Other drug-related morbidity

The toxicological laboratory has started with the study of drugs prevalence in fatality.

b) Psychiatric co-morbidity

According to the study "An eight year naturalistic observational study of heroin-addicted, methadone maintained psychiatric patients" (Lovrečič, Center for Treatment of Drug Adicts Koper and Maremmani, PISA-SIA Group) dually diagnosed patients need a higher stabilization dosage (highest dosage

maintained for a minimum of one month), as high as 150 mg/day, than patients with no additional diagnosis who on the average become stabilized on 120 mg/day. This difference is statistically significant. The higher stabilization dosage range (80-120mg/day) needed for dually diagnosed patients suggests that unresponsiveness to standard treatment observed in this category may actually be due to under medication. The need for such high dosages may derive from pharmacocynetic issues, since the psychotropic drug dosages needed to treat this category of patients are also higher than average.

The time needed to reach stabilization is as long as 6 months for patients without dual diagnosis (min max), whereas dually diagnosed patients require as long as 14 months on the average to reach stabilization. On the whole, dually diagnosed patients needed higher stabilization dosage and a longer time to reach it; the latter factor is not exclusively due just to higher dosages.

Therefore, greater care is recommended for such subjects during the stabilization phase; dose adjustment may be required even after some years of ongoing treatment.

The PISA-SIA Group is an operational unit of the Department of Psychiatry, University of Pisa, Italy. It comprises a hospital division, a Day Hospital and an Outpatient Unit. The Outpatient Service runs a programme of methadone maintenance designed to meet the needs of two types of patients.

The first type of patients comprises those who fail to respond favourable to standard protocols (methadone dosages are generally in the 60-80 mg/day range, with the maximum of 100 mg/day). In the PISA-MMTP are no dosage limits and patients are encouraged to accept an increase of their dosage if they continue to show addictive behaviour. They are referred to public services that treat addiction and operate on a territorial basis.

The second type of patients comprise of heroin-addicted psychiatric patients who are resistant to standard psycho-pharmacotherapy. These patients do not remain compliant with pharmacological treatment; once they have left the hospital they usually discontinue the treatment and show psychopathological symptoms and addictive behaviours despite the number of admissions to

hospital (at least two in the previous two years). After referral by the hospital division of the Department, they receive methadone maintenance treatment as soon as they leave hospital.

Data emerging from our naturalistic study make it possible to identify another subgroup of heroin addicts who should be started on methadone as a priority.

A third or a half of all opiate addicts may suffer from mental disorders.

Enrolment in treatment makes a significant positive impact on their psychological well-being.

Methadone maintenance reduces maladaptive behaviors (likelihood of overdose and law-breaking); it is effective on the risk behaviors of pregnant addicts, with worthwhile benefits for both, the mother and the fetus; it is effective on risk-behaviours in HIV-infected addicts. Our data shows that even those mentally ill heroin addicts who have proved to be resistant to treatments, both for addiction and mental illnesses, and are non-compliant with psycho-pharmacotherapy are likely to develop an adaptive behaviour as long as they are maintained on an adequate methadone programme. Thus both, compliance with the treatment of addiction and the possible treatment of the concomitant mental illness, become achievable aims.

Therefore, even in dually diagnosed patients methadone maintenance confirms its power to reverse maladaptive behaviours.

c) Other important health consequences (e.g. drugs and driving, acute and chronic drug effects...)

According to the article Drugs and traffic safety – slovenian aproach (Majda Zorec Karlovsek, Borut Stefanič)

The Institute of forensic medicine in Ljubljana performs toxicological analysis of blood and urine samples taken from traffic participants apprehended due to suspicion of alcohol and drugs. Retrospective study of requests for toxicological analysis gets the insight in growing problem of drugged driving in Slovenia. The activities of institute in this field are directed also in the law enforcement,

education, epidemiological research and prevention issues.

Table 3.4.1. The number of requests for toxicological analysis in cases of suspicion of drug impaired driving

Year Police controls

(PC) Traffic accidents

(TA) All Ratio

PC/TA

1991 3 3 6 1.00

1992 3 9 12 0.33

1993 4 3 7 1.33

1994 13 27 40 0.48

1995 42 23 65 1.82

1996 73 35 108 2.09

1997 155 69 224 2.25

1998 206 99 305 3.08

1999 516 166 682 3.11

2000 667 221 888 3.02

Source: Majda Zorec Karlovšek, Borut Stefanič, Institute of Forensic Medicine, Faculty of Medicine

Average age among drivers in the accident group was 27.5 years for males and 29.3 years for females and in the non-accident group 24.9 years for males and 25.3 years for females.

Table 3.4.2. Frequency at which drugs were encountered

Police controls Traffic accidents All

(n=1307) Benzodiazepines 14.2% 31.6% 17.5%

Opiates 19.7% 24.0% 28.6%

Cannabinoids 66.2% 38.0% 60.8%

Cocaine 8.7% 5.2% 8.0%

Methadone 26.6% 25.6% 26.4%

Amphetamines 11.5% 8.0% 10.9%

Others 4.0% 18.0% 6.7%

Source: Majda Zorec Karlovšek, Borut Stefanič, Institute of Forensic Medicine, Faculty of Medicine

Health conditions and driving ability of special groups of drivers During the Slovenian symposium on traffic medicine held in may 1998 in Rogaška Slatina several conclusions and recommendations concerning health conditions of traffic participants are given.

It is obvious that a special regulation is necessary for drug rehabilitation programmes, methadone substitution programme and driving ability.

To the problem of drivers attending methadone maintenance programme a special conference was performed in June 2001, organised by the Government Office on Drugs and the Institute of Forensic Medicine.