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Recovery and social
reintegration
The San Patrignano model on drug addiction
kaunas june 2017 1
The basic principles
1. free of charge
2. educational program, no opiodid substitutiontreatment.
3. not confessional.
4. Based on individual needs and not on addictivedrugs.
5. Long duration: 3-4 years.
6. Strong commitment of former drug users.
7. Based on volunterring
kaunas june 2017 2
Admission procedures
one of the following ways:
1. directly by phone, both traditional and electronic mail or by filling in the special form. Assuming a place is available, entry is immediate, without the sort of waiting periods which very often put at risk the resolve of the addict to seek help.
2. Through peripheral Volunteers Associations.
3. Through the National and Local Health System
4. Through courts and prefectures (for example, alternative sentencing)
Kaunas June 2017
Admission procedures
•There are no formal admission criteria: only a genuine motivation to change is required for entry in the therapeutic program
•Entering addicts are advised that they are not simply making an attempt to stop using drugs, but that they are choosing a radical change in their life.
•Only a major psychiatric disease is a medical contraindication to the therapeutic program:
1. Chronic psychosis (not drug induced).2. Severe eating disorders3. violence.
Kaunas June 2017
The Associations
San Patrignano has 40 associations all over Italy and 3 abroad: England, Scotland, Croatia, and, the next year, in Paris.
Founded by former drugaddicts who finished the program, or their parents.
Their role is to catalyzerequests for help and providesupport for young people in their desire to change
Kaunas June 2017
ADMISSION IN 2016
Interviews by admission office 396
New admission 310
Average age of the new comers 31
Minors in program 24
Filed applications by people in prison 17
In 2016 we have received around 2000 letters and 450 e-mails
Kaunas June 2017
Continuum tutoring
The staff of the admission office in liason with the
coordinator of the assigned group closely follows
the whole process of recovery, from the admission,
through the vocational activities to the social
reintegration.
Kaunas June 2017
Drugs detoxification
Illegal drugs and/or substitutivetreatments should be tapered beforeentry:
At home, in collaboration with public health services for addiction .
In private clinics connected with San Patrignano admission offices, refunded by Public Health Services.
In pre-admission center (Botticella), where is possible to taper methadone, buprenorphyne, and benzodiazepines.
In San Patrignano Medical Center.
Kaunas, June 2017 8
Getting prepared to the admission
Immediate help and a safe
house for those in need
Kaunas June 2017
Kaunas June 2017
Starting up
Botticella is a first step introducing the
residents to community life.
Kaunas June 2017
Kaunas June 2017
The reasons to chose Botticella
• To assess motivation to change
• To complete detoxification
• To investigate psychiatric symptoms without drugs
• When an additional intermediate step before entering the community is needed.
Kaunas June 2017
Entering the program in Botticella
• In Botticella there is a permanent staff of educators (3), psychologist (1).
• A doctor is available once a week, but for immediate needs the San Patrignano Medical Center is available.
• For every guest entering, a personal mentor, generally in a midpoint of his therapeutic program, come from the San Patrignano Community..
Kaunas June 2017
Activities in Botticella
A range of different tasks and activities to
increase life skills and preparing for
community life.
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Learning to take care of the house
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Gardening
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Green maintenance
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Basic cooking
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Preparing lunch and dinner and
enjoying them all together
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Assisting the SP cheese factory in the
cheese ripening process
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Sharing moments together,
exchanging views
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Sharing the room
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A library at residents’ disposal
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Facing difficult moments together
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Getting medical support
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Duration of the program in Botticella
• Normally one month
• The duration length depends on
each individual and the progress
made
Kaunas June 2017
A new challenge: pre-admission for women
Kaunas June 2017
Kaunas June 2017
The program proposed by San
Patrignano: a pilot project
Kaunas June 2017
The program is implemented in Botticella. The
members of this project are included in a
"parallel segment" of the social and residential
fabric, to be involved in the group dynamics and
the interactions with other people residents
there, for a period of not less than 12 months
Location and program of
recovery from gambling
Kaunas June 2017
health care
management of drug related
disease
Kaunas, June 2017 32
The San Patrignano Medical Center
Created for the management of medical complications related to drug addiction:
• infections associated with syringe use or exchange (HIV/AIDS, hepatitis C or B/cirrhosis, endocarditis, etc.),
• withdrawal syndrome, • psychiatric diseases, • sexually transmitted disease, • odontoiatric diseases, • tuberculosis, • pneumonia, etc.
