Morbosità e mortalità: un approccio multicausa al fenomeno della droga Roberta Crialesi, Alessandra Burgio, Francesco Grippo, Marilena Pappagallo Migliorare la comprensione del fenomeno droga: quali dati per le politiche Roma, 26 gennaio 2015 Istat, Aula Magna Roma, 26 gennaio 2015

Elementi chiave della strategia europea di riduzione del danno La riduzione della perdita di vite umane causata dal consumo di stupefacenti è una priorità strategica delle politiche di lotta alla droga e uno degli obiettivi di salute pubblica dell’Unione europea Valutare scientificamente le conseguenze dirette e indirette dell’uso di droghe non è semplice. Nel corso degli ultimi anni, le politiche di riduzione del danno hanno stimolato l’adozione di approcci basati su dati incontrovertibili. Uno degli approcci più innovativi per fornire un quadro realistico dell’impatto delle droghe sulla salute della popolazione italiana è quello basato sulla comorbidity e sulla cause multiple di decesso Occorrono indicatori innovativi per misurare, in modo più accurato, la reale dimensione del fenomeno estendendo l’osservazione a tutti i casi, direttamente o indirettamente, collegati all’abuso di droghe. Roma, 26 gennaio 2015

Obiettivi dello studio Analizzare la mortalità indotta da droga e l’ospedalizzazione dei pazienti tossicodipendenti per descrivere l’evoluzione nel tempo dei principali indicatori secondo il genere, l’età e le macro aree di residenza Utilizzare l’approccio per cause multiple per fornire nuovi indicatori basati su tutte le informazioni riportate sia nel certificato di morte sia nelle SDO valutare statisticamente le associazioni tra l’abuso di droga e altre condizioni patologiche Roma, 26 gennaio 2015 Roma, 26 gennaio 2015

Causes of Death Register Refers to all cases occurred in Italy Certifying physician reports a sequence of conditions leading to death on the death form: Part 1: Line a (Underlying cause) ___________________________________ Line b (complications) ___________________________________ Line c ___________________________________ Line d ___________________________________ Part 2 (Other causes ___________________________________ Contributing) ___________________________________ Coding Each Condition: Icd-10 codes B24 C46 J18.9 A41.9 F11.2 SELECTION Process UC: B24 HIV disease Since 2003 data also this information is available MULTIPLE CAUSES OF DEATH Specimen based on Istat D4 Hiv infection Kaposi’s sarcoma Heroin dependency for many years Pneumonia Septicemia In Italy, until 2003 data only this information was published Traditionally, final statistics are based on UNDERLYING CAUSE OF DEATH One for each record defined as: the disease of injury which initiated the train of events leading directly to death, or the circumstances of the accident or violence which produced the fatal injury Istat mortality database is collected, for each death occurred in Italy, health information by the certifying physicians. The death forms contain all diseases and condition leading to death, among which the underlying cause of death is selected and coded according the International classification of diseases (Icd) provided by Who. Since 1999 personal information is available. Personal information of the decedent is available at Istat, including personal identification number (codice fiscale) and can be used in accordance to the rules on personal data handling and confidentiality. (personal identification number is missing for 13% of the records). Until 2002 final statistics where based on the Underlying cause of death which is one single cause per record, selected according the rules of the Icd. This is defined as: a) the disease of injury which initiated the train of events leading directly to death, or b) the circumstances of the accident or violence which produced the fatal injury. Since 2003 each condition reported by the certifying physician is coded and available for the analysis. The analysis of all condition reported on the certificate is called Multiple cause analysis. In Italy an average of 4,2 conditions are reported. The International Classification of Diseases (Icd) contains instruction for coding each condition and for the selection of the Underlying cause. Roma, 26 gennaio 2015

