Il ruolo dell'ospedale nella gestione dell'assistenza integrata ai tossicodipendenti ed ai soggetti a rischio: un'esperienza dell'Azienda Policlinico Umberto I di Roma

Summary - The role of the hospital in the integrated health care of drug addicts and at-risk subjects: the experience of the Azienda Policlinico Umberto I in Rome Introduction. It is well known that drug-abuse subjects, alcoholists, or individuals misusing pharmaceuticals, during their history as psychoactive substance consumers, are very likely to come across one or more hospital facilities, on account of alcohol/drug-related diseases (withdrawal syndrome, overdose, acute poisoning, infectious diseases, etc.), or because of other acute clinical conditions (e.g. trauma). On these occasions, the hospital should not reply exclusively in terms of diagnosis and therapy of the immediate episode, but also in terms of steering these subjects towards the most competent community services, taking advantage of the vulnerability that often accompanies the access to an emergency department. This vulnerability may represent an important opportunity either to realize preventive intervention or to start a therapeutical and rehabilitive path. In the present paper the authors report the results of the research project “An integrated approach for reception, treatment, and prevention for drug-addicts and at-risk subjects”, object of an agreement drawn up by the Hygiene Section of the Department of Experimental Medicine and Pathology of the University of Rome “La Sapienza”, the Department of Social Affairs of the Presidency of the Minister Council and the MURST. The project proposes a model which assigns to the hospital a significant role in the so called “integrated network of services”, which represents the current pattern of the health care for drug addicts. Methods. The project took place in the emergency department of the Azienda Policlinico Umberto I of Rome. All subjects with direct or indirect signs of alcohol and drug abuse were evaluated by a multidisciplinary team formed by specialists in internal medicine, psychiatrists and psychologists, toxicologists, nutritionists, social assistants and public health specialists. The patients were hospitalized in case of need and, after the assessment by the specialists’ team, were sent to the existing community services (alcoholics anonymous associations, therapeutic communities, Ser.T., mental health centers, etc.). Results. In the period 1998-2000, 453 subjects were recruited in the project, for a total of 499 accesses to the emergency department. According to the most frequently used substance, subjects have been classified in 6 groups: alcohol (41.5%), heroin (17.2%), polyabuse (15.2%), at-risk subjects (10.7%), pharmaceuticals (9.7%) and cocaine (4.6%). At-risk subjects include both occasional psychoactive substance consumers and ex-addicts. The sample showed several features homogeneous in all groups, such as, for instance, gender (male, for the most), age (around 30 years, with the exception of alcoholists, aged 44 on average), schooling (generally low), occupational status (mostly being unemployed) and severity code (usually “green” or “yellow”). The age of beginning of substance abuse was generally low (18-25 years), whereas the frequency of admission to the hospital was generally high (more than 50% of cases). Subjects on average showed a good nutritional status. The compliance to the treatment, that should be perceived as a full willingness to follow the research team’s suggestions, was high (more than 70%). The compliance increased significantly, in a multiple logistic regression model, if subjects had a regular job and were aware of their disease condition. Conclusions. The results of this study indicate that the involvement of the hospital emergency department within the integrated network of services for drug-addicts is an effective tool to initiate interventions. Specifically, data on the compliance to the treatment seems to confirm that the vulnerability which often accompanies the access to the emergency department may represent the occasion for the opening of a “therapeutical window” for drug-abuse subjects, alcoholists, and individuals misusing pharmaceuticals. Such opening may then trigger a virtuous circle, leading to important therapeutical and preventive results. The authors conclude with some considerations on the organization of the health care for drug-addicts, outlining the central role inside the network of SerTs, which, however, should include hospitals and emergency services among their preferential partners. The steady dislocation of Ser.T. personnel inside the hospital emergency services is likely to achieve effective and stable connections between the hospital and the community services.