Kaunas, June 2017 33
The San Patrignano Medical Center
poliambulatory with diagnostic
instrumentation
computerized data bank
sera- and plasma-bank
(for research)
50 bed medical ward,
• Hospice and a long term rehabilitation center for AIDS patients, not only drug addicts but also patients without resources, coming from other hospitals:
• homeless,
• illegal people,
• patients with neurological o psychiatric diseases,
• patients without access or unable to adhere to HIV treatments
Kaunas, June 2017 34
A complete medical evaluation is
completed in the first weeks:
•Medical and toxicological history
•Medical, dermatologic, and gynecologic visit (for STD, scabies, and other diffusive diseases)
•Blood screening for HIV, hepatitis B and C, Syphilis
•Chest x ray and intradermal-PPD (for tuberculosis)
•ECG and respiratory functional test (also for sport)
•Dental examination and treatment
•Blood and serum samples taken from each subject and stored for medical research
Kaunas, June 2017 35
The changing pattern of drug
addiction
40 years of drug epidemiology
kaunas june 2017 36
Progressing toward poly-substances addiction
0
20
40
60
80
100
120
1980 1982 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 2010 2012 2014 2016
alcohol add. heroin iv cocaine
np cocaine ecstasy bzd
Kaunas, June 2017 37
Rapidly changing of
epidemiology of drug addiction
From intravenous to non parenteral use
From heroin to polysubstances addiction.
Partial decrease in injection related risk
behaviours.
Unchanged sexual related risk behaviours.
Kaunas, June 2017 38
Trend toward non parenteral patway of
drug use
0,00%
20,00%
40,00%
60,00%
80,00%
100,00%
120,00%
19
80
19
81
19
82
19
83
19
84
19
85
19
86
19
87
19
88
19
89
19
90
19
91
19
92
19
93
19
94
19
95
19
96
19
97
19
98
19
99
20
00
20
01
20
02
20
03
20
04
20
05
20
06
20
07
20
08
20
09
20
10
20
11
20
12
20
13
20
14
20
15
20
16
20
17
e.v. non e.v.
Kaunas, June 2017 39
injecting behaviours among PWID
by year of admission
0
10
20
30
40
50
60
70
80
90
100
19801989
19921995
19982001
20042007
20102013
2016
%
no sharing high risk
Kaunas, June 2017 40
Injecting behaviours by year of starting drug
use
0
10
20
30
40
50
60
70
80
90
100
<1970
1974
1978
1982
1986
1990
1994
1998
2002
2006
2009
2013
%
no sharing
high risk
Kaunas, June 2017 41
SEXUAL RISK
Occasional sexual partners
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
F M
no
yes
CONDOM USE
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
F M
REGULAR
SOMETIMS
NEVER
Kaunas, June 2017 42
Condom use with occasional partners among
PWID
0,00%
10,00%
20,00%
30,00%
40,00%
50,00%
60,00%
70,00%
80,00%
90,00%
19
80
19
81
19
82
19
83
19
84
19
85
19
86
19
87
19
88
19
89
19
90
19
91
19
92
19
93
19
94
19
95
19
96
19
97
19
98
19
99
20
00
20
01
20
02
20
03
20
04
20
05
20
06
20
07
20
08
20
09
20
10
20
11
20
12
20
13
20
14
20
15
20
16
20
17
regolare
no
saltuario
Kaunas, June 2017 43
Prevalence of HIV and HCV infection PWID
by year of residential treatment admission
0
10
20
30
40
50
60
70
80
90
100
19801983
19861989
19921995
19982001
20042007
20102013
2016
%HCV
HIV
Kaunas, June 2017 44
Prevalence of HIV and HCV infection PWID
by year of starting use of syringes
0
10
20
30
40
50
60
70
80
90
100
<19711980
19831986
19891992
19951998
20012004
20072010
20132016
%HCV
HIV
Kaunas, June 2017 45
HCV –Ab pos. prevalence in PWID and needle
sharing behaviour (9.851 sogg.)
