Bollettino epidemiologico nazionale

Unrecognized health problems: Treatment of alcohol abuse and the Italian National Health Services

Although the per capita consumption of alcohol in Italy has declined over the past 20 years (1), the percentage of the population that drinks alcohol remains high, especially in the northern part of the country.  Periodic surveys on the health status of the population demonstrate that consumption is particularly high in the Piedmont Region of northwest Italy (2).  In 1994, 1.2% of the Italian population over the age of 14 years reported drinking alcohol outside the context of meals on a daily basis.

The Centers for the Treatment of Substance Abuse (SERT), which were originally designed to provide care for drug abusers, have in recent years also begun to provide treatment for alcohol abuse and to provide rehabilitation services for alcoholics. In the Piedmont Region a regional law has given the SERTs the responsibility of coordinating public and private alcohol treatment services.  Since 1996, the SERTs have been providing data to the Ministry of Health summarizing their activities regarding treatment of alcohol abuse.

The present study is designed to evaluate the extent to which the SERTs of the Piedmont Region provide services to the alcohol-dependent population by comparing the number of persons under treatment by the SERTs with the number of persons hospitalized for alcohol-related problems in the region.

For purposes of the study, two data sources were used for the years 1997, 1998, and 1999.  The first source consisted of two different forms that are routinely filled out by each SERT and sent to the Ministry of Health, one of which contains aggregate data on the number of alcohol abusers under treatment by age and sex and the other of which contains information on hospital admissions and causes of admission of alcohol abusers under the care of each SERT. The second data source was the computerized system of hospital discharge records, which provided data on first admission during each of the three calendar years for residents of the Piedmont Region, both within and outside the region. Records were selected for those who had one of the following International Classification of Disease 9^th Revision codes regarding alcohol-related diagnoses listed as the primary diagnosis or as one of the three secondary diagnoses:

a)    Organic diseases: 291 (alcoholic psychoses); 571.0-571.3 (alcoholic fatty liver, acute alcoholic hepatitis, alcoholic cirrhosis of the liver, and unspecified alcoholic liver damage); 425.5 (alcoholic cardiomyopathy);

b)    Other alcohol-related diagnoses: 303 (alcohol dependence syndrome); 305.0 (alcohol abuse); 790.3 (elevated blood alcohol); these codes were often used for those admitted for alcohol detoxification (3).

Between 1997 and 1999, the number of clients under treatment for alcohol abuse in the Piedmont Region’s SERTs increased 27%, from 2741 in 1997, to 2991 in 1998 to 3492 in 1999.  During the study years, approximately 14% of the alcohol abusers under treatment were admitted to the hospital (from 396 to 474 admitted annually), with an estimated one-third of the admission due to organic damage resulting from alcohol abuse. During these same years, the number of Piedmont residents hospitalised with alcohol-related problems was approximately 5500.  Two-thirds of these admissions were for organic problems (neurologic or liver damage); the remaining third had other alcohol-related diagnoses.

Comparing the number of admissions among alcohol abusers under treatment in the SERTs with the information from the hospital discharge data base for the three years under study, it appears that 1) among Piedmont residents hospitalized for alcohol-related problems, 7-9% were being treated by the SERTs; 2) among those undergoing alcoholic detoxification, 13-16% were being treated by the SERTs; and 3) among those admitted for alcohol-correlated conditions, 4-5% were under treatment in the SERTs.

¹ source: hospital discharge records, Piedmont Region

Although the number of alcohol-dependent patients under treatment in the SERTs has increased in recent years, they represent only a small fraction of those who are need of treatment for alcohol-related problems.   Too many patients (approximately 95%) with serious organic problems resulting from alcohol abuse have not been seen by the SERTs, which instead seem to be providing care for a population with a much lower prevalence of organic problems. It appears that, in the hospital setting, the diagnostic evaluation and treatment of the organic problems of these patients assumes precedence over ensuring referral for treatment of the underlying behavioral problem of alcohol abuse.

A second finding is that 85% of the patients admitted for detoxification treatments are referred not by the SERTs but by general practitioners, or by other units such as gastroenterology or neurologic services.

It is likely that persons with major alcohol abuse problems are seen infrequently by the health care system, and when they do present, they often have extensive organic damage.  They also are reluctant to use the services of the SERTs, which are generally believed to be solely for the treatment of the abuse of illegal substances.  To better serve the population in need, the SERTs should be better equipped to deal with treatment requests, and efforts should be made to encourage general practitioners to refer patients with alcohol problems to the SERTs for treatment.

