Συμπλήρωμα στην Ελληνική Βιβλιογραφία για τα Ναρκωτικά και το Αλκοόλ

Ερευνητικό Πανεπιστημιακό Ινστιτούτο Ψυχικής Υγιεινής Διευθυντής: K.N. Στεφανής Συμπλήρωμα στην Ελληνική Βιβλιογραφία για τα Ναρκωτικά και το Αλκοόλ Επιμέλεια έκδοσης: Πετρούλα Πρασσά 2014

Copyright: Ερευνητικό Πανεπιστημιακό Ινστιτούτο Ψυχικής Υγιεινής (ΕΠΙΨΥ) 2015 Τ.Θ. 66 517, Τ.Κ. 156 01, Παπάγου Τηλέφωνο: 210 6536902 Fax. 210 6537273 Email. ektepn@ektepn.gr Ιστοσελίδα: www.ektepn.gr Issn: 1792 6289 1

Με τη χρηματοδότηση του Υπουργείου Υγείας 2

Πρόλογος Επιστ. Υπεύθυνης του ΕΚΤΕΠΝ Για μία ακόμη χρονιά εκδόθηκε σε ηλεκτρονική μορφή, το Συμπλήρωμα στην Ελληνική Βιβλιογραφία για τα Ναρκωτικά και το Αλκοόλ 2014. Η έκδοση αυτού του τόμου προϋποθέτει την επικοινωνία με τους Έλληνες επιστήμονες και τους επαγγελματίες που δραστηριοποιούνται στον χώρο των ναρκωτικών και του αλκοόλ, τη συλλογή των δημοσιεύσεών τους, των παρουσιάσεών τους σε συνέδρια ή των βιβλίων τους. Για το έτος 2014 το Συμπλήρωμα στην Ελληνική Βιβλιογραφία για τα Ναρκωτικά και το Αλκοόλ περιλαμβάνει 70 επιστημονικές εργασίες, 43 από αυτές ξενόγλωσσες και 27 ελληνικές. Οι στόχοι της έκδοσης αυτής είναι η ενημέρωση των επαγγελματιών του χώρου για τις ερευνητικές και επιστημονικές εξελίξεις στο πρόβλημα των ναρκωτικών και του αλκοόλ κατά το έτος αναφοράς, η αναγνωρισιμότητα της ελληνικής προσπάθειας στο ζήτημα αυτό και η προβολή του έργου των ανθρώπων που καταβάλλουν την προσπάθεια αυτή. Επομένως, η επιτυχία των στόχων βασίζεται σε μεγάλο βαθμό στην ανταπόκριση των συνεργατών του δικτύου στην πρόσκληση του ΕΚΤΕΠΝ να αποστείλουν το υλικό τους. Η κυρία Πετρούλα Πρασσά «έβαλε τα δυνατά της» και φέτος να συλλέξει και να αξιοποιήσει τις προσκτήσεις της Ελληνικής Βιβλιογραφίας για τα Ναρκωτικά και το Αλκοόλ 2014. Για το έργο αυτό, που κάθε χρόνο αναλαμβάνει και φέρνει σε πέρας μόνη της, της αξίζουν συγχαρητήρια. για τη γενικότερη προσφορά της στο ΕΚΤΕΠΝ της αξίζουν πολλές ευχαριστίες από εμένα προσωπικά και από όλους τους συναδέλφους μας. Μανίνα Τερζίδου Επιστημονικά Υπεύθυνη του ΕΚΤΕΠΝ 3

Εισαγωγή Το Συμπλήρωμα στην Ελληνική Βιβλιογραφία για τα Ναρκωτικά και το Αλκοόλ για το έτος 2014 περιλαμβάνει τις διαθέσιμες προς το ΕΚΤΕΠΝ εργασίες Ελλήνων επιστημόνων για το πρόβλημα της χρήσης των ναρκωτικών και του αλκοόλ. Στην έκδοση αυτή περιέχονται βιβλιογραφικές αναφορές οι οποίες αφορούν άρθρα σε ελληνικά και διεθνή επιστημονικά περιοδικά, βιβλία, κεφάλαια σε βιβλία, πρακτικά συνεδρίων, καθώς και ανακοινώσεις σε συνέδρια. Η Βιβλιογραφία φέτος -αν και εξακολουθεί να είναι χωρισμένη σε δύο ενότητες, όπως ακριβώς παρουσιάζεται τα τελευταία χρόνια-, έχει τις αναφορές μαζί με τις περιλήψεις τους. Η πρώτη Ενότητα περιλαμβάνει την ελληνική και ξενόγλωσση βιβλιογραφία για το αλκοόλ και η δεύτερη την ελληνική και ξενόγλωσση βιβλιογραφία για τα ναρκωτικά. Η παρούσα έκδοση είναι μόνη ηλεκτρονική και προσβάσιμη μέσω της ιστοσελίδας του ΕΚΤΕΠΝ www.ektepn.gr. Ευχαριστούμε το δίκτυο των συνεργατών μας για την ανταπόκρισή τους στο αίτημά μας για αποστολή των εργασιών τους. Πετρούλα Πρασσά Τομέας Τεκμηρίωσης & Εκδόσεων ΕΚΤΕΠΝ 4

