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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.

OBJECTIVE: Early identification of Harmful Drinking (HD) is difficult, and underestimated. The aim of our retrospective study was to investigate the presence of HD in a population of subjects who had their driving license suspended due to driving under the influence of alcohol. MATERIALS AND METHODS: We retrospectively recruited 979 subjects. During the first appointment (T0), clinical and laboratory characteristics of patients were evaluated, and the AUDIT questionnaire was administered. Two groups were then defined: Harmful Drinking (HD) and non-HD, and all subjects underwent a brief interview for 5-10 minutes before being assigned to a group. RESULTS: 95.9% of our sample were identified as non-HD, whereas 4.1% of them were HD; twenty-one (2.1%) of the HD underwent a control appointment (T1), and 17 (1.7%) of them were diagnosed with alcohol use disorder (AUD); there was a statistically significant reduction in mean daily alcohol intake (p

The aim of this study was to examine the mortality trends and causes of death in Northern Italy in a cohort of a population of individuals treated for alcohol use disorder (AUD) over a 38-year follow-up period (1978-2016).6,198 patients attending eighteen centres for addiction treatment (CATs) for AUD were recruited.During the follow-up period, 19.5% of the whole cohort died. The crude mortality rates (CMRs) were elevated (21.34 x 1000 person-years [PY]), higher for men and increasing with age group. The CMRs were higher for all cancers, followed by digestive system diseases, diseases of the circulatory system, transport accidents, and suicide. The standardised mortality ratios (SMRs) were at least three times higher for women and for men, and they were more elevated in younger patients and have been falling since 2009. Multivariate analysis confirmed that the mortality risk was higher for males and increased with age and decreased over time. The patients' main characteristics changed over time and, along with a greater presence of women and non-natives, fewer marginalised people and more socially integrated people turned to CATs.The mortality risk in treated AUD is confirmed to be higher when compared with the general population, although it is decreasing. In addition, there is enough epidemiological data to assert that, independent of age and gender, the major causes of death in AUD patients are cancers, gastrointestinal disease, cardiovascular disease (CVD), and injuries.

Harmful and hazardous alcohol consumption is one of the most significant public health problems in Italy and Europe. Habitual excessive consumption and occasional excessive consumption, known as binge drinking, are the two main risk behaviours related to alcohol. Harmful drinking and alcohol dependence have strong social repercussions in terms of their social and economic impact and contribution to productivity losses. In addition, the terms alcohol abuse and alcohol dependence have been recently substituted by the only term of alcohol use disorder (AUD). The issues presented in this review demonstrate that excessive alcohol consumption is a growing public health concern and an appropriate national action plan is needed to increase the prevention of harmful and hazardous consumption and encourage patients to seek healthcare. To date, the main problem is the under-treatment of the population at risk, manifested as the time-lag between the onset of AUD and the first clinical detection. In order to address this, the Screening, Brief Intervention, and Referral to Treatment (SBIRT) strategy has been shared across countries in Europe and is supported by a Systematic Review of Reviews on SBIRT in primary healthcare. Unfortunately, there are still obstacles in the implementation of this approach. The main problem would appear to be general practitioners' difficulty in carrying out accurate and widespread screening, because they may minimize the problem. A more concerted effort in the training of healthcare professionals could address this by enabling the creation of renewed networks for the early identification of harmful and hazardous drinkers. These networks could prevent the occurrence of avoidable alcohol-related conditions, such as alcohol-related liver disease (ALD), while allowing for the timely implementation of evidence-based brief interventions.

