Migliorare la comprensione del fenomeno droga: quali dati per le politiche Roma, 26 gennaio 2015 Istat, Aula Magna

1. 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

2. • 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.
Elementi chiave della strategia europea di riduzione del danno
Roma, 26 gennaio 2015 2

3. 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
3Roma, 26 gennaio 2015

4. 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.
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) ___________________________________
Hiv infection
Kaposi’s sarcoma
Heroin dependency for many years
Pneumonia
Septicemia
Coding Each
Condition: Icd-10
codes
B24
C46
J18.9
A41.9
F11.2
SELECTION
Process
UC: B24
HIV disease
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:
(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 data also this information
is available
MULTIPLE CAUSES OF DEATH
Specimen based on Istat D4
4

5. 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.
5

6. Numero di decessi droga-indotti avvenuti in Italia registrati nel database ISTAT sulle
cause di morte (popolazione presente). Anni 1980-2011 Confronto con Emcdda
6
Numerodidecessi

7. Trends per genere ed età Anni 1992-2011

8. Mortalità indotta da droghe per macroarea e anno di decesso.
Poolazione residente, anni 1992-2010. Tassi std.di mortalità per 1.000.000 abitanti
Geografia

9. Underlying cause of death Multiple cause of death
Ratio
Multiple/
Underlyingdeaths
crude
rate
standardiz
ed rate
deaths
crude
rate
standardiz
ed 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 0,69 1.293 1,10 1,07 1,6
Drug-related deaths in selected age groups as
underlying and multiple cause. Years 2009-2011
Total
2006-2008
1.193 1,03 1,03 1.606 1,39 1,36 1,3
9

10. 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.
)(ln96.1ln)(ln%95 RRSERRRRCI 
Assumed that RR is approximately log-normally distributed:
where
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
Cause A
mentioned
Cause A not
mentioned
Mention of drug-related
cause
Without mention of drug-
related cause
dADˆ
Ad
Dˆ
Ad
Dˆ
Ad
Dˆ
dD
d
D
Ad
dA
d
Ad
d
dA
p
p
D
D
D
D
RR
ˆ
ˆˆ
/
ˆ

Ad
Ad
dA
dA
D
p
D
p
RRES
ˆ
)ˆ1(
ˆ
)ˆ1(
)(ln




Associations of conditions with drug-related causes.

11. 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 0,9 0,1 7,0 3,9-12,6 11
I38 Endocarditis, valve unspecified 1,2 0,3 2,0 1,0-3,9 15
J00-J99 Diseases of the respiratory system 32,6 24,6 1,2 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 1,1 0,2 19,5 14,3-26,7 14
R00-R99 Symptoms signs and ill-defined causes 38,6 33,6 1,1 1,1-1,2 499
R75 Laboratory evidence of human immunodeficiency virus [HIV] 1,3 0,1 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 12

12. 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
Co-morbidity approach
13

13. Number of hospital discharges for drug-related disorders
0
2,000
4,000
6,000
8,000
10,000
12,000
1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012
• From 10,968 in 1999 to 5,857 in 2012 (-46.6%)
• Sharp decrease between 1999 and 2003, smoothed afterwards
Crude
rates (a)
Standardized
rates (a)
1999 19.3 18.5
2012 9.8 10.2
(a) per 100,000 residents
Number of patients treated in outpatient facilities for drug-related disorders
14

14. 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 15

15. Drug-related hospitalizations 15-64 years. Main diagnosis
and All diagnosis. Years 2006-2008, 2009-2011
Main diagnosis All diagnosis
Age discharges
crude
rate
discharges
crude
rate
2006-2008
15-44 13,834 19.3 40,721 56.8 2.9
45-54 2,222 9.1 8,625 35.4 3.9
55-64 811 3.8 2,653 12.4 3.3
2009-2011
15-44 11,801 16.8 32,611 46.3 2.8
45-54 3,265 12.4 9,727 36.8 3.0
55-64 1,356 6.1 3,041 13.6 2.2
Ratio
All/Main
15-64 years
Main diagnosis All diagnosis
Gender discharges
crude
rate
standardized
rate
discharges
crude
rate
standardized
rate
2006-2008
males 11,407 19.4 21.7 35,617 60.6 66.7 3.1
females 5,460 9.3 10.4 16,382 27.9 30.8 3.0
total 16,867 14.4 16.1 51,999 44.2 48.9 3.1
2009-2011
males 9,831 16.6 18.6 30,663 51.6 57.3 3.1
females 6,591 11.0 12.2 14,716 24.7 27.2 2.2
total 16,422 13.8 15.4 45,379 38.1 42.3 2.8
Ratio
All/Main
• 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
• 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.)
16

