The History of Addiction Clinics and Treatment in Italy: An Overview and Future Directions

Abstract

The history of addiction treatment in Italy reflects a complex evolution shaped by cultural, social, and legislative changes from the mid-20th century to the present. This paper explores the transition from more moralistic and punitive to public health-oriented approaches, the development of therapeutic communities, and the establishment of specialized outpatient clinics. It highlights the impact of pivotal legislation, the rise of harm reduction strategies, and the integration of behavioral addictions into the healthcare framework. Challenges such as stigma, emerging addiction patterns, and the need for integrated care models are some of the future directions of the addiction treatment alongside Italy’s progressive steps in offering personalized and multidisciplinary care.

1. Introduction

The history of addiction treatment in Italy is long and rich, spanning from the second half of the 20th century up to now. This specialized sector of Italian healthcare has undergone significant transformations over decades, moving gradually from a moralistic vision, where addiction was viewed as a personal failing, a moral weakness, or even a criminal act, to a public health and prevention-oriented approach (Peele 1987). The public health approach recognizes addiction as a complex medical and social issue requiring scientific, therapeutic, and harm reduction strategies, in parallel with a more profound comprehension of the problem in science, in politics and in public opinion (Crépault et al. 2023). The 20th century has seen a rise in psychoactive substance use among the general population: this led the United Nations to publish the Single Convention on Narcotic Drugs (1961) and the Convention on Psychotropic Substances (1971) in order to control a great number of natural and synthetic compounds. In the 1970s, heroin use made its first reported appearance in Italy; the “drug addicts”, referring to those who used psychotropic substances to the point of becoming addicted, were considered as stereotypical people lacking willpower to stop using these substances (Floriani 2009).

A few years would pass before public healthcare services and structures were activated with the aim of containing the phenomenon; the private social sector moved faster, anticipating the creation of the Italian National Health Service (Servizio Sanitario Nazionale, SSN).

Since the late 1960s and early 1970s, therapeutic communities represented the first articulated, widespread, and effective response to problematic use, abuse, and addiction, particularly heroin addiction (Dipartimento Politiche Antidroga 2021). The emergence of these communities was driven by a sharp rise in substance use across Italy and Europe. In Italy, heroin use remained relatively rare in the 1960s, but by the 1970s, it had begun to escalate, with reports of increased use among young people, particularly in urban centers. Early reports from the 1970s indicate that approximately 5000 people across Italy were initially involved in regular heroin use. This number soon rose exponentially, particularly among young adults (Paoli 2004). During that time, heroin soon spread among people disappointed by the outcome of the student protest movements and progressively also among middle and lower class youth, as well as southern immigrants (Paoli 2004). Furthermore, research highlighted that Italy has had the one of the highest C hepatitis (HCV) prevalences in Western Europe (Kondili et al. 2021), and also, HIV-related disease was one of the most common causes of death throughout the world (GBD 2017 HIV Collaborators 2019). As is well known, infectious diseases such HCV and HIV are conditions closely related to injecting drug use (Artenie et al. 2023).

This growing public health concern prompted the establishment of therapeutic communities for addiction, which emerged from diverse movements, often with Catholic roots but also incorporating secular components of civil commitment. These communities provided structured, abstinence-based residential programs focused on psychological and educational rehabilitation. The majority of these communities did not provide any form of medical or pharmacological support, factors that became crucial in addiction treatment in the following years.

The urgency of addressing addiction led to the passage of Italy’s first dedicated drug legislation, Law 685 of 1975 (Gazzetta Ufficiale della Repubblica Italiana 1975). This law marked a crucial turning point by formally distinguishing addiction treatment from psychiatric care and advocating for specialized facilities for drug users. The shift in policy acknowledged that substance use was no longer a marginal issue but a growing public health challenge requiring targeted interventions, through therapeutic communities which were directly supported by the government. These facilities offered an alternative to the prevailing punitive and psychiatric approaches, emphasizing recovery, social reintegration, and human dignity. They operated under a biopsychosocial model, recognizing addiction as a condition influenced by biological, psychological, and social factors (Cordini, Clerici and Carrà 2013).

These state-supported facilities differed from the earlier Church-funded therapeutic communities by incorporating medical supervision, pharmacological treatments (such as opioid agonist therapy), and structured psychological and social support programs. This approach signaled a move toward a more scientific and pragmatic vision of addiction treatment, focusing on harm reduction and long-term recovery.