Various epidemiological and biological evaluations and the recent publication of the DSM-V (diagnostic and statistical manual of mental disorders) has imposed on the scientific community a period of reflection on the diagnosis and treatment of what in the DSM-IV was defined as "addiction". To date, the term "addiction" has been replaced by the DSM-5, because there is no global scientific consensus that has unequivocally characterized its clinical characteristics. This, we will talk about substance/alcohol use disorders (SUDs/AUDs) and disorders related to behavioral alterations (DBA) that can generate organic diseases, mental disorders, and social problems. In the first psychotic episode 40-70% of subjects meet the criteria of a SUDs/AUDs, excluding tobacco dependence. Substances can not only be the cause of a psychotic onset, but they can also disrupt a psychotic picture or interfere with drug therapy. The pharmacodynamic profiles of many substances are able to provoke the phenomenology of the main psychotic symptoms in a way that can be superimposed onto those presented by psychotic subjects without a history of SUDs/AUDs. The Department of Addictions (DAs) must not be absorbed by or incorporated into the Departments of Mental Health (DMH), with which, however, precise operational cooperation protocols will have to be defined and maintained, but it will have to maintain its own autonomy and independent connotation. Addiction Medicine is a discipline that brings together elements of public health, prevention, internal medicine, clinical pharmacology, neurology, and even psychiatry. The inclusion of the DAs in those of DMH refers purely to a problem of pathology that has to do with lifestyle, choices, and behaviors. These, over time, show their dysfunctionality and only then do related problems emerge. Moreover, epidemiological, social, and clinical motivations impose the creation of alcohological teams dedicated to alcohol-related activities. The collaboration with self-help-groups (SHGs) is mandatory. The action of SHGs is accredited in numerous international recommendations both on the basis of consensus and evidence in the literature.

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 refereesfirst 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 betterway. However, some issues remain controversial, and others remain unresolved.

Allo scopo di raggiungere e mantenere la completa astinenza da bevande alcoliche, è necessario che i pazienti con cirrosi epatica alcolica sottoposti a trapianto ortotopico di fegato siano valutati e seguiti prima e dopo il trapianto attraverso un approccio multidisciplinare. L’esperto di alcologia o alcologo presente all’interno delle equipè trapiantologiche ha il compito di effettuare una valutazione specifica (alcologica) caratterizzata da: anamnesi, esame obiettivo, somministrazione di scale, valutazione dei parametri di laboratorio ed eventuale impostazione di un trattamento farmacologico (anti-astinenziale od anti-craving). Tuttavia, nei pazienti affetti da cirrosi epatica alcolica, il rischio di epato-tossicità limita notevolmente l’opzione farmacologica; il baclofene è l’unico approccio farmacologico che le linee guida dell’Associazione Europea per lo Studio del Fegato hanno recentemente indicato come sicuro ed efficace. Infine, la figura dell’alcologo deve partecipare al processo decisionale di inserimento in lista OLT ed al monitoraggio del paziente nella fase pre-OLT. Quindi, la stretta collaborazione con gli epatologi ospedalieri, con le U.O. di alcologia territoriali, con i servizi territoriali per le tossicodipendenze (Ser.T.), con la famiglia e con le associazioni (es: gruppi di auto-mutuo aiuto) risulta di fondamentale importanza.

L'obiettivo primario del trattamento della dipendenza da bevande alcoliche è il mantenimento della completa astinenza. La modalità di intervento è multi-professioanle e multi-modale.

Nel nostro paese, la terapia della dipendenza da alcol non ha avuto per molto tempo un luogo di cura specifico nel Servizio Sanitario Nazionale. Il paziente alcolista con comorbidità psichiatrica e conseguente comportamento socialmente problematco, poteva accedere ad un Servizio Psichiatrico.

L'abuso di alcol comporta un danno a carico di numerosi organi e apparati, determinando quadri patologici diversi a seconda che si tratti di un insulto acuto o ripetuto nel tempo. Tuttavia, poiché quasi il 90% dell'alcol ingerito raggiunge, attraverso il sangue portale, il fegato e qui viene metabolizzato, questo organo presenta una particolare suscettivilità al danno prodotto dall'uso inappropriato di questa sostanza.

Each year, about 20 000 patients are treated with SO and there is an overall good clinical experience. One major concern is that SO is used as a recreational drug and there has been indeed a sharp increase in cases the number of patients in treatment due to GHB addiction and overdosing. Nevertheless, only in approximately 10% of the treated population, craving for or abuse of SO, is observed. Taking all randomized controlled trials (RCTs), clinical controlled trials and controlled prospective studies into consideration, SO appears to be more effective than placebo on alcohol abstinence, controlled drinking and relapses to heavy drinking, and seems to be also more effective than other approved pharmacological interventions. The low number of available studies, the low sample size and the low quality of the included studies limit the validity of these results and suggest the need of conducting new high-quality RCTs with appropriate sample size. A large RCT (SMO.IR trial sponsored by the French Company D&A Pharma) involving almost 500 patients in nine European countries is now on its way to provide data for EMA approval.

