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1 Page 1 of 6 JOURNAL FOR DRUG ADDICTION AND ALCOHOLISM 22nd year: 1999 no 2 (abstracts and a selection of the articles in English ) Characteristics of subjects contacted by street workers of the city of Bologna in the first semester of 1998 Raimondo Maria Pavarin*, Adriano Salsi** Summary The objective of the study is to reveal the characteristics of subjects contacted by street workers in the city of Bologna and, in particular, those subjects who do not make themselves available to the public drug addiction services of the city (SER.T.). Data from the study will be used for the planning and design of specific prevention programs and for the proper rationalization of resources. Analysis of information arriving from sources established by the Osservatorio aziendale delle dipendenze patologiche (Observatory Board for Pathological Addiction) of the Local Health Center (USL) of the city of Bologna, in collaboration with the local government of Bologna, will be utilized for the Information System of Metropolitan Social Assistance project (S.I.S.M.A.). Keywords: Street workers, Heroin addiction, Evaluation, Prevention Introduction The strategy adopted to reduce harm is based mainly on contact with subjects who do not turn to public/private agencies for drug addiction. Information systems are based on changes in the use of the SER.T. and the therapeutic centers, and the target of specific prevention projects is most often measured against standard types based on literature. With regard to work on the streets, it is necessary to provide public agencies with information on the characteristics of the subjects contacted (an aspect of the underworld of drug addiction), in addition to communicating the extent of work achieved. The objective of this study is to reveal characteristics of subjects contacted by street workers in the city (1) of Bologna and, in particular, those subjects who do not make themselves available to the public drug addiction services of the city (SER.T.). Data from the study will be used for the planning and design of specific prevention programs and for the proper rationalization of resources. In collaboration with the local government of Bologna, analysis of information arriving from sources established by the Observatory for Pathological Addiction of the USL in Bologna will be utilized for the Information System of Metropolitan Social Assistance project (S.I.S.M.A.). The main problem we confronted regards the impossibility of requesting personal data from the subjects contacted and the consequent impossibility of obtaining univocal codification. For this reason, the decision was made to repeat the study each year and to insert a code for subjects previously contacted in 1998 in the form for collecting 1999 data. This offered an opportunity to sharpen the analysis of the new types of drug use. The informative system of the street unit

2 Page 2 of 6 During 1997, the USL of the city of Bologna initiated the Observatory for Addiction, and this has made the flow of data coming from sources other than SER.T. possible: therapeutic centers, emergency services, hospitals, mortality records, anti-drug agencies of the state police, street workers. Street Workers (S.W.), fill out a drug user file for each contact made in the course of the year (1 January December 1998) with information on age, sex, nationality, residence, drug(s) abused and method(s) of intake, relationship with the SER.T. and the therapeutic centers, work, housing situation, AIDS and Hepatitis C tests taken in the last six months. In addition, a daily file is filled out for every action taken, with information (organized by contact, sex and nationality) summarizing the syringes distributed and exchanged, and the condoms, vials of water and citric acid that are distributed. This data is entered into a database and elaborated each semester by the Observatory. This permits punctual monitoring of the work achieved by the Street Workers and a careful analysis of the phenomenon of drug addiction in Bologna, as well as a comparison with data produced by other sectors. Analysis of drug users Characteristics 369 subjects were contacted by the Street Workers of the city of Bologna in the first semester of 1998 (average age 28.7, DS 5.8 ), 82.7% males (average age 28.8, DS 5.5) 17.3% females (average age 28.2, DS 6.8) [table 1]. For 5.4% the prevalent problems concern "social maladjustment" (average age 28.5). 94% are of Italian nationality (average age 28.8, DS 5.8), 6% are foreigners (average age 27.6, DS 5.6), 35.5% are residents of Bologna (average age 29.3, DS 5.9), 49.9% come from outside Bologna (average age 27.8, DS 5.5), 14.4% have no stable residence (average age 30.4, DS 5.7). 14.1% work (average age 28.9), 18.2% do not work (average age 27.9), 9.5% live "on the street" (average age 26.7), i.e., do not have a residence. 11.4% use the S.S.A. (average age 30.9), 33.9% have never been to the SER.T. (average age 27.5). 22.2% are presently receiving methadone treatment at the SER.T. (average age 31), 58.3% have never undergone methadone treatment (average age 28). 45.9% have been in at least one therapeutic center in the past (average age 29.4), 49.9% have never been in one (average age 28.1). 239 subjects (64.8%) claimed they were taking several drugs (average age 28.3). Volume of activity The total number of "contacts" was (subjects came to the van more than once); 82.6% were male, 17.3% female, 93.2% Italians, 6.8% foreigners. In greater detail: 76.2% of the contacts were with Italian males, 16.9% were with Italian females; 6.4% with foreign males, 0.4% with foreign females (table 2). Based on an average per semester, each subject had 17 contacts, (20 for foreign males); 18 syringes were distributed for every 10 contacts; 2 syringes were exchanged for every 100 contacts, (7 exchanges for foreigners, 5 for females), on the average 1 condom was distributed for every 2 contacts (3 for every 2 contacts for Italian females). Females (17.3% of the total) account for 40% of the volume of syringes exchanged and for 55% of the total number of condoms distributed. Foreigners (6.8% of the total) contribute to 20% of the syringes exchanged and to 14% of the total condoms distributed. Health issues Information on previous Hepatitis C testing concerns 62.6% of the subjects contacted. 73.7% had been given the test in the last 6 months (average age 29.2), 7.9% had not been tested (average age 24.9), 17.1% had been tested "some time ago" (average age 28.5).