Ενότητες Βιβλιογραφίας Ενότητα Πρώτη: Α Λ Κ Ο Ο Λ Ενότητα Δεύτερη: Ν Α Ρ Κ Ω Τ Ι Κ Α 5

Θεματικές: 1. Επιδημιολογία 2. Εργαλεία Διαγνωστικά κριτήρια 3. Θεραπεία 4. Θεωρία 5. Μελέτες Παράγοντες Χρήσης 6. Μολυσματικές και άλλες ασθένειες 7. Ποινική Δικαιοσύνη 8. Πρόληψη 9. Στρατηγική Πολιτική και Νομοθεσία 10. Συννοσηρότητα 11. Φαρμακοφυσιολογία Βιολογία 12. Ψυχοκοινωνικές Προεκτάσεις 6

Πρόσφατη Έκδοση: ΕΠΙΨΥ (2015) Ετήσια Έκθεση του ΕΚΤΕΠΝ για την Κατάσταση του Προβλήματος των Ναρκωτικών και των Οινοπνευματωδών στην Ελλάδα 2014. Εθνικό Κέντρο Τεκμηρίωσης και Πληροφόρησης για τα Ναρκωτικά. Το ΕΚΤΕΠΝ καταθέτει στο Ευρωπαϊκό Κέντρο Παρακολούθησης Ναρκωτικών και Τοξικομανίας (EMCDDA), σε ετήσια βάση, (σύμφωνα με τις συμβατικές υποχρεώσεις του προς αυτό), Έκθεση στην αγγλική γλώσσα, για την Κατάσταση του Προβλήματος των Ναρκωτικών στην Ελλάδα. Οι αγγλικές εκθέσεις είναι διαθέσιμες από το ΕΚΤΕΠΝ σε CD. Επισκεφτείτε την Ιστοσελίδα του ΕΚΤΕΠΝ: www.ektepn.gr 7

Θα θέλαμε να ευχαριστήσουμε όλο το δίκτυο των συνεργατών μας για την συνεισφορά τους. 8

