Past development and

future outlook on clinical

guidelines in Italy

Augusto Consoli

Department for Addiction Prevention and Treatment,

National Health Service, Torino 2

Italian Society of Drug Addiction (SITD)

Pompidou Group
Treatment Conference on Guidelines and Recommendations
Nicosia 11-13 May 2009

The considerations that I will try to
carry out in this short presentation are
oriented to illustrate the work carried
out in the course of the last 10 years
in Italy, in the difficult process both
cultural that professional and
organizational relative to the
development and the application of
clinic and prevention Guide Lines in
addiction field.
Guidelines International Network
Medical Clinical Guidelines
(publ. 1999-2009)
France 32
Australia 28
Germany 15
United Kingdom 12
USA 11
Spain 10
Netherlands 4
Switzerland 4
Canada 2
Norway 2
Russian Fed. 2
International 29
http://www.g-i-n.net/
 Italian Guidelines

Oncology 3
Orthopaedics 2
Surgery 2
Cardiology 2
Epatology 2
Geriatrics 1
Visual diagnostic 1
Pharmachology 1
Virology 1
Psychiatry 1

http://www.pnlg.it/lgn

But actually in Italy there are many more
Guide Lines in the several fields of
medicine and surgery but the fact, as an
example, that they are not marked on GIN
network is a possible pointer that, in spite of
the efforts till now made, the spread and the
sharing of the guide lines among the health
professionals in Italy is still to develop
ulteriorly.
Drug Addiction - International guidelines for:

Prevention

Harm reduction

Substitution treatments

Psychosocial treatments

Treatments for specific groups

(e.g. women, migrants, prisoners)
In Italy have been carried out some attempts or
documents to develop GuideLines in drug addiction
field…

Prevention GL based on:

2002 WHO GL, 2003 NIDA GL, 2005 EMCDDA GL

Methadone treatments
Studio Vedette

Dual diagnosis treatments GL

Italian Psychiatry Association on Addiction

Residential and psycho-social treatments pointers

Piemonte Working Group on Evidence-Based Healthcare

GL to promote smoking cessation

Istituto Superiore di Sanità
…but

it’s not always easy to distinguish between

guidelines, protocols, recommendations, best
practices, standards, policies;

on many issues there is no availability of
relevant documents based on clinical
evidence, even when already developed by
other countries;

there is a cultural resistance to the
standardization of treatments and low
inclination to the use of manuals (except
where there are high technical contents)

a debate is still ongoing about the real
possibility of using the guidelines in clinical
practice;
 What do we mean by Guidelines?

Operating instructions

onspecific, limited and explicit issues (fields of

reference and application);

based
on high quality scientific contents (RCT
and meta-analysis);

drafted according to progressive levels of

consistency;

includingprocedures for periodic evaluation

and review.
 Italian National Project on Guidelines
(PNLG)

Check-list of criteria used to evaluate

guidelines

1. Essential requirements
2. Ethical aspects
3. Relevance and appropriateness
4. Structural quality
5. Acceptability
6. Technical and scientific validity
7. Applicability

G. 8. Outcomes
F. Gensini, A. Biggeri, A. Caputi, A.A.Conti, A. Liberati e coll.
 Essential requirements

Statement of the followed methodology

Statement of purpose and scope of

application

Support of the best scientific evidence

available

Presence of multidisciplinary expertise in

the team

Explanation of the timing and methods of

application of the lines and their
modification

Identification of the recipients and

explanation of the transfer process
 Ethical aspects

• Absence of potential conflicts of interest

(for example funding from industry)

• Appropriate and relevant topics in terms of

social utility

• Clarification of objectives expected of each

treatment

• Assessment of cost-benefit
 Relevance and appropriateness

• Relevance to public health system

• Risk of applying/not applying the treatment
• Assessment of costs
• Prognostic evaluation
• Clinical significance of GL for the quality of
life too
• The GL make it easier and more objective
the decision making process
• Provides criterion to evaluate the quality of
care promoted by GL
 Points of view on GL after focus groups

Pro Cons

Fair to the people Low elasticity

Low pertinence to
Appropriateness of care
operational dimension

Protection from Encouragement of a

professional misconducts defensive approach

Support for treatment Quickly overcome by

evaluation research evolution

Better use of available Expensive to build and

resources maintain
Despite some risks, and looking for the advantages
most Italian professionals now agree that the use
of guidelines is essential to improve quality and
adequacy of treatments offered.

But the selection of the contents of such claims,

the process of their preparation and procedures for
their implementation and progressive review,
should be part of a plan properly constructed and
maintained.
For this reason we stress the importance
of:

1.promoting the adequacy and quality of

care, enhancing the availability of
diagnostic and therapeutic instruments;

2.fostering the exchange between

professionals on best practices and
practical operational problems;
3.supporting the dissemination of the most
updated literature and GL, as North
American and WHO guidelines, or those
developed in other EU countries, as well as
the evidence of researches carried out at
national and international level;
4.identifying a working group with
experienced professionals in drug addiction
field, experts in the development of clinical
guidelines, members of scientific societies,
representatives of key national institutions
(eg: Istituto Superiore di Sanità and
Dipartimento Nazionale Politiche Antidroga),
to support a strategy to develop and
disseminate guidelines for the treatment of
addictions, even identifying a ranking of
topics;
5.encouraging regional governments to adopt
incentives or rewards for health care centers
that use evidence-based practice and follow
approved clinical guidelines.
 Il Dipartimento Nazionale Politiche Antidroga-
DNPA
The role of the National Department for Anti-drug
Policies

However it is necessary to develop national
policies, that favor a homogeneity in the
elaboration and in the spread of GL.

In this direction, an ulterior opportunity is

given by the the activities of the National
Department for Anti-drug Policies (DNPA)
structure of the Prime Minister's Office.

This structure that will be able to develop in
this field important initiatives of sovra-
regional character has started the
elaboration policies addressed in various
fields, beginning from the field of prevention
and treatment of adolescents, thought as
one of the more problematic tasks to face.
 Pompidou Group
Treatment Conference on Guidelines and Recommendations
Nicosia 11-13 May 2009