Presidenza del Consiglio dei Ministri
DIPARTIMENTO POLITICHE ANTIDROGA
Website consultations, short
residential and daily community
services for cocaine treatment in
Italy
AUGUSTO CONSOLI
10-12 MAY 2010
Assumptions_1
The transversality of cocaine consumptions doesn’t allow to
identify
a
single
intervention
model
for
a
very
heterogeneous typology of consumers, who need different
approaches and progressive objectives.
We should deepen the reflection on the most suitable
procedures for receiving and taking charge of the demands
of people who often keep their own social and affective
dimensions separate from consumptions hardly perceived
as problematic.
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Presidenza del Consiglio dei Ministri
DIPARTIMENTO POLITICHE ANTIDROGA
Assumptions_2
This perspective, which involves a redefinition of
traditional processes of access to the health care
services and which is oriented to promote the
emergence of hidden problems, invests both the
outpatient services as well as the residential ones and
the organizational structures as well as the therapeutic
settings.
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Presidenza del Consiglio dei Ministri
DIPARTIMENTO POLITICHE ANTIDROGA
Main question
Which factors must be evaluated in order to select a
good treatment for problematic cocaine users?
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Presidenza del Consiglio dei Ministri
DIPARTIMENTO POLITICHE ANTIDROGA
General factors
Individual factors (a) and environmental factors (b)
a)biological, cognitive, behavioral aspects (including
consumption patterns)
b)familiar, working, social factors (incl. illicit drugs availability)
Adequacy (c) and accessibility (d) of treatment
c)referring to both therapists and patients
d)physical and cultural factors
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Presidenza del Consiglio dei Ministri
DIPARTIMENTO POLITICHE ANTIDROGA
Consumption patterns
Typologies
Age
Patterns of use
Starter
16-18
Episodic use; in group with other drugs and/or
alcohol; snorted or smoked
Weekender
18-25
Occasional use; in group, with other drugs and/or
alcohol; snorted or smoked
Pure
18-25
Continuous use; alone/ small group; episodic use
of other drugs; preserved social functioning;
snorted, smoked, injected
Polyuser
18-35
Continuous use of different drugs (cocaine, heroine,
benzodiazepine, alcohol); snorted, smoked, injected
Relapser
> 35
Ex heroin or alcohol user; several cocaine relapse;
former tretment courses; snorted, smoked, injected
> 30
Continuous use; episodic use of other drugs;
preserved social functioning; snorted, smoked,
injected
Senior
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Presidenza del Consiglio dei Ministri
DIPARTIMENTO POLITICHE ANTIDROGA
PCS research_I
Sample: 3899 cocaine users (average age: 29)
Consumption patterns:
89% snorted; 28% smoked; 3% injected
Co-consumption
Alcohol
Cannabis
Ecstasy
Popper
LSD
Heroin
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LTP
92%
83%
50%
45%
36%
30%
Presidenza del Consiglio dei Ministri
DIPARTIMENTO POLITICHE ANTIDROGA
LYP
79%
57%
17%
9%
8%
15%
Pavarin et al.
PCS research_II
First use of cocaine: average age 20
use of cocaine/other
illicit drugs
1°substance
2°substance
3°-5°substance
+ 6°substance
cocaine
3,2%
12,5%
53,8%
26,4%
cocaine +
heroin*
2,1%
4,4%
40,5%
48,4%
TOT
2,8%
9,8%
49,3%
33,6%
*cocaine + heroin:
first cocaine, then heroin: 37,4%
first heroin then cocaine: 62,6%
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Presidenza del Consiglio dei Ministri
DIPARTIMENTO POLITICHE ANTIDROGA
Pavarin et al.
PCS research_III
Cocaine
Cocaine +
heroin
Age
27,8
32,5
Illicit drugs: age of first use
16,8
15,2
Cocaine: age of first use
20,4
19,7
Illicit drugs: duration of
consumption
11,2
17,4
Cocaine: duration of consumption
6,2
11,4
Elapsed time between 1°use of
illicit drugs and 1°use of cocaine
3,6
4,5
Illicit drugs: N
3,8
6,8
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Presidenza del Consiglio dei Ministri
DIPARTIMENTO POLITICHE ANTIDROGA
Pavarin et al.
Italian situation
In Italy, over the last 7-8 years, several innovative
treatment projects have been developed to meet the
high
spread
of
cocaine
consumption,
to
which,
paradoxically, corresponds a limited care demand.
Many of these experiences have been monitored and
evaluated by National Cocaine Project, which promoted
collaboration
between
national/regional
public/private structures.
