome, and 11% had drug dependence. Most participants with comorbid disorders were diagnosed before PG, with a more elevated prevalence regarding mental disorders. Almost seven years had elapsed on average between the first admission and the diagnosis of PG. CONCLUSIONS: The results of this study highlight a growing demand for PG treatment addressed not only to SERD, but also to psychiatric and hospital services, based on the increase in SERD attendance from 2013. Many of them had already been treated for mental health problems before, but their percentage remained costant over time.

Accesses for alcohol intoxication to the emergency department and the risk of re-hospitalization: An observational retrospective study.

BACKGROUND: Alcohol use disorders (AUD) are a frequent cause of admission to emergency departments (EDs) for acute alcohol intoxication (AAI). Patients with AUD present a higher risk of readmission to EDs for AAI than the general population, however, the distinction between sporadic AAI and AAI in the context of AUD in the ED setting is difficult. AIMS: To analyze the epidemiological characteristics of patients admitted to EDs because of AAI and to identify factors associated with repeated admissions in order to develop a risk stratification system for patients with AUD based on objective data that can be easily applied in an ED setting. METHODS: An observational retrospective study was performed. All patients with diagnosis of AAI at admission in 2014 were enrolled. RESULTS: Five hundred and sixty-five patients were enrolled, of which 92 (16%) were admitted more than once to the ED. At multivariate analysis, factors associated with readmission were past episodes of alcohol abuse, social discomfort, previous traumas and psychiatric disorders. Basing on this parameter, a risk-score for re-hospitalization was developed. This score has a high predictive power for the risk of readmission to the ED (AROC 0.837, 95%CI 0.808-0.866), moreover, the cumulative probability of readmission within one year, increased in parallel with score value, being highest in patients presenting 3 or more risk factors. CONCLUSION: The present study demonstrates that several risk factors stratify the risk of re-hospitalization in patients admitted to EDs for AAI, allowing the identification of those presenting more severe conditions and who would likely benefit from multidisciplinary intervention.

Mortality Trends among Cocaine Users Treated between 1989 and 2013 in Northern Italy: Results of a Longitudinal Study.

A total of 852 participants attending 11 centers for addiction treatment in north Italy following problems due to cocaine abuse between 1989 and 2013 were recruited. Two typologies were created: cocaine users (never heroin) (CU) and heroin and cocaine users (HCU). During the 38-year follow-up period, 4.8% of the whole cohort died. Over the whole period, tumors were the main causes of death; starting in 2010, suicide deaths became the first cause of death. Among CUs, most deaths were due to road accidents and suicide; among HCUs, most of the deaths were from opiate overdose and from cardio-circulatory system diseases. The excess mortality observed for all causes in either sex was 6.24; higher in females (15.03) as compared in males (6.23), higher in HCUs (9.06) as compared in CUs (5.21). The directly age-sex standardized mortality rates were 5.31 per 100, higher for females, declining after 2009 for all patients and after 2004 for HCUs. Multivariate analysis confirms the decreasing trend in the risk of death and shows a higher mortality risk for participants in the under-25 age group. Among cocaine users, special attention should be paid to the prevention of suicide deaths.

Mortality trends among heroin users treated between 1975 and 2013 in Northern Italy: Results of a longitudinal study.

BACKGROUND: The aim of this study was to examine heroin mortality trends and changes in causes of death, across time and age, in a cohort of the heroin population of treated. METHODS: 5899 subjects attending twelve centers for addiction treatment (SERT) in north Italy following problems due to heroin abuse between 1975 and 2013 were recruited. RESULTS: This study documented elevated mortality among subjects with primary heroin abuse, with an elevated death risk in all the classes of age, declining until 2009 ad increasing starting from 2010. AIDS was the first cause of death, followed by overdose and liver-related diseases. In the course of time mortality for AIDS and for drug-related deaths has declined, whereas liver mortality and all tumors mortality have risen over time, becoming the most common causes of death by the end of the follow up. As compared with the general population, the excess mortality (SMR) observed for all causes in either sex was 13.2, higher in females (SMR=21.5) as compared with males (SMR=12.1). Higher SMRs were found in 25/34 age-group patients, with a progressive decrease in subjects with age >34years. CONCLUSIONS: In the course of time, among heroin users, mortality and the causes of death have changed; for SERT clients special attention should be paid to the prevention and treatment of liver-related diseases.