High risk= also with unknown people
Low risk = only with partner or trustworthy friendsKaunas, June 2017 46
The San Patrignano rehabilitation program
Addicted people should be offered a drug free option, because they can live without drugs;
they need:
• a safe environment
• time (years)
• and a broad spectrum of opportunities and activities to educate themself in feeling rewarded by natural and social activities.
Kaunas, June 2017 47
The educational program
How to recover from addiction?
kaunas june 2017 48
Common personality traits in drug users.
• Low self-esteem
• Self-pity.
• Egocentrism (narcisism)
• Presumption
• Anti-sociality
• Impulsivity
Kaunas, June 2017 49
The Environment we try to offer
• Community as «society».
• A society withoutcommon escape (drugs).
• Hundreds of people living without drugs.
• Basic ethical principles.
• No physical and psychological violence.
• Equality: same rights, same duties.
• Intensity of relationships.
Kaunas, June 2017 50
Self-esteem and accountability
The basic work is to learn the
way to connect reward with:
• interest,
• responsibility,
• strong commitment,
• perseverance,
• but also fatigue, if not pain .
In the scientific dictionary this translates in a new brain neuro-adapatation that leads to a renewed capability of finding reward with from natural behaviours.
Kaunas, June 2017 51
All of these activities are fundamental educative instruments because they can give gratification but, at the same time, demand engagement in progressive responsibilities.
Activities (in order of timing)
52Kaunas, June 2017
Psychiatric and psychological
problems
kaunas june 2017 53
When educational
program is not enaught
30% of people needindividual psychoterapy:
Childhood abuse.
Eating disorder
Sexual identity disorder, etc.
25% of people needpsychiatric treatment:
Maior depression
Panic attacks
Drug related psychosis
OCD,
Severe personality disroders,
PTSD,
ADHD, etc
Kaunas, June 2017 54
2. Adverse childhood experiences-PTSD
Child abuse:
1. Physical
2. Sexual
3. Psychological
4. Physical/emotional neglect
Pathological family environment:
1. Alcohol or drug addicted parent (s)
2. Crime-involvement of parent (s).
3. Mental disease or suicide in family.
4. Violence between parents
5. Adoption, absence of one or either parents, separation.
Kaunas, June 2017 55
Adverse childhood experiences
in the San Patrignano cohort
1. Parents separation: 30%
2. Adoption: 3,3%.
3. Father psychiatric disease: 7%
4. Mother psychiatric disease: 19,5%.
• Abuse low self esteem
• Childhood sexual abuse : 22,39% among females and 3,43%among males.
• For physical abuse, psychological abuse, and neglect, data were not collected.
Kaunas, June 2017 56
psychiatric diseases
prevalence of psychiatric disease needingpharmacotherapy
• The more common prescribed drugs are (in order): antidepressants, mood stabilizers, antipsychotics, and, rarely, benzodiazepines.
Kaunas, June 2017 57
results
Retention in treatment
Social reintegration
Long term recovery
kaunas june 2017 58
S. Patrignano retention in
treatment
Year of entry
Number ofPWUD
12 months
24 months
36 months
48 months
2012 356 92,4% 78,9% 70,8% 57,6%
2013 418 84,9% 74,2% 68,7%
2014 360 88,6% 83.3%
2015* 278 90,3%
* 2015 data are related to the first 10 months
Kaunas, June 2017 59
2015: 217 social reintegration
2015
remained
unemploied
agricolture
students
food
handicraft
commerce
building
2016: 226 social reintegration
2016
remained
unemploied
agricolture
students
food
handicraft
commerce
building
JOB 2015 2016 2017
• remained 17 15 8
• unemploied 23 19 10
• agricolture 9 14 3
• students 9 6 5
• food 21 18 6
• handicraft 25 26 5
• commerce 8 4 2
• building 16 8 2
• offices 4 11 1
• mechanic 3 3 0
• catering/restorants 55 64 7
• health 22 23 1
• services 23 24 4
• others 11 16 8
• total 217 226 62
San Patrignano
Results
1995: 1° follow up study; 70% effectiveness.
2005: 2° follow up study; 72% of long lasting drugfree recovery.
2014: 3° follow up study (limited to these enteredin a 12 months period) ; still ongoing. 81% of retention in residential treatment at 36 months. No data on post-treatment recovery.
Kaunas, June 2017 63
Kaunas, June 2017 64
THANK YOU
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