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Presidenza del Consiglio dei Ministri
DIPARTIMENTO POLITICHE ANTIDROGA
and
National Cocaine Project
The project, conceived for problematic cocaine users and
ATS, surveyed specialized treatment units. Such units were
created to respond to particular therapeutic user needs,
with the aim of enhacing and developing the treatment offer.
Specifically, individual and group counseling, educational
intervention and psychotherapy (mainly CBT) have been
activated.
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Presidenza del Consiglio dei Ministri
DIPARTIMENTO POLITICHE ANTIDROGA
The creation of these units was preceded by a
monitoring of specialized services already existing to
assess best practices and procedures. The project also
included widespread training activities in order to
enhance specific skills and general efficiency
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Presidenza del Consiglio dei Ministri
DIPARTIMENTO POLITICHE ANTIDROGA
Main NCP Aims
to highlight some features of different treatments and settings
to seek preliminary indications of possible auto-selection of
patients compared to different treatments and settings
to assess retention in treatment
compared to the profiles of treated patients
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Presidenza del Consiglio dei Ministri
DIPARTIMENTO POLITICHE ANTIDROGA
National Cocaine Project Network
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Presidenza del Consiglio dei Ministri
DIPARTIMENTO POLITICHE ANTIDROGA
Some NCP programmes
NAME
WHERE
TIPOLOGY
APPROACHES
Ego
Vicenza
Outpat. resid.
CBT
La Rupe
Bologna
Outpat. resid.
CBT
Progetto Cocaina
Varese
Outpatient
CBT
Villa Soranzo
Venezia
Residential
CBT
Torino
Outpatient
CBT
Colombarone
Day care center
CBT
Prog.Integrato Coca
Modena
Outpat. resid.
CBT
Nicodemo
Brescia
Outpatient
CBT + SET
Prog. Conoscenza
Firenze
Outpatient
CBT + BST
Milano, Roma
Outpat. resid.
SFT
Bologna
Outpat. resid.
BT + MET
Reggio Emilia
Outpatient
SFT + TSG
WebCoCare
CD Mod.Cocaina
Contraddiction
Narciso
No Cocaine
BST: brief strategic therapy
MET: motivational enhancement therapy
BT: behavioral therapy
SFT: systemic family therapy
CBT: cognitive behavioral therapy
TSG: twelve steps groups
SET: supportive expressive therapy
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Presidenza del Consiglio dei Ministri
DIPARTIMENTO POLITICHE ANTIDROGA
Shared aims
• to increase accessibility (web-based services, specialistic
and non-traditional centers, extended opening hours/days,
…);
• to offer more treatment options (parallel or sequential)
consistent with the characteristics of the patients;
• to deepen the diagnostic evaluation (using standardized
instruments also useful for clinical research) in the
preliminary stages of the programme;
• to focus on motivation, through a brief but intense
involvement;
• to encourage abstinence for the duration of the programme
• to allow patients to maintain their employment and activities.
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Presidenza del Consiglio dei Ministri
DIPARTIMENTO POLITICHE ANTIDROGA
1-Colombarone Community
Center
Target:
• Cocaine Users
• For ages 25-50
• No abstinence in outpatient program
• Frequent/severe relapses
Programme duration:
• 2 preliminary counseling sessions
• 2 weeks + 2 days (total 10/12 consecutive days; Mon/ Fri h.9/17)
• for 3 months after the course: 12 group meetings once
a week
• 2 modules per year
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Presidenza del Consiglio dei Ministri
DIPARTIMENTO POLITICHE ANTIDROGA
Colombarone Community Center
Programme:
Groups (10 people max)
• cognitive-behavioral tr.
• craving management
• psycho-educational int.
• focal approach (here-and-now)
• learning and relaxation techniques
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Presidenza del Consiglio dei Ministri
DIPARTIMENTO POLITICHE ANTIDROGA
2-La Rupe Short Residential
Program
Target:
• Cocaine users
• No psychiatric disorders
Program duration:
• Time-out week-end
• Time-out 15 days
• Time-out 2 months
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Presidenza del Consiglio dei Ministri
DIPARTIMENTO POLITICHE ANTIDROGA
La Rupe Short Residential Program
Program:
• intensive residential program (followed by outpatient
program);
• cognitive behavioral groups (max 10 pp.);
• individual counseling
• body-expression techniques.
