Italian Guidelines for the treatment of alcohol dependence

Linee guida italiane per il trattamento dell’alcolismo


1Centro di Riferimento Alcologico della Regione Lazio (CRARL), Sapienza University of Rome, Italy
2Department of Human Neurosciences, Sapienza University of Rome, Italy
3Institute of Cell Biology and Neurobiology, IBCN-CNR, Rome, Italy

SUMMARY. The European Union is the heaviest-drinking region in the world, with the highest proportion of total diseases and premature deaths due to alcohol. In Italy, this phenomenon involves about the 13% of the population over 18 years and more than the 25% of the patients admitted to the Italian Hospitals. Unfortunately, only the 5% of these admitted patients are recognized as people affected by Alcohol Use Disorder (AUD). Insufficient knowledge, lack of access to care and the few resources available in the management of the problem are major causes of delays in the diagnosis, finally contributing to significant clinical consequences much harder and costly to handle. In view of the above considerations, this special issue of the Rivista di Psichiatria is dedicated to a series of articles concerning the Italian Guidelines for the treatment of alcohol dependence. Developed in collaboration with many experts and esteemed scientific societies such as the Referral Center for Alcoholism of the Lazio Region (CRARL), the Italian Society of Drug Addiction (SITD), the Italian Society for the Treatment of Alcoholism and its Complications (SITAC), the Italian Society of Psychiatry and Dependence (SIPDip) the Italian Society of Dependency Diseases (SIPaD) and the Institute of Cell Biology and Neurobiology of the National Research Council (IBCN-CNR), these Guidelines provide to the operators evidenced-based statements aimed at increasing the knowledge and the appropriate use of medications for people affected by AUD. With the possibility of a dynamic updating, the overall goal of these Guidelines will be to guarantee the homogeneity of treatments and a qualitative improvement in the assistance of patients with AUD, thus reducing the significant psychosocial and public health consequences related to this important psychiatric condition.

KEY WORDS: alcohol, alcohol dependence, alcohol use disorder, treatment guidelines.

RIASSUNTO. L’Europa è la regione con il più forte consumo di alcol al mondo, con la più elevata percentuale di malattie totali e morti premature alcol-correlate. In Italia, questo fenomeno coinvolge circa il 13% della popolazione oltre i 18 anni e oltre il 25% dei pazienti ospedalizzati. Sfortunatamente, solo il 5% di questi pazienti vengono riconosciuti come persone affette da disturbo da uso di alcol (DUA). Una scarsa conoscenza della malattia, la mancanza di accesso alle cure e le poche risorse messe a disposizione nella gestione del problema sono tra le principali cause di ritardo nella diagnosi, alla fine con conseguenze cliniche molto più importanti e costose da gestire. Alla luce di ciò, abbiamo deciso di dedicare questo numero speciale della Rivista di psichiatria a una serie di articoli riguardanti le linee guida italiane per il trattamento della dipendenza da alcol. Realizzate in collaborazione con numerosi esperti e importanti società scientifiche italiane come il Centro di Riferimento Alcologico della Regione Lazio (CRARL), la Società Italiana Tossicodipendenze (SITD), la Società italiana per il Trattamento dell’Alcolismo e le sue Complicanze (SITAC), la Società Italiana Psichiatria delle Dipendenze (SIPDip), la Società Italiana Patologie da Dipendenza (SIPaD) e l’Istituto di Biologia Cellulare e Neurobiologia (IBCN-CNR), queste linee guida forniscono agli operatori una serie di raccomandazioni basate su prove di efficacia volte ad aumentare la conoscenza e un uso appropriato dei farmaci per le persone affette da DUA. Con la possibilità di un continuo aggiornamento, l’obiettivo principale di queste linee guida sarà quello di garantire l’omogeneità dei trattamenti e un incremento qualitativo nell’assistenza dei pazienti affetti da DUA, così da ridurre le conseguenze psicosociali e sulla salute pubblica di questa importante malattia psichiatrica.

PAROLE CHIAVE: alcol, disturbo da uso di alcol, dipendenza da alcol, linee guida per il trattamento.