However, at the time of enacting the 1975 law, the scale of substance use was still not widely perceived as an ‘epidemic.’ While alcohol use disorder and tobacco consumption were recognized as prevalent issues, psychoactive substance use was still viewed by much of the public as a phenomenon limited to small, marginalized groups rather than a widespread social crisis (Gatti 2018). Nonetheless, as heroin use continued to grow throughout the late 1970s, the demand for treatment services increased, reinforcing the necessity for a structured public health response.

Italian policymakers during those years were also influenced by international trends, particularly the ‘war on drugs’ declared by U.S. President Nixon in 1971. The establishment of the Drug Enforcement Administration (DEA) in the U.S. underscored a global shift toward drug control efforts, focusing more on punitive measures rather than therapeutic interventions (Nixon 1971). Italy’s 1975 law reflected the very same intentions stated by the U.S. president at the time, highlighting a great importance given to the war on drugs and criminalization of both users and suppliers, but also acknowledged the importance of prevention and treatment. Subsequent years, however, saw a gradual withdrawal of the healthcare system from direct involvement in addiction treatment, leaving many of the responsibilities to private and social sector initiatives.

2. The Rise of Heroin Addiction and the Creation of Specialized Outpatient Clinics

In the late 1970s and early 1980s, heroin use surged dramatically, particularly among young people. Italy, much like the rest of Europe, experienced a rapid increase in heroin availability due to changes in global drug trafficking routes and a growing demand for narcotics (Barrio et al. 2013). The phenomenon was closely linked to broader social and economic transformations, including urbanization, youth unemployment, and cultural shifts.

At the time, substance abuse was widely stigmatized and misunderstood, seen more as a moral failing or criminal issue than a medical condition requiring treatment (Frank and Nagel 2017): this was also reflected in the stigmatization of substance users, a condition that grew roots in Italian public opinion and still persists in the present day. This perspective shaped the Italian government’s response, which leaned heavily on punitive measures, including incarceration for drug possession and use. However, as such conditions spread and overwhelmed prisons and law enforcement, it became increasingly clear that this approach was insufficient to address the growing crisis.

During those years, Italy, much like the rest of Europe, was forced to face the rapid and alarming spread of HIV/AIDS (Gökengin et al. 2016). By the mid-1980s, it became clear that intravenous drug use was a major driver of HIV transmission. Sharing contaminated needles among heroin users led to a surge in HIV cases, particularly among younger populations. Studies conducted at the time revealed alarmingly high rates of HIV prevalence among drug users (Camoni et al. 2014; Vermund and Leigh-Brown 2012). Specifically, one study (Camoni et al. 2014) highlighted a relevant rise in HIV prevalence among injecting drug users in the early 1980s (from 3.8% in 1980 to 34.6% in 1987). According to the authors of the same study (Camoni et al. 2014), in the male and female general population, an increase in prevalence of HIV was observed until late 1980s, and then, it decreased gradually. The decrease was attributable to the efficacy of prevention campaigns and harm reduction strategies, as well as the implementation of antiretroviral treatment.

Furthermore, heroin users frequently develop other infections and related medical conditions, such as hepatitis C (Taylor et al. 2012). These public health concerns played a crucial role in shaping Italy’s approach to addiction care, leading to a stronger emphasis on medical supervision, prevention, and comprehensive treatment services.

The intertwining of opioid intravenous use and HIV/AIDS created a dual crisis that overwhelmed healthcare systems and sparked widespread fear. The early years of the epidemic were marked by stigma and misinformation, with people living with HIV often subjected to severe discrimination. This was especially true for drug users, who were already marginalized and faced even greater barriers to accessing healthcare and social support. The combined heroin and HIV crises forced Italian policymakers and healthcare professionals to rethink their strategies. By the late 1980s, harm reduction approaches began gaining traction, despite resistance from some sectors of society. Needle exchange programs were introduced in some regions to reduce the transmission of HIV among intravenous drug users (Packham 2022). These programs provided sterile syringes and encouraged safer injection practices, directly addressing one of the primary routes of HIV transmission.

In addition to needle exchanges, outreach programs targeted at drug users sought to educate them about the risks of HIV and the importance of testing and treatment, frequently offering free screening tests and medical orientation to this cohort of users. Peer support networks also began to emerge, providing spaces for individuals to share experiences and access resources without fear of judgment. These programs contributed to increased HIV testing rates and earlier diagnosis, which, in turn, improved treatment outcomes. Research has shown that harm reduction initiatives, particularly those combining syringe exchange, opioid substitution therapy, and HIV education, were associated with lower rates of new infections and improved health outcomes for drug users (Milaney et al. 2022; Vermund and Leigh-Brown 2012). These efforts marked a significant shift in the perception of addiction: from a purely criminal issue to a public health challenge requiring compassion and evidence-based interventions.