The lack of recognition of their problem on the part of persons who are alcohol-dependent is compounded by the lack of referral mechanisms and integrated care.  In recent years, patients with alcohol problems are seen by psychiatric services, the SERTs, hospitals, social services, and a variety of private and voluntary organizations such as the Club for Alcoholics in Treatment and Alcoholics Anonymous.

The need for better integration among the various organizations involved has resulted in the formation in recent years  of work groups for patients with alcohol dependence problems, which represents a partial response to the problem.  As these data demonstrate, however, there is much that remains to be done if the services are to meet the needs for treatment.

Giuseppe Salamina¹, Enrica Galvani ¹, Antonella Carcieri², Alessandro Migliardi³, Marco Dalmasso³

¹Epidemiologic Observatory for Substance Dependance, Epidemiology Service, Grugliasco (TO)
²Department of Public Health and Microbiology, University of Turin
³Epidemiology Service, ASL5, Grugliasco (TO)

Comment:

In recent years, the prevalence of alcohol-related problems has been a subject of considerable debate in public health circles.  Much of the information available in Italy comes from estimates of alcohol consumption based on fiscal data (imports and exports) and from estimates of family consumption from sample surveys conducted by the National Statistics Institute (ISTAT) on household expenditures and from ISTAT’s multipurpose surveys on lifestyle.

It is common knowledge that in Southern Europe, wine is consumed more commonly than other alcoholic beverages.  This tendency has deep roots in the culture of the area, although substantial changes have occurred in the last decade.

In reality, such changes have not affected the finding that wine still accounts for most of the alcohol consumed in Italy (75-80%). In spite of the significant reduction in consumption in recent years (a 33% decline between 1981 and 1998), the median per capita consumption of alcohol as expressed in grams of pure alcohol remains among the highest in Europe. The frequency of exposure of the population to alcohol and to a significantly elevated risk of alcohol-related problems is demonstrated by the number of alcohol-dependent clients reported to the Ministry of Health by services or working groups dedicated to alcohol dependence: in 1998, 26,708 alcohol-dependent clients (20,567 males, 6.141 females) of whom 76% are between the ages of 30 and 59 years and 9% are between the ages of 19 and 29 years.

Until 1983, ISTAT examined alcohol consumption in a detailed fashion as part of their sample surveys on the health status of the Italian population and estimated the proportion of the population that were heavy drinkers, defined as those who consumed more than 96 grams/day of alcohol. The data provided by these surveys showed a north-south gradient, from 1.8% in the north to 1.6% in the center and 1.0% in the south, with the greatest consumption in the 45-64 year age group, residents of mountainous areas of the north, and among those with low educational attainment.

More recent ISTAT data show that there are considerable differences in alcohol consumption from one area of Italy to another, although in all areas, males are more likely to be heavy drinkers than females.  Using the definition of heavy drinking as the consumption of more than ½ liter of wine per day (approximately 50 grams of alcohol), the 1995-1998 multipurpose surveys showed a decline in consumption for both men (from12.2% to 9.7%) and for women (from 1.8% to 1.5%).

The use of computerized hospital discharge records can contribute to an evaluation of alcohol-related conditions on the health services, even though this may represent an underestimate. The increase in the numbers of persons with alcohol dependence being treated in the SERTs of the Piedmont Region and the high rate of hospitalisation of these patients (14%), 30% of whom had problems  related to organ damage, underlines the inability of the medical system and the lack of organizational capacity on the part of the social and health services to identify in a timely way those at risk, providing them with information (brief interventions), counselling, and, in certain circumstances, referring them to specialized centers for the treatment and rehabilitation of alcoholics.

A recently approval of a law concerning alcohol and alcohol-related problems emphasizes the necessity of reforming the curricula of the health and social service professions and psychology to include training on alcohol and alcohol abuse. The need for better integration between the various public entities and private self-help groups identified by the authors may be assisted as well by this new law, which calls for the identification at local, provincial, and regional level of a specific unit that is to be housed either within the Local Health Agencies of the area or within other public or private structures accredited by the local health agency and will be designed to provide acute and long-term management of alcohol abusers.

References

1.  Scafato E, Cicogna F. Alcologia 1998; 10:72-74.

2.  Stili di vita e condizioni di salute. Indagini Multiscopo sulle famiglie Anni 1993-1994. ISTAT. Roma 1996

3.  Siliquini R, Salamina G, Ruschena M. Utilizzo delle schede di dimissione ospedaliera per la sorveglianza degli eventi sanitari legati all’uso di sostanze. In: Faggiano F, Ruschena M (a cura di). OED Piemonte – Rapporto 2000. Dal Fare al Dire 2000;2 (suppl.):13-21

Emanuele Scafato
Observatory for Smoking, Alcohol, and Drugs
Laboratory of Epidemiology and Biostatistics
Istituto Superiore di Sanità. Roma