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Presidenza del Consiglio dei Ministri
DIPARTIMENTO POLITICHE ANTIDROGA
3-WebCoCare Website Counseling
Target:
• Cocaine users
• No exclusion criteria
Program duration:
• preliminary web-based counseling (1-6 months)
• CBT (6 months)
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Presidenza del Consiglio dei Ministri
DIPARTIMENTO POLITICHE ANTIDROGA
Substances
associated
with
cocaine
use
Sostanze
associate
all'uso
di cocaina
60
52,9%
50
46%
Percentuali
40
%
eroina
benzodiazepine
alcool
amfetamine
extasy
thc
lsd
30
20
10,5%
10
4,7%
5,3%
5,9%
3,7%
0
Tipi di sostanze
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Presidenza del Consiglio dei Ministri
DIPARTIMENTO POLITICHE ANTIDROGA
Età del campione
Age
1,4%
0-17
18-22
23-26
27-30
31-34
oltre 35
manca dato
5,7%
17,4%
26,8%
15,6%
13,4%
19,7%
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Presidenza del Consiglio dei Ministri
DIPARTIMENTO POLITICHE ANTIDROGA
Frequency of use / age
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Presidenza del Consiglio dei Ministri
DIPARTIMENTO POLITICHE ANTIDROGA
Years of consumption / age
> 3 years
1-3 years
6-12 monthes
1-6 monthes
< 1 month
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Presidenza del Consiglio dei Ministri
DIPARTIMENTO POLITICHE ANTIDROGA
WebCoCare – ASI 2009
Concluded (17)
Interrupted (27)
Comparison
MEAN
SD
MEAN
SD
T Test
p
Medical
0,47
0,72
0,33
0,55
0,71
0,479
Employment
0,53
0,51
0,70
0,99
0,67
0,508
Alcohol
1,35
0,93
1,26
0,81
0,35
0,726
Drugs
2,53
0,51
2,81
0,68
1,48
0,146
Legal
0,18
0,39
0,22
0,51
0,31
0,752
Familiar
1,76
0,66
2,30
0,87
2,15
0,037
Psychological
1,88
0,70
2,37
0,69
2,28
0,027
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Presidenza del Consiglio dei Ministri
DIPARTIMENTO POLITICHE ANTIDROGA
WebCoCare – MMPI-2 2009
Concluded (17)
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Interrupted (27)
Comparison
MEAN
SD
MEAN
SD
T Test
p
L
49,3
5,0
41,4
5,3
4,61
0,001
F
57,3
9,5
64,1
8,9
2,19
0,035
K
45,5
8,8
40,7
5,6
1,96
0,057
Hs
57,1
11,4
57,8
11,8
0,20
0,841
D
54,5
12,4
58,7
7,9
0,64
0,522
Hy
57,8
11,2
55,5
11,8
0,60
0,554
Pd
61,4
15,0
64,7
10,9
0,77
0,448
M
54,5
10,1
52,4
9,7
0,62
0,539
Pa
56,1
9,4
59,2
10,3
0,95
0,346
Pt
55,4
12,5
57,8
10,4
0,62
0,539
Sc
55,6
10,7
56,3
12,1
0,18
0,860
Ma
59,5
16,5
60,5
11,6
0,21
0,832
Si
48,3
5,9
51,7
7,6
1,48
0,146
Presidenza del Consiglio dei Ministri
DIPARTIMENTO POLITICHE ANTIDROGA
WebCoCare Website Counseling
Program:
Web-based counseling
frequent/severe relapses
and/or psychiatric disorders
and/or poly-consumption
NO
CBT and
familiy counseling
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YES
motivational
counseling
psychiatric consultation
residential program
Presidenza del Consiglio dei Ministri
DIPARTIMENTO POLITICHE ANTIDROGA
Webcocare research conclusions
• We can observe that:
a) some areas of functioning of the person seem to be
predictive of retention in CBT, as well as some selfperceptions and attitudes towards therapy;
b) the personality traits do not seem related to
retention.
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Presidenza del Consiglio dei Ministri
DIPARTIMENTO POLITICHE ANTIDROGA
NCP Conclusions
Other research should be focused on selecting the most
appropriate treatment for cocaine users:
identifying shared indicators of effectiveness;
seeking further predictive indicators of effectiveness by
studying:
patients characteristics (symptoms, autonomy, craving, ...)
treatments characteristics (contexts, duration, therapists, ...)
Actually we know that some treatments (CBT, community
reinforcement, contingency management) shows a good
effectiveness in treating cocaine users, but we have to better
investigate the relationship between type of patients and type
of treatments.
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Presidenza del Consiglio dei Ministri
DIPARTIMENTO POLITICHE ANTIDROGA
Thanks for your attention
Pompidou Group
Conference on stimulant abuse treatment
Strasbourg 10-12 May 2010
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Presidenza del Consiglio dei Ministri
DIPARTIMENTO POLITICHE ANTIDROGA