3. Legislation and Clinical Changes in the 1990s

The 1990s were a pivotal decade for addiction treatment in Italy, marked by significant legislative and institutional changes that shaped the landscape of care for substance abuse or addiction. One of the most consequential developments was the promulgation of Ordinary Law No. 162/90 and President of the Republic’s Decree (DPR) 309/90, which aimed to create specialized addiction treatment centers known as Servizi per le Tossicodipendenze (SerT) and establish a more structured system funded by the government for addressing addiction. This law mandated regional governments to create public services dedicated to alcohol and substance use disorders, offering treatment and integrating prevention, therapy, and social reintegration into their mandates.

Services offered by SerT included opioid agonist maintenance therapy (methadone and, later, buprenorphine). Opioid agonist programs were particularly significant, as they provided a safer alternative to heroin and helped reduce the health risks associated with intravenous drug use (Maremmani et al. 2009). The use of methadone became a critical tool in mitigating the diffusion of HIV infections, reducing the harm associated with needle sharing and offering a pathway of stabilization; even the general public, worried about the spread of AIDS, rapidly grew accustomed to and accepted methadone therapy.

During this period, SerT clinics began to diversify their approaches to treatment, working to address the underlying social and economic issues contributing to addiction and offering a more holistic approach than previous interventions. They expanded beyond the provision of pharmacological therapies to include psychotherapeutic interventions, counseling, educational, and social support services. This integrated, multidisciplinary approach sought to address the multifaceted needs of individuals struggling with addiction, recognizing that effective treatment required addressing not only the physiological but also the emotional, cognitive, and social dimensions of addiction. In SerT clinics, medical treatment was provided not only by psychiatrists, but also by infectious disease specialists, internal medicine doctors, as well as pharmacologists, ensuring a comprehensive approach to care. This differed from Mental Health Centers, where only psychiatrists are present, highlighting the distinct focus of addiction treatment.

The 1990s also witnessed a growing emphasis on social reintegration. SerT clinics collaborated with local organizations, therapeutic communities, and social cooperatives to support patients and promote their reintegration and social functioning if needed. This included facilitating access to housing, employment opportunities, and community engagement. The focus on holistic care was later extended to families, with services designed to involve and support the loved ones of people who use psychoactive substances.

Despite these advancements, the role of SerT clinics remained ambiguous, caught in a tension between their healthcare mission, together with therapeutic communities offering long-term rehabilitation, on one side, and on the other their entanglement with systems of surveillance and containment in association with law enforcement agencies, judiciary organs, and prisons.

Further reforms were influenced by a 1993 referendum that led to the repeal of some of the more repressive aspects of earlier drug laws. Nevertheless, the role of SerT clinics within the Italian National Health System (SSN) remained unclear between basic healthcare service and specialized care. Regional disparities in service provision persisted, highlighting the ongoing challenges in achieving equity in addiction treatment. For example, in some regions, SerT treated all types of addictions, while in other regions, some addictions (such as nicotine addiction) were managed by hospitals or other institutions. Moreover, in some regions, the SerTs collaborated more closely with other mental health clinics like Mental Health Centers and psychiatric hospitals, while in other areas. they were more isolated services. Furthermore, economic disparities between regional health services (especially in northern and more populated regions, compared to southern and less populated ones) led to disparities in introductions of newer and more costly therapeutic approaches and drugs, alongside having less human capital in terms of healthcare workers employed in the same outpatient setting.

4. The 2000s: Introduction of LEA and Its Impact on Addiction Treatment

The period from 2000 to 2010 marked a decade of further transformation for addiction treatment in Italy, reflecting significant shifts in public health policy, legislative reform, and societal attitudes towards substance use and related issues. Central to these developments was the introduction of the Essential Levels of Assistance (Livelli Essenziali di Assistenza, LEA) in 2001 (Gazzetta Ufficiale della Repubblica Italiana 2001). This framework radically changed healthcare delivery by defining a set of guaranteed services that the Italian government was required to provide to all citizens through regional health systems. Among these essential services were those dedicated to addressing addiction, an acknowledgment of the pressing need for accessible and standardized treatment for individuals struggling with substance use disorders.

The implementation of the LEA in 2001 formalized the inclusion of addiction services as a core component of Italy’s public healthcare system. With the introduction of LEA, all substance use disorder treatment was funded and granted by the government, while the treatment of behavioral addictions (such as gambling disorder) was still not included. Prior to this, addiction treatment was characterized by significant regional disparities. In some areas, SerT clinics provided comprehensive public care, while other regions relied heavily on scattered private or social sector initiatives. The LEA sought to address this patchwork system by ensuring that all citizens had access to essential addiction services, regardless of their geographic location.