Il concetto di Alcolismo (AD) come malattia del cervello (Diana M., 2013) trova la sua articolazione nelle acquisizioni neuro scientifiche e nella loro applicazione nel setting clinico. Un elemento fondamentale di questo processo è stato la acquisizione della centralità del craving (desiderio irresistibile, compulsione…) nel mantenimento della dipendenza e nella genesi della ricaduta. La validazione di strumenti farmacologici e psicologici atti a contrastare il craving prevenendo la ricaduta nell’uso di alcol costituisce, oggi, un importante obiettivo nella ricerca e nella clinica. L’utilizzo del Sodio Ossibato (SO) o Acido Gamma-idrossibutirrico (GHB) come anti-astinenziale ed anti-craving si colloca nel contesto descritto. Il ventennale uso del GHB per il trattamento dell’alcolismo in Italia ha permesso di precisarne le caratteristiche, le indicazioni ed il potenziale di abuso e di definire le tipologie dei pazienti e le modalità di utilizzo che ne massimalizzano l’efficacia riducendone i rischi.

Almost 10% of the world's population is affected by alcohol use disorder (AUD). The combination between psychosocial intervention and pharmacological treatment seems to be the most effective approach for patients affected by AUD. Among effective drugs useful in the treatment of AUD, GABAB-ergic medications have been tested with encouraging results (i.e. sodium oxybate, baclofen, gabapentin, pregabalin and tiagabine). The present review will summarize available data on these medications.

Craving plays an important role in the pathogenesis of alcohol dependence and relapse. In this review we have tried to analyse how many contrasting theories have been formulated in order to clarify the concept of craving. Many complex neurobiochemical mechanisms are implicated in the etiology of craving; these mechanisms involve several neurotransmitters, such us dopamine, opioids, glutamate, and serotonin. On the other hand comportamental and/or cognitive aspects could also play a role in the etiology of craving. The coexistence of many and often contrasting theories can indicate that different subtypes of patients could have different mechanisms at the basis of alcohol craving, suggesting that it could be advisable to personalize the anti-craving therapy.

Metadoxine is approved in Europe for alcohol intoxication and is also indicated for alcoholic liver disease (ALD). This study aims to investigate the use of metadoxine as a potential pharmacotherapy for alcohol dependence (AD).This is a retrospective study of 94 outpatients with AD, who received metadoxine for alcohol intoxication and were assessed for alcohol consumption, craving [Visual Analog Scale (VAS)] and liver-related and alcohol-related biomarkers [aspartate aminotransferase (AST), alanine aminotransferase (ALT), gamma-glutamyl-transpeptidase, mean corpuscular volume].Range of metadoxine dose was 500-2000 mg/day, with a mean dose of 1277(s.d.290) mg/day, and for a period of 2-42 days, with a mean period of 8.9(s.d.7.0) days. Follow-up data were available for 52 patients (55.3%); 35(67.3%) patients were completely abstinent. There was a significant decrease in drinks per week, even after substituting baseline drinking as follow-up data for dropouts (p 0.001) and examining drinking pre-treatment and post-treatment for those who did not achieve abstinence (p 0.001). There was a significant decrease in the VAS (p 0.001) and a significant improvement in the AST/ALT ratio (p = 0.03).Despite important limitations, this study represents a further preliminary observation suggesting metadoxine as a novel alcohol pharmacotherapy, including in alcohol-dependent patients with ALD.