3 Page 3 of 6 Information on previous testing for AIDS regards 62.3% of the subjects contacted; 7.8% were never tested, 20% had been tested in the past, 72.2% within the last 6 months. The prevalent abused substance (more than one response was possible) was heroin for 93.2% of the cases (average age 28.6), 40.4% cocaine (average age 28.1), 38.2% psychoactive drugs (average age 27.4), 13.6% methadone on the black market (average age 28.5), 12.5% alcohol (average age 28.7). Methods of intake 94.3% (348 subjects out of 369) take the drugs intravenously. 97.4% of heroin users "shoot up", 1.5% inhale, 0.9% smoke it. 81.9% of cocaine users inject it intravenously, 16.8% inhale it, 0.7% smoke it. 51.5% of psychoactive drug users inject the drugs intravenously, 44.7% take them orally. Methadone: 18% inject the drug intravenously, 76% take it orally. Analysis of drug users Subjects contacted by the SW were distinguished into three types: presently under the care of the SER.T., under the care of the SER.T. in the past, never under the care of the SER.T. (the "unknowns"). This information makes it possible to more closely examine certain aspects of the phenomenon of drug addiction in Bologna and to outline characteristics in a precise manner (table 3). 34.5% (125 subjects) have never been to the SER.T. 30.4% have been. Of this later group, 60.6% (77 subjects) claim to be in methadone treatment. Females comprise 15.2% of the unknowns and 24.4% of those attending the SER.T. 9.6% of the unknowns (a total of 5.4%) suffer from problems predominantly linked to "social uneasiness" and not to drug addiction. The percentage of those living on the streets, i.e., who do not have a home, does not differ for those who are unknown and those who are under the care of the SER.T. (9.6%), as is the case for those who work (15%). 72.8% of the unknowns have never been in any therapeutic center (SER.T. 37.8%). 12% of the unknowns (SER.T. 0.8%) are foreigners, 47.2% are residents outside of Bologna (SER.T. 45.7%), 20% are without a stable residence (SER.T. 7.9%), 8.8% use the S.S.A. (SER.T. 13.4%). 15.2% abuse alcohol (SER.T. 12.6%), 36% psychoactive drugs (SER.T. 40.2%). 88% inject the drugs intravenously (SER.T. 95.3%; in the past, SER.T. 100%). Results Street Workers attract many from the male underground, many subjects under 30, and almost all those who reside outside Bologna, most probably due to the central role drugs play in the zone in which these groups habitually operate (the area around the central train station) [table 4]. The age difference evidences two very distinct types of drug users: 1. On the average, older subjects include: those with no stable residence; those under the care of SER.T.; those following a methadone treatment; and alcoholics, to prove the strength of the SER.T. in their effort to rescue all types, in consistency with their strategy to reduce the harm and to observe how long-term social uneasiness is not directly connected to the intervention of the public agencies; 2. on the average, those who are younger are: foreigners, residents outside Bologna, those who live on the street, those who have never been to the SER.T., those who never attended therapeutic centers, users of psychoactive drugs and subjects who were never tested for infectious diseases. This considerable group of subjects is accountable in part to a fringe group: non-residents in the city, with potentially risky behavior and an uncontrollable health