One of the most notable impacts of the LEA was the accreditation and integration of private and social service providers into the national framework. These organizations, which had often operated independently and without a common framework, were now subject to formal evaluation and alignment with public healthcare standards. This process ensured that their services met quality benchmarks comparable to those of public clinics, expanding the reach and consistency of addiction treatment across Italy. The result was a more cohesive network of care, encompassing both public and private initiatives, that provided a foundation for more effective and equitable treatment.

In 2006, a new government law (the Fini–Giovanardi law) introduced new regulations that further altered the legal and social context of addiction treatment. This law controversially equated soft and hard drugs in terms of penalties, leading to heightened criminalization of drug users. Traditionally, “soft” drugs included cannabis and its derivatives, which were perceived as having a lower risk of addiction and harm, while “hard” drugs referred to substances like heroin, cocaine, and synthetic opioids, which carry a higher potential for dependence and severe health consequences. Nevertheless, although there appears to be agreement as to which psychoactive substances should be regarded as “hard” and “soft,” there are no clear criteria for categorization in these definitions, and further research is needed (Janik et al. 2017).

However, this approach faced substantial criticism from public health experts and advocacy groups, who argued that it undermined efforts to treat addiction as a health issue rather than a criminal one. Parts of the Fini–Giovanardi law were ultimately overturned by Italy’s Constitutional Court in 2014, but the debates it sparked during the 2000s highlighted the ongoing tension between punitive and rehabilitative approaches to drug use.

5. The Last Decade and the Evolution of Addiction Treatment Services

Over the last decade, addiction treatment services in Italy have continued to evolve, reflecting broader changes in societal attitudes, public health priorities, and the challenges posed by an increasingly diverse landscape of addiction. One of the most symbolic changes during this time has been the transformation of SerT (Servizi Tossicodipendenze) into SerD (Servizi per le Dipendenze). This rebranding marked a significant shift in focus, emphasizing that addiction extends beyond substance use disorders to include behavioral addictions, such as gambling disorders and internet addiction. This broader approach was a response to the growing recognition that addiction is a multifaceted issue that cannot be adequately addressed through a one-size-fits-all model.

The name change from SerT to SerD also reflected a deeper evolution in the services’ mandate. Historically, SerT clinics were predominantly focused on addressing heroin addiction, which had dominated the drug landscape in previous decades. However, as new patterns of drug use emerged—including the proliferation of synthetic drugs and the rise of recreational substances—alongside increasing awareness of non-substance-related disorders (e.g., gambling disorder), the scope of these clinics needed to expand. The updated terminology signaled this shift, aligning the services more closely with contemporary understandings of addiction as a spectrum of behaviors and conditions that require diverse interventions.

Another critical development in this period has been the emphasis on personalized and multidisciplinary care. Teams within SerD clinics typically include medical professionals, psychologists, professional nurses, social workers, and educators who work collaboratively to provide tailored treatment plans for individuals. By focusing on comprehensive care, SerD has sought to improve treatment outcomes and support individuals in achieving sustainable recovery.

Efforts to reduce the stigma associated with addiction have also intensified in recent years. Recognizing that societal perceptions can act as a barrier to seeking help, SerD clinics have worked to promote a more compassionate and supportive image of addiction treatment. Public awareness campaigns and community outreach initiatives have aimed to shift the narrative from one of blame and punishment to one of understanding and care. This cultural shift has been instrumental in encouraging more individuals to access services and in fostering a societal perspective that views addiction as a public health challenge rather than a moral failing.

In addition to addressing substance use disorders, SerD has also expanded its services to tackle behavioral addictions, such as gambling disorder and, more recently, problems related with technology use, such as internet gaming disorder (Demetrovics and Griffiths 2012; Saunders et al. 2017). This evolution has been driven by the recognition that these behaviors can have similarly devastating effects on individuals and families as traditional substance use disorders. By broadening their scope, SerD clinics have demonstrated a commitment to adapting to the changing landscape of addiction and meeting the diverse needs of the populations they serve.

The transformation of SerT into SerD represents more than just a change in terminology; it signifies a broader cultural and institutional shift in how addiction is understood and treated in Italy. By embracing a multidisciplinary and inclusive approach, SerD has positioned itself as a cornerstone of the country’s efforts to address the evolving challenges of addiction, ensuring that care remains responsive, equitable, and effective in the face of changing societal needs.