Mortality risk in a cohort of Italian alcoholic individuals treated for alcohol dependence.

INTRODUCTION AND AIMS: The aim of this study was to investigate the mortality risk and to explore the presence of subjects more at risk of dying in a cohort of alcoholic individuals treated for alcohol dependence over a lengthy follow-up period. DESIGN AND METHODS: A total of 2363 subjects attending 10 centres for addiction treatment for alcohol dependence were recruited. RESULTS: During the 17 year follow-up period, 14.7% of the entire cohort died. Total standardised mortality rates (SMR) were higher in women (SMR = 5.94) as compared with men (SMR = 4.65). Higher SMRs were found for several diseases, for traumatic episodes (SMR = 6.65) and in younger patients (18-44 age group) (SMR = 8.16). Alcoholic women showed a higher survival rate as compared with men. In addition, a higher risk of death for men and unemployed subjects, with a progressive increase of risk in line with the increase of the age of admission to treatment, and with a progressive decrease of risk after 1 year from the beginning of the treatment, was also found. DISCUSSION AND CONCLUSIONS: This study confirms that mortality risk in alcoholic individuals in treatment is higher in comparison with the general population. Moreover, alcoholics men, unemployed, >40 years at time of admission and during the first year of treatment are more at risk to die. Thus, much more attention to patients with these characteristics should be planned by the professional staff working in centres for addiction treatment. [ Pavarin R M, Caputo F, Zoli G, Domenicali M, Bernardi M, Gambini D. Mortality risk in a cohort of Italian alcoholic individuals treated for alcohol dependence Drug Alcohol Rev 2017;36:186-191].

Estimate of the prevalence of subjects with gambling-related problems requiring treatment: a study in Northern Italy.

This study analyzes the data related to subjects who for the first time turned to a hospital or to a Public Treatment Service Dedicated to Drug Addicts or to a Community Mental Health Center for problems related to pathological gambling in the metropolitan area of Bologna (Northern Italy) in the period 2000/2015. The aims were to describe characteristics and problems of pathological gamblers (PGs), and to estimate the prevalence of PGs using the capture-recapture method. Four hundred and ninety-five residents were identified, with an estimate of 1570 PGs and a prevalence of 1.78 per 1000. We highlight a high number of new cases in the period after 2010. Most patients are males, aged from 40 to 50 years, 12% were born abroad, one in three suffers from other mental disorders, 9% has alcohol dependence, 8% drug dependence. We should point out the low level of education and the high number of unemployed subjects.

First Consumers, Then Socially Integrated: Results of a Study on 100 Italian Drug Users Who Had Never Turned to Public or Private Addiction Services.

This study, which addressed a per quota sample of 100 socially integrated drug users (SID) residing in Emilia Romagna (Italy) who have never referred to a public/private Addiction Service, has four main aims: (1) to describe the phenomenology of substance use in all its different facets; (2) to identify feared unwanted consequences due to the use of illegal substances and possible behaviors finalized to preventing them; (3) to identify possible common consumption rules; (4) to identify any differences among the SID. Two types of consumers have been compared: the "law-breakers" (i.e. those who have committed an illegal activity to procure money) and the "law-abiders" (no such action).From the interviewees some discontinuous consumption trajectories over time are reported in relation to the different levels of disposable income and the change in the relationship with the substances. Most of these consumers fear being stigmatized or labeled as drug-addicts, and cause themselves physical, psychological or economic harm; instead only a minority fear developing addiction. The most widespread protective behavior is to purchase through trusted direct channels, followed by the attempt to limit the doses and to consume only in positive emotional states. Rules of conduct implemented at a general level by all the consumers were evidenced, which the law-breakers finalize towards a greater attention to their own psycho-physical health and to better handling the effects produced by the substances, while the law-abiders seek to keep their status as consumers secret.