4 Page 4 of 6 problem (table 5). The unknowns are adjacent to an area associated with the fringe group and are characterized by being younger, by having a high percentage of males and foreigners, by lacking stable residence, by not usually being under the care of drug addiction services, and by having problems also due to situations of social uneasiness, which then develop into drug addiction. This group includes a large number of alcoholics. Comparison of the characteristics of those using the Bologna SER.T. in the first semester of 1998 (source: USL, city of Bologna Observatory Board on Drug Addiction) with subjects contacted by the SW who claimed not to ever have been to the SER.T. yields further proof of the characteristics of the "underground" that were previously identified: a low average age, the lowest percentage of females, a high percentage of residents from outside the city, a high percentage of individuals with no stable residence, the lowest percentage of heroin addicts (3). The health situation gives cause for worry: only about half of the subjects who have not visited the SER.T. have had Hepatitis C and AIDS tests (we are unaware of the results) and 88% utilize the intravenous method of taking drugs. Interpretation of the activity data suggests models of behavior that are very different for male and female drug addicts, with the latter seeming to dedicate more attention to behavior that is potentially risky and/or dangerous for others (4). Contributors: Michelina Ruo, Marina Vigni, Fabrizio Ruggieri, Street Workers, City of Bologna Vincenzo Castelli, Monica Brandoli, Ufficio Tossicodipendenze Comune di Bologna (Office for Drug Addiction of the City of Bologna) Notes 1. Nine street workers operate in the city of Bologna. They are hired by the city with short-term, renewable contracts, based on a proven level of professionally in the field after training by the Municipal Office for Drug Addiction. Two daily rounds of 4 hours each, 7 days per week, are scheduled with the logistical support of a fully equipped van to distribute syringes, condoms, and information to promote safe sex and safe needle use, and to hold meetings for support/orientation and HIV counseling. 2. Contact file: V1 - DATE V2 - SEX 1- M 2 - F V3 - AGE V4-1 - ITALIAN 2 - ER V5 - RESIDENCE 1 - BOLOGNA 2 - OUTSIDE BOLOGNA 3 WITHOUT STABLE RESIDENCE V6 CHARACTERISTICS 1 DRUG ADDICTION 2 SOCIAL UNEASINESS V7- ABUSED SUBSTANCE VEIN INHALATION SMOKE ORAL -1- HEROIN -2- PSYCHOACTIVE DRUGS -3- ALCOHOL -4- COCAINE -5 -METHADONE V8 - USES THE S.S.A. 1-YES NO V9 - SER.T. AT THE PRESENT TIME 1-YES NO SOME TIME AGO V10 TREATMENT METH. AT PRESENT TIME 1-YES NO V11 THERAPEUTIC CENTER IN THE PAST 1-YES NO V12 AIDS TEST LAST 6 MONTHS 1-YES NO SOME TIME AGO V13 HEPATITIS C TEST LAST 6 MONTHS 1-YES NO SOME TIME AGO 3. Pavarin R.M., Salsi A. "Stima della prevalenza di tossicodipendenti nella città di Bologna nel 1997 e analisi del sommerso" ("Estimate of the Prevalence of Drug Addiction in the City of Bologna in 1997 and Analysis of the Underground"), Bollettino per le farmacodipendenze e l alcolismo (Bulletin on Drug Addiction and Alcoholism) no. 3, 1998.

5 Page 5 of 6 4. It is the shared impression of the workers that at least 50% of the drug addicts contacted by the street unit resort to prostitution in the area adjacent to the train station of Bologna, even if only on an occasional basis. Table 1. Activities of the street workers of the city of Bologna in the first semester of 1998: materials distributed according to type of use - Comparisons SUBJECTS CONTACTS M SYRINGES DISTRIBUTED M SYRINGES EXCHANGED AVERAGE CONDOMS AVERAGE TOTAL , , , ,5 MALES , ,8 96 0, , , ,8 59 0, ,5 ITALIANS , , , ,4 ERS , ,5 32 0, ,0 ITALIAN MALES , ,8 96 0, ,2 MALES ITALIAN , ,5 0 0, , , ,8 27 0, , ,5 45 1,7 32 1, ,1 Table 2. Activities of the street workers of the city of Bologna in the first semester of 1998: materials distributed according to type of contact - Comparisons CONTACTS % SYRINGES DISTRIBUITED % SYRINGES EXCHANGED % CONDOMS % TOTALS , , , ,0 MALES , , , , , , , ,4 ITALIANS , , , ,5 ERS 423 6, , , ,5 ITALIAN MALES MALES ITALIAN , , , , , ,4 0 0, , , , , ,7 27 0,4 45 0, , ,7 Table 3. Activities of street workers of the city of Bologna in the first semester of 1998: Characteristics of drug users A comparison between drug addicts contacted by street workers and those contacted by the SER.T. DRUG ADDICTS CONTACTED BY THE BOLOGNA SER.T DRUG ADDICTS CONTACTED BY THE STREET:WORKERS AND UNKNOWN TO SER.T. TOTAL CONTACTED BY THE STREET WORKERS Number Average age 33,2 27,5 28,7 Percentage M/F 3,1 5,6 4,8

6 Page 6 of 6 % no stable residence 2,3 20,0 13,8 % heroin 92,7 87,2 93,2 % hepatitis C tests 62,7 59,2 62,6 % HIV tests 80,1 58,4 62,3 % living outside Bologna 10,7 47,2 49,6 Table 4. Activities of street workers of the city of Bologna in the first semester of 1998: characteristics of use Comparison by age YOUNGER Foreigners Residents outside Bologna Homeless have never been to the SER.T. No therapeutic center Abuse of psychoactive drugs OLDER no stable residence Alcoholics Heroin Addicts currently undergoing methadone treatment use the S.S.A. no AIDS test no Hepatitis C test Table 5. Drug addiction in Bologna: First semester, 1998 Possible comparisons Under the care of Ser.t Attending therapeutic programmes In contact with Street workers Dismissed from hospital Emergency medical interventions Related criminal charges Overdose deaths Number of subjects Average age 33,2 30,0 28,7 31,8 28,6 27,4 31,8 Percentage M/F 3,1 4,2 4,8 3,6 31,4 26,0 % with HIV test 80,1 81,3 62,3 % with hepatitis C test 62,7 79,7 62,6 % methadone maint. 45,2 22,2 % heroin addicts 92,7 100,0 93,2 % foreigners 0,1 6,0 67,5 7,7 % no stable residence 2,3 14,4 % living outside Bologna 10,7 34,8 49,9 73,1