6. New Challenges and Directions in Addiction Treatment in Italy

In recent years, the treatment of substance use disorders in Italy has faced a series of emerging challenges, prompting shifts in strategies and priorities within the Servizi per le Dipendenze (SerD). Among the most pressing issues is the persistent stigma surrounding addiction. Despite advances in understanding addiction as a chronic medical condition, social perceptions often continue to frame it as a moral failing or personal weakness. This stigmatization can discourage individuals from seeking help and undermine recovery efforts. Addressing this requires nationwide awareness campaigns about the neurobiological and social roots of addiction and to promote empathy towards individuals struggling with this condition.

Another significant challenge lies in the rise of new forms of addiction. Alongside traditional substance use disorders, behavioral addictions, such as gambling disorder, internet and social media addiction, sex addiction, and gaming disorder, have become increasingly prevalent, particularly among the younger population. The proliferation of online gambling platforms (Hing et al. 2022), aggressive marketing strategies by betting companies (Guillou-Landreat et al. 2021), and the increasing accessibility of digital technology are some of the factors which have contributed to the growing prevalence of gambling disorder. Similarly, the rise in internet addiction—particularly internet gaming disorder—has been fueled by the increasing presence of social media, online gaming communities, and the widespread availability of smartphones (Appel et al. 2020). These behavioral addictions pose unique challenges compared to substance use disorders, as they are often more socially acceptable, harder to detect, and intertwined with everyday digital life. This makes early intervention and specialized treatment approaches crucial.

Similarly, the proliferation and wide online availability of Novel Psychoactive Substances (NPSs) and “smart drugs” present unique difficulties for treatment providers, as these substances often fall outside the scope of established treatment models (Sajwani 2023). Furthermore, the recent rise in interest for the therapeutic use of some psychoactive substances (e.g., cannabis for Multiple Sclerosis or psychedelic substances to treat psychiatric disorders) represents a challenge for professionals working in addiction medicine (Tupper et al. 2015). The SerD system must adapt to these changes, requiring updated training for clinicians and the development of innovative therapeutic approaches to address these emerging patterns of addiction.

The integration of mental healthcare into addiction services represents a further critical direction for SerD. Many individuals with substance use disorders also experience co-occurring psychiatric conditions, such as anxiety, depression, or schizophrenia (Subodh et al. 2018). Treating these comorbidities effectively demands a multidisciplinary approach that bridges the gap between mental health services and addiction clinics.

In this area, much progress has been made in recent decades, as the SerTs are integrated within a network that involves close cooperation with the Mental Health Centers (where non-substance-related psychiatric conditions are treated), psychiatric departments, and infectious disease and hepatology outpatient clinics (Dipartimento Politiche Antidroga 2021).

While SerD was originally designed as a specialized addiction service, its function has increasingly evolved to act as a crucial link between specialized care and basic healthcare services. Given the complexity of addiction treatment—where medical, psychological, and social factors all play significant roles—effective care requires close coordination between SerD clinics and general practitioners, who often serve as the first point of contact for individuals with substance use disorders. Indeed, general practitioners play a vital role in early detection, harm reduction, and referral to specialized care, ensuring that addiction is addressed as part of a patient’s overall health rather than as an isolated issue (Knight 2001).

Prevention also remains an underfunded and underutilized aspect of addiction treatment in Italy. While treatment services have expanded, preventive measures in healthcare services—such as community outreach programs—often take a backseat, while other forms of prevention such as increased policing on drug use and continuous effort against crime and drug markets receive the most attention in the eye of the public opinion and national funding. Increasing investment in other forms of prevention programs such as educational intervention in schools, peer education, life skills training, and harm reduction programs, which all proved to be useful as evidence-based tools, could play a crucial role in reducing the incidence of addiction, particularly among younger populations, and alleviating the burden on SerD clinics (Malick 2018).

Italy’s health services are generally evolving, focusing on providing personalized care. To navigate the challenges provided by the ever-changing drug market and the multitude of different types of patients affected by substance and/or behavioral addictions, Italy’s outpatient and inpatient services should evolve as well. Specifically, it would be beneficial to place greater emphasis on personalized care and harm reduction strategies, such as the provision of information, health aids for the prevention of common diseases, unwanted pregnancies, and Sexually Transmitted Diseases, as well as withdrawal crisis management (sterile syringes, condoms, Naloxone, etc.), alcohol measurement, counseling, and comfort items. In the same way, it would be important to increase the effort and focus on harm reduction strategies, which continue to evolve, and address not only the risks associated with substance use but also the broader societal and health impacts of addiction (Bergamo et al. 2019; Velasco et al. 2015).

Tailoring treatment plans to individual needs, whether through medical, psychological, or social interventions, is already becoming central to SerD professionals. By embracing change and addressing new challenges, the future of substance use disorder treatment in Italy holds the promise of more inclusive, effective, and compassionate care.