Drug-induced mortality: selection of Icd codes (EMCDDA selction B for international comparison and time series) ICD-10: years 2003, 2006-2011  Mental and behavioural disorders due to psychoactive substance use F11: opioids; F12: cannabinoids, F14: cocaine; F15: other stimulants, including caffeine; F16: hallucinogens; F19: other psychoactive substances Accidental poisoning X421): narcotics and psychodysleptics [hallucinogens], not elsewhere classified; X412antiepileptic, sedative-hypnotic, antiparkinsonism and psychotropic drugs, not elsewhere classified Intentional self-poisoning X621): narcotics and psychodysleptics [hallucinogens], not elsewhere classified; X612): antiepileptic, sedative-hypnotic, antiparkinsonism and psychotropic drugs, not elsewhere classified. Poisoning undetermined intent Y121): psychodysleptics [hallucinogens], not elsewhere classified, undetermined intent; Y112): antiepileptic, sedative-hypnotic, antiparkinsonism and psychotropic drugs, not elsewhere classified, undetermined intent. 1) in combination with the T-codes: T40.0-9: Poisoning by narcotics and psychodysleptics [hallucinogens]; 2) in combination with T code: T43.6 Poisoning by psychotropic drugs, Psychostimulants with abuse potential. . Roma, 26 gennaio 2015

Numero di decessi droga-indotti avvenuti in Italia registrati nel database ISTAT sulle cause di morte (popolazione presente). Anni 1980-2011 Confronto con Emcdda Numero di decessi

Trends per genere ed età Anni 1992-2011 Age Higher mortality rates are observed in age group 25-44 year in the all period of study (1992-2010). Until 2003 the age group 15-24 was the second in the rank of mortality rate. Nevertheless in recent years its place was taken by age group 45-54 year. In fact, this last age group showed a slightly increasing trend until 2007 (Figure 3). Roma, 26 gennaio 2015

Geografia Mortalità indotta da droghe per macroarea e anno di decesso. Poolazione residente, anni 1992-2010. Tassi std.di mortalità per 1.000.000 abitanti Geography Geography of mortality for drug-induced causes has changed in the last 20 years of observation (Figure 4). From 1992 to 2001 mortality was higher in Northern and Central Italy compared with southern regions and Islands. Since 2002 values of North and South became comparable reaching in 2010 values ranging from 2,8 from the South and 5,5 of the Islands. On the other hand the Centre shows higher values (from 7,4 in 2010 to 10,9 in 2007). Nevertheless, geographical differences should be more deeply studied taking into account also the difference in certification quality and practices. Roma, 26 gennaio 2015

Underlying cause of death Multiple cause of death Drug-related deaths in selected age groups as underlying and multiple cause. Years 2009-2011   Underlying cause of death Multiple cause of death Ratio Multiple/ Underlying deaths crude rate standardized rate 15-44 year 605 0,87 816 1,18 1,3 45-54 175 0,67 398 1,53 2,3 55-64 33 0,15 79 0,36 2,4 Total 15- 64 males 692 1,19 1,17 1.115 1,91 1,84 1,6 females 121 0,21 0,20 178 0,30 0,29 1,5 Total 813 0,69 1.293 1,10 1,07 Rapporto multipla underlying come misura della «sottostima» L’analisi sulle cause multiple è stata effettuata per le età 15-64 anni perché sono le classi di età in cui si concentra il maggior numero di decessi (circa il 90%) Il rapporto multiple-UC varia per età ma non per sesso, come per l’UC le differenze per sesso sono grandi Comparing the rates for drug-related deaths in the two periods 2006-2008 (table 3) and 2009-2011, we observe a decrease in both underlying and multiple causes indicators with a greater reduction for the underlying standardized rate: -50% compared to -28% observed for the multiple standardized rate. This reduction is observed in both sexes although with greater rapidity in men. Total 2006-2008 1.193 1,03 1.606 1,39 1,36 1,3 Roma, 26 gennaio 2015

Number of drug-induced deaths Number of deaths Year Roma, 26 gennaio 2015

Associations of conditions with drug-related causes. Methods Age-standardized relative risk (RR) was used to measure association among drug related cause and the other conditions reported on the death certificate The relative risk can be seen as a measure of the strength of association of a certain cause with drug-related condition. Cause A mentioned Cause A not mentioned Mention of drug-related cause Without mention of drug-related cause Proportion of estimated deaths with a specific condition A among those WITH mention of drug-related cause Proportion of estimated deaths with a specific condition A among those WITHOUT mention of drug-related cause Assumed that RR is approximately log-normally distributed: where Roma, 26 gennaio 2015