According to the World Health Organization1, in Europe there is the highest consumption of alcohol in the world. Furthermore, in Europe, the alcohol abuse is the main risk factor for the health of young people and the harmful use of alcohol causes 3.3 million deaths every year worldwide, or 15.9% of the total deaths. About the 25% of deaths in young people aged 20 to 39 are attributable to alcohol. Indeed, the 5.1% of the overall burden of illness and accidents is attributable to alcohol, measured in Disability-Adjusted Life Years (DALYs), expressed as the number of years lost due to ill-health, disability or early death.
In the last Report of the Ministry of Health to Parliament on alcohol and alcohol related problems (2017), it is indicated that, in 2016, the 64.7% of Italians aged 11 and over (equal to 35 million and 171 thousand people) consumed at least one alcoholic beverage, with a significantly higher prevalence among men (77.3%) than women (52.9%), with an increase in consumption compared to the previous year, as also confirmed by the data of the Italian Statistic Institute (Istituto Nazionale di Statistica - ISTAT) report of 2017 (64.7% of the population).
According to this situation, health protection policies in the field of alcohol are still insufficient to deal with it in a concrete way. To partial justification, we must recognize that there are elements of great difficulty determined by the complexity of the various factors (biological, psychological and social) that contribute to producing the damage related to an incongruous use of alcohol; it is crystal that every action that somehow wants to be effective, should move in a multi-disciplinary context. Unfortunately, the professionals involved often talk different languages, follow different models of reference and have great difficulty in understanding and collaborating. The lack of knowledge of the problem, the small number of centres that deal with it, and the few resources invested in the territory, determine serious problems of management of this phenomenon that involves about 13% of the population over 18 years and more than 25% of the patients admitted to the Italian Hospitals. Quite interestingly, only the 5% of these admitted patients are recognized by professionals as people affected by alcohol use disorder (AUD). This reduced ability to identify, combined with the lack of attention that is given to alcohol-related problems by the medical point of view, is a missed opportunity to start the treatment of such related alcohol problems and associated disorders and increases the likelihood that subjects with AUD in the initial phase undergo serious clinical complications, more difficult and costly to manage.
This unpleasant situation in Italy is the direct consequence of the failure to implement what was suggested (and not implemented) in the framework law on alcohol and alcohol-related problems (Legge 30 marzo 2001, n.125, GU 18.04.2001 of the Italian Republic)2 introducing the teaching of alcohol in the university system: the training project of the University should, in fact, provide for the possibility of modifying the teaching contents, adapting them to the demands of the territory, modulating the training to adapt it to the new diseases and emerging problems: it should be stressed that, in this historical moment, tumours, geriatrics and substance addictions symbolize the new frontiers of health of our society.
Despite this, the University system, with the exception of tumours, continues to neglect these problems: this means that professionals who should take care of the treatment and rehabilitation of those who suffer from AUD are not prepared to face these events. Actually, this situation may be defined as is a real social-health emergency, as they have not been given the knowledge, practical experience and the baggage of useful tools to deal with substances and behaviours addictions. When these problems arise in the real life, they are not recognized by professionals as pertinent to their line of work; very often the work is based on the experience of elderly colleagues, on non appropriate information and/or without clinical evidences, dealing AUD questions in a non-homogeneous way or delegating to other services or to the private-social what is not recognized for its own competence. Thus, the phenomenon of “border pathologies” associated with those problems that do not belong to anyone are confined outside their professional competence.
For this reason we felt the need to build a common reference, a model from which to grow, over the years, an established codification to treat people affected by AUD. In this work we have found the collaboration of many experts, of Scientific Societies such as the Italian Society of Drug Addiction (SITD), the Italian Society for the Treatment of Alcoholism and its Complications (SITAC) and the Italian Society of Dependency Diseases (SIPaD) who contributed and shared the contents and settings of these Guidelines for the treatment of alcohol abstinence and addiction.
The Diagnostic and Statistical Manual of Mental Disorders (DSM) published by the American Psychiatric Association in the last revision (DSM-5)3 includes alcohol in the section of “Substance Use Disorders” evidencing specific arguments: acute intoxication; alcohol abstinence syndrome; alcohol addiction; alcohol-related diseases.
Based on the complexity of the topic, in these guidelines we have chosen to deal primarily with the Abstinence and Alcohol Dependence, to deal later with the other topics associated with AUD. For this elaboration we referred to the GRADE system (Grading of Recommendations Assessment Development and Evaluation)4 for the evaluation of scientific evidences and recommendations. In this system, the power of the recommendations depends on the evidences in the literature and on their quality. The evidence has been reported at three different quality levels: high quality; moderate; low or very low.
Furthermore, two levels of recommendations have been defined: strong; weak.
The main objective in elaborating these Guidelines was to provide operators working in the field of alcohol disorder with both suggestions and recommendations on how to proper manage alcohol disorder in its aspects of diagnosis and care. Furthermore, we add other specific objectives:
• to create a shared knowledge on alcohol-related problems that allows to all operators to get to know, within the service or between services, with a common language and clinical evidences;
• create the basis for developing training programs;
• identify clinical areas that need to be investigated and better understood through shared scientific research;
• make the clinical treatment as uniform as possible in all the services dealing with alcohol addiction.

Based on these features, everyone can participate by proposing suggestions and/or corrections by filling this form ( The proposed information will be carefully examined by an international Scientific Committee and, if accepted, the novel indications will be inserted in the updated Guidelines. This will ensure their dynamic updating, which will make it a useful working tool also in order to guarantee the homogeneity of the treatments and the qualitative improvement of the offer of assistance to the patients with alcohol-related problems and diseases. To this purpose, a crucial contribution is also guaranteed by the Scientific Committee including foreign experts belonging to the National Institute of Alcohol Abuse and Alcoholism (NIH-NIAAA, USA) and to Italian, US, European and non-European Institutions and Universities. This working group will allow the guidelines to grow in a concrete way, in parallel with the growth of scientific research and clinical evidences.
1. Global status report on alcohol and health 2014. World Health Organization (WHO) 2014.
2. Relazione del Ministro della Salute al Parlamento sugli interventi realizzati ai sensi della legge 30.3.2001 n. 125 “Legge Quadro in materia di alcol e problemi alcol correlati”. Ministero della Salute. 2017.
3. Diagnostic and statistical manual of mental disorders: DSM-5. American Psychiatric Association. 2013 (5th ed).
4. Guyatt GH, Oxman AD, Kunz R, et al.; GRADE Working Group. Going from evidence to recommendations. BMJ 2008; 336: 1049-51.