OBJECTIVE: Evaluation of the interaction between alcohol intake and cofactors [hepatitis B virus (HBV), hepatitis C virus (HCV), body mass index] and coffee consumption on the risk of cirrhosis. DESIGN: Seven hundred and forty-nine consecutive patients with chronic liver disease referring to units for liver or alcohol diseases in Italy during a 6-months period. Teetotalers were excluded. The odds ratios (OR) for cirrhosis were evaluated using chronic hepatitis cases as the control group. RESULTS: An alcohol intake of more than 3 units/day resulted associated with the likelihood of cirrhosis both in males (OR 4.3; 95% CI=2.5-7.3) and in females (OR 5.7; 95% CI=2.3-14.5). A multiplicative interaction on the risk of cirrhosis between risky alcohol intake and HBsAg or HCV-Ab/HCV-RNA positivity was observed. A reduction of cirrhosis risk was observed in subjects consuming more than 3 alcohol units/day with increasing coffee intake. The OR for the association with cirrhosis decreased from 2.3 (95% CI=1.2-4.4) in subjects drinking 0-2 cups of coffee/day to 1.4 (95% CI=0.6-3.6) in those drinking more than 2 cups/day. CONCLUSIONS: In subjects with an alcohol intake >3 units/day the coexistence of HBV or HCV multiplies the risk of cirrhosis. Coffee represents a modulator of alcoholic cirrhosis risk.

The association between venous thromboembolism and cancer has been widely documented and the main factor responsible for cancer-induced venous thromboembolism is considered mostly linked to a hypercoagulation state induced by the cancer itself. There is no consensus on investigative strategies for occult cancer in a patient with a thrombophilic condition. We report a patient who manifested an isolated episode of pulmonary embolism without specific evident sources of venous thromboembolism. The routine clinical and laboratory work-up to detect an occult cancer did not reveal any malignancy. A history of duodenal ulcer in association with a recent slight alteration in bowel habits led us to perform an esophagogastroduodenoscopy which was negative for malignancy, and a barium enema followed by colonoscopy, which revealed the presence of a tumor limited to the large intestine. An unexplained clinically evident hypercoagulation state, even in the presence of mild clinical symptoms, needs more thorough diagnostic strategies when simple methods of screening for occult cancer are negative.

The aim of this study was to evaluate the energy expenditure, substrate oxidation, and body composition in alcoholics during addiction and after several months of abstinence.A total of 32 alcoholics without liver cirrhosis and malabsorption were consecutively recruited. A total of 55 social drinkers, matched for gender and height, were studied as a control group. Anthropometry and bioimpedance analysis were performed to assess body composition, and indirect calorimetry was used to measure basal metabolic rate (BMR) and substrate oxidation. Total abstinence was then achieved in 15 subjects. At 1, 2, 3, and 6 months of abstinence, the metabolic variables and the energy intake were re-examined.At enrollment (T0) alcoholics compared to controls showed a significant decrease in body mass index (22.2+/-2.71 vs 23.6+/-1.3 kg/m2; p0.05), fat mass (14.1+/-4.5 vs 16.7+/-3.3 kg; p0.01), an increased BMR normalized by fat-free mass (34.5+/-3.7 vs 32.1+/-2.01 kcal/kg/day; p0.01), a lower nonprotein respiratory quotient (npRQ: 0.76+/-0.03 vs 0.83+/-0.03; p0.001), with a consequently higher lipid oxidation (0.08+/-0.02 vs 0.04+/-0.02 g/min; p0.01), and a lower carbohydrate oxidation (0.05+/-0.02 vs 0.10+/-0.03 g/min; p0.01). Although at 1 and 2 months of abstinence the metabolic parameters had improved, only after 3 months of abstinence did alcoholics show values of body mass index (23.2+/-2.6 kg/ m2), fat mass (17.0+/-5.34 kg), BMR/fat-free mass (33.1+/-2.78 kcal/kg/day), npRQ (0.82+/-0.02), lipid oxidation (0.05+/-0.03 g/min) and carbohydrate oxidation (0.11+/-0.04 g/min) comparable to those of controls; these values remained constant at 6 months.Three months of abstinence from alcohol could represent the minimum time necessary to obtain a normalization of the metabolic variables considered and of the nutritional status for these patients, probably related to a regression of the functional alterations of the microsomal ethanol oxidizing system and of mitochondria secondary to chronic ethanol abuse.