Associations of conditions with drug-related causes. 1 Associations of conditions with drug-related causes. 1.293 cases, Italy 2009-2011 Icd10 Condition Prevalence in drug users deaths Prevalence in non-drug users deaths Age-standardized RR CI95% Certificates mentioning the condition among drug users deaths A00-B99 Infectious and parasitic diseases 23,8 9,4 3,4 3,2-3,7 308 B20-B24 AIDS 7,1 1,2 5,9 4,8-7,2 92 B15-B19, B94.2 Viral hepatitis 18,2 2,5 10,7 9,7-11,8 235 F01-F99 Mental and behavioural disorders (excluded those included in EMCDDA) 14,2 4,0 6,8 6,2-7,5 184 F10 Mental and behavioural disorders due to use of alcohol 9,6 0,9 17,5 15,4-20,0 124 I00-I99 Diseases of the circulatory system 40,4 48,0 1,1 1,0-1,2 522 I33 Acute and subacute endocarditis 0,1 7,0 3,9-12,6 11 I38 Endocarditis, valve unspecified 0,3 2,0 1,0-3,9 15 J00-J99 Diseases of the respiratory system 32,6 24,6 1,1-1,3 422 K00-K92 Diseases of the digestive system 22,1 16,1 1,8 1,6-1,9 286 K70, K73-K74 Cirrhosis, fibrosis and chronic hepatitis 16,2 6,2 3,6 3,2-4,0 209 K70 Alcoholic liver disease   3,3 1,3 2,7 2,0-3,6 43 K73 Chronic hepatitis, not elsewhere classified   0,2 19,5 14,3-26,7 14 R00-R99 Symptoms signs and ill-defined causes 38,6 33,6 1,1-1,2 499 R75 Laboratory evidence of human immunodeficiency virus [HIV]   9,1 5,4-15,2 17 V00-Y99 External causes of death (excluded those included in EMCDDA) 52,6 14,0 2,4 2,2-2,6 680 Roma, 26 gennaio 2015 Roma, 26 gennaio 2015

Co-morbidity approach Schede di Dimissione Ospedaliera (SDO) La diagnosi principale è utilizzata per la costruzione di indicatori statistici (come per le cause di morte) International Classification of Diseases 9th Revision, Clinical Modification (ICD9CM) Diagnosi principale e fino a 5 Diagnosi secondarie In media sono riportate 2.5 diagnosi per ricoveri ordinary e 1,6 per day hospital Le Diagnosi sono codificate direttamente in ospedale DIAGNOSI PRINCIPALE definita come la malattia che alla dimissione viene identificata come la principale responsabile del trattamento e delle procedure fornite dall’ospedale. DIAGNOSI SECONDARIA Definite come quelle condizioni che coesistono al momento del ricovero o che si sviluppano in seguito a tale momento e che influenzano il trattamento ricevuto e/o la durata della degenza Data on hospital discharges are collected by the Italian Ministry of Health since 1995. Data refer to all admissions in hospital occurred in Italy both for resident and for non resident patients. The classification adopted for the diseases is the International Classification of Diseases 9th revision, Clinical Modification (ICD-9-CM). In addition to the main diagnosis, up to five secondary diagnoses could be reported in the form. An average of 2.5 diagnosis are reported for inpatient acute care and 1.6 for day care. The main diagnosis is defined as the condition identified at the end of hospitalization episode which required the treatment and the procedures provided by the hospital. The secondary diagnoses are defined as those conditions that coexisted at the time of admission or that were developed during the treatment having an influence on the treatment itself and/or on the length of stay. Data refers to events (hospital discharges) and not to patients, then if a person is re-admitted during the year he/she is counted more than once. The descriptive analysis based on the main diagnosis refers to years 1999-2012, while for the co-morbidity approach two periods are compared: 2006-2008 and 2009-2011. Roma, 26 gennaio 2015

Number of hospital discharges for drug-related disorders From 10,968 in 1999 to 5,857 in 2012 (-46.6%) Sharp decrease between 1999 and 2003, smoothed afterwards Number of patients treated in outpatient facilities for drug-related disorders Roma, 26 gennaio 2015