16. Drug-related hospitalizations by substance (dependence, abuse or poisoning)
15-64 years - All diagnosis.
Ratios All diagnosis / Main diagnosis
0
10
20
30
40
50
2006-2008 2009-2012
Mixed or unspecified
substances
Cannabis, Amphetamine
and other psychostimulant
Cocaine
Opioid type (Heroin,
Methadone, Opium, etc.)
19,773
9,130
5,374
17,722
15,908
7,803
5,461
16,207
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
2006-2008 2009-2012
Mixed or unspecified
substances
Cannabis, Amphetamine
and other psychostimulant
Cocaine
Opioid type (Heroin,
Methadone, Opium, etc.)38.0% 35.1%
17.6%
17.2%
10.3% 12.0%
34.1% 35.7%
Standardized hospitalization rates for drug-related disorders
per 100,000 residents (absolute numbers in the bars)
Ratios Males / Females
17

17. Associations of conditions with drug-related diagnosis (1)
ICD9CM
code Condition
Prevalence in
hospitalizations
for drug
disorders
Prevalence in
hospitalizations
NOT for drug
disorders
Age
standardized
RR CI95%
Hospital
discharge
records with
mention of the
condition
among
hospitalizations
for drug
disorders
INFECTIOUS AND PARASITIC DISEASES (001-139)
042
Human immunodeficiency virus [HIV]
disease 7.77 0.53 13.08 12.63-13.53 3,528
070 Viral hepatitis 11.38 0.76 12.55 12.19-12.91 5,162
112 Candidiasis 1.51 0.10 15.11 13.98-16.34 684
MENTAL DISORDERS (290-319)
295 Schizophrenic disorders 4.86 0.73 5.57 5.32-5.82 2,204
296 Affective psychoses 10.70 0.93 11.51 11.20-11.83 4,854
298 Other nonorganic psychoses 3.65 0.29 11.11 10.55-11.70 1,656
300 Neurotic disorders 7.75 0.87 11.42 11.10-11.74 3,518
301 Personality disorders 19.37 0.54 28.92 28.28-29.58 8,790
303 Alcohol dependence syndrome 8.31 0.33 21.81 21.08-22.57 3,772
307
Special symptoms or syndromes, not
elsewhere classified 3.35 0.27 17.08 16.36-17.82 1,520
309 Adjustment reaction 1.63 0.13 12.81 11.91-13.77 741
Roma, 26 gennaio 2015 18

18. Associations of conditions with drug-related diagnosis (2)
ICD9CM
code Condition
Prevalence in
hospitalizations
for drug
disorders
Prevalence in
hospitalizations
NOT for drug
disorders
Age
standardized
RR CI95%
Hospital
discharge
records with
mention of the
condition
among
hospitalizations
for drug
disorders
DISEASES OF THE NERVOUS SYSTEM AND SENSE ORGANS (320-389)
345 Epilepsy 1.68 0.63 2.57 2.39-2.76 762
346 Migraine 12.78 0.19 100.07 97.91-102.27 5,799
DISEASES OF THE CIRCULATORY SYSTEM (390-459)
401 Essential hypertension 3.12 4.70 1.33 1.29-1.38 1,417
DISEASES OF THE RESPIRATORY SYSTEM (460-519)
486 Pneumonia, organism unspecified 1.00 0.26 3.84 3.50-4.21 456
491 Chronic bronchitis 1.20 1.09 1.68 1.57-1.80 545
518 Other diseases of lung 2.34 1.16 2.24 2.12-2.37 1,062
DISEASES OF THE DIGESTIVE SYSTEM (520-579)
571 Chronic liver disease and cirrhosis 6.27 1.90 3.35 3.23-3.47 2,845
SYMPTOMS, SIGNS, AND ILL-DEFINED CONDITIONS (780-799)
780 General symptoms 2.44 1.39 1.84 1.74-1.95 1,107
INJURY AND POISONING (800-999)
965
Poisoning by analgesics, antipyretics, and
antirheumatics 2.31 0.01 313.35 288.93-339.84 1,050
969 Poisoning by psychotropic agents 1.38 0.05 28.02 25.79-30.45 627
SUPPLEMENTARY CLASSIFICATION OF FACTORS INFLUENCING HEALTH STATUS AND CONTACT WITH HEALTH SERVICES (V01-V82)
V02 Carrier or suspected carrier of infectious diseases 1.12 0.18 5.76 5.25-6.31 510
Roma, 26 gennaio 2015 19

19. 20
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=classificazion
e&lingua=italiano
Riferimenti bibliografici
Roma, 26 gennaio 2015

20. Grazie per l’attenzione
crialesi@istat.it
Roma, 26 gennaio 2015 21