Trends by age Age-specific hospitalization rates for drug-related disorders per 100,000 residents Higher hospitalization rates in the age group 25-44 years followed by 15-24 years before 2009 and 45-54 years too afterwards Age gaps reduced over time Roma, 26 gennaio 2015 Roma, 26 gennaio 2015

Drug-related hospitalizations 15-64 years Drug-related hospitalizations 15-64 years. Main diagnosis and All diagnosis. Years 2006-2008, 2009-2011 Hospitalizations with mention of drug use or poisoning is 2.8 higher than the number based on the Main diagnosis Gender gap: std rates higher for men (1.5 times for main diag., 2.1 times for all diag.) All diagnosis: Decreasing std rates… …due to the decrease in the age group 15-44 years… …while rates slightly increase after 45 years of age Roma, 26 gennaio 2015

Ratios All diagnosis / Main diagnosis Drug-related hospitalizations by substance (dependence, abuse or poisoning) 15-64 years - All diagnosis. Ratios All diagnosis / Main diagnosis Standardized hospitalization rates for drug-related disorders per 100,000 residents (absolute numbers in the bars) Ratios Males / Females Roma, 26 gennaio 2015

Associations of conditions with drug-related diagnosis (1) Roma, 26 gennaio 2015 Roma, 26 gennaio 2015

Associations of conditions with drug-related diagnosis (2) Other conditions associated to the drug disorders are: poisoning by analgesics, antipyretics and antirheumatics (RR=313.3, prevalence 2.3%), poisoning by psychotropic agents (RR=28.0, prevalence 1.4%); And other conditions as migraine (RR=100.1, prevalence 12.8%), pneumonia -organism unspecified- (RR=3.8, prevalence 1%), chronic liver disease and cirrhosis (RR=3.3, prevalence 6.3%), epilepsy (RR=2.6, prevalence 1.7%), other diseases of lung (RR=2.2 prevalence 2.3%), chronic bronchitis (RR=1.7, prevalence 1.2%), essential hypertension (RR=1.3, prevalence 3.1%). Roma, 26 gennaio 2015 Roma, 26 gennaio 2015

Riferimenti bibliografici Istat, Navigando tra le fonti demografiche e sociali, 2009 http://www3.istat.it/dati/catalogo/20100325_01/Navigando_tra_le_fonti_demografiche_sociali.pdf WHO. International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10). Geneva: WHO; 1992. Emcdda methods and definitions http://www.emcdda.europa.eu/stats07/DRD/methods Istat. Cause di morte. Anno vari. http://www.istat.it/it/archivio/ Emcdda, Data, drug related death and mortality http://www.emcdda.europa.eu/stats/archive. Istat. Cause multiple di morte. Anno 2008. http://www.istat.it/it/archivio/66021 Istat, I.Stat, Salute e sanità, Ricorso ai servizi sanitari, Ospedalizzazione per disturbi psichici http://dati.istat.it/ Ministero della Salute, La classificazione delle malattie ICD9CM. http://www.salute.gov.it/ricoveriOspedalieri/paginaMenuRicoveriOspedalieri.jsp?menu=classificazione&lingua=italiano Roma, 26 gennaio 2015

Grazie per l’attenzione crialesi@istat.it Roma, 26 gennaio 2015 Roma, 26 gennaio 2015

The multiple cause approach estimates 60% more drug-related mortality. The victims of drug poisoning or abuse sharply decreased during the last decades. In the last twenty years, the percentage of individuals aged 45-54 year increased. The multiple cause approach estimates 60% more drug-related mortality. The analysis of all conditions allows to describe the most relevant pathological pattern of drug-users deaths in Italy. Further developments: linkage between sources. Roma, 26 gennaio 2015 Roma, 26 gennaio 2015

Limitations and Warning 1: the Multiple Causes of Death approach Results are strongly related to the quality of certificate completion (the percentage of unknown or uninformative causes of death, in the age group 25-44, the most affected by drug-induced mortality, shows about 4% of poorly informative or unknown causes of death while it is 0,3% when all the age groups) All results of MCOD approach refer to the deaths and cannot be extended to the general population If the drug condition is present at the time of death but non contributing to it, this condition is not reported by the physician Roma, 26 gennaio 2015 Roma, 26 gennaio 2015