Ενότητα Πρώτη Αλκοόλ 9

Ξενόγλωσση Βιβλιογραφία 1 Christoforou, Z., Karlaftis, M., Yannis, G. (2013). "Reaction times of young alcoholimpaired drivers." Accid Anal Prev in press. Young individuals who drive under the influence of alcohol have a higher relative risk of crash involvement. As such, the literature has extensively investigated the factors affecting such involvement through both post-accident surveys and simulator experiments. The effects of differentiated breath alcohol concentrations on young driver behavior, however, have been largely unaddressed, mainly as a result of the difficulty in collecting the necessary data. We explore young driver behavior under the influence of alcohol using a driving simulator experiment where 49 participants were subjected to a common predefined dose of alcohol consumption. Comparing reaction times before and after consumption, allows for interesting insights and suggestions regarding policy interventions. As expected, the results indicate that increased reaction times before consuming alcohol strongly affect post-consumption reaction times, while increased BrAC levels prolong reaction times. A 10% increase in BrAC levels results in a 2% increase in reaction time. Interestingly, individuals with faster alcohol absorption times perform better regardless of absolute BrAC level, while recent meals lead to higher reaction times and regular exercising to lower. 2 Kuntsche, E., Rossow, I., Simons-Morton, B., Bogt, T. T., Kokkevi, A., Godeau, E. (2013). "Not early drinking but early drunkenness is a risk factor for problem behaviors among adolescents from 38 European and North American countries." Alcohol Clin Exp Res 37(2): 308-314. Background: Many studies have reported that the earlier the age at first drink (AFDrink) the higher the later drinking levels and related problems. However, unless adolescents proceed into drunkenness, it is unclear why consuming small quantities at early age should lead to later problems. This study investigates the link between AFDrink and problem behaviors (smoking, cannabis use, injuries, fights, and low academic performance) among 15-year-olds who did and did not proceed into drunkenness. Among those with drunkenness experience, we tested whether AFDrink predicted problem behaviors over and above the age at first drunkenness (AFDrunk). Methods: Multilevel structural equation models were estimated based on a sample of 44,801 alcohol-experienced 15- year-olds from 38 North American and European countries and regions who participated in the Health Behaviour in School-aged Children cross-national survey. Results: Overall, there was a significant association between AFDrink and all 5 problem behaviors. However, this was the case only among those with drunkenness experiences but not among those never drunk. Among the former, AFDrunk was a strong predictor for all 5 problem behaviors, but time from first drink to first drunk did not predict problem behaviors. Conclusions: Not early alcohol initiation but early drunkenness was a risk factor for various adolescent problem behaviors at the age of 15, that is, there was not consistent relationship for the time before the first drunkenness (i.e., since first drinking). Besides targeting early drinking, particular efforts are needed to impede early drunkenness to prevent associated harm in adolescence and beyond. 3 Nezi, V., Deutsch, M., Gazouli, M., Alexopoulou, A., Paparrigopoulos, T., Liappas, I. A., Dourakis, S. P. (2013). "Polymorphisms of the CD14 genes are associated with susceptibility to alcoholic liver disease in greek patients." Alcohol Clin Exp Res 37(2): 244-251. Background: The incidence and severity of alcoholic liver disease (ALD) in chronic drinkers has been found to correlate with some environmental factors and especially with the dose of alcohol consumption, but it is obvious that other parameters clearly contribute to individual alcohol susceptibility. Chronic ethanol exposure leads to continuous endotoxin-mediated Toll-like receptor-4 (TLR-4) and CD14 activation and subsequent cytokine release resulting in chronic inflammation with continued hepatocellular damage. Therefore, genetic studies of polymorphism in TLR-4 and CD14 genes seem to be appropriate in determining genetic susceptibility to ALD. Our aim is to evaluate in a series of Greek drinkers, the possible association of polymorphisms in the TLR-4 and CD14 genes with ALD. Methods: In 96 patients with ALD polymorphism of TLR-4 and CD14 genes were studied compared with 104 patients with cirrhosis of other etiology, 100 healthy subjects, and 50 patients 10

with a history of alcohol abuse but without liver disease. Results: No association between ALD and the presence of the Asp299Gly and Thr399Ile polymorphisms in the TLR-4 gene could be documented in our patients. Regarding the CD14-159 (C/T) genotypes, TT genotype and T allele were found to be overrepresented in alcoholic patients compared with patients with nonalcoholinduced liver disease and healthy controls. On the other side, when compared patients with ALD and patients with alcohol abuse and no liver disease, TT genotype was found to be significantly less frequent. There is no statistically significant association with the presence of the T allele and the severity of ALD, suggesting that CD14 polymorphism does not influence disease severity in advanced stages of the disease. Conclusions: In our series in Greek patients with alcohol abuse and alcoholic cirrhosis, a significant negative association with the CD14 endotoxin receptor gene polymorphism (TT genotype) but not with the TLR-4 gene polymorphism was documented. 4 Nikolaou, K., Field, M., Duka, T. (2013). "Alcohol-related cues reduce cognitive control in social drinkers." Behav Pharmacol 24(1): 29-36. Alcohol-related stimuli attract social drinkers' attention (attentional bias). We devised a dual task to test whether attentional biases to alcohol-related stimuli are modulated by cognitive control mechanisms. Sixteen nondependent healthy social drinkers were required to respond to the direction of a central arrow (target) and to ignore adjacent congruent (low cognitive load) or incongruent (high cognitive load) distracting arrows (flankers) in the presence of alcohol-related, neutral or plain grey backgrounds. Percentages of correct responses to the target and reaction time of correct responses (latency) were recorded. The difference score of the flanker effect (latency incongruent-latency congruent) between trials when backgrounds were alcohol-related relative to when they were neutral was also computed. Latencies increased in the presence of the alcohol-related images relative to both the neutral and the grey displays, but only under high cognitive load. Response accuracy did not show this significant difference. The flanker effect difference score correlated positively with the participants' average weekly alcohol intake. The data suggest that the presence of alcoholassociated stimuli attenuates cognitive control processes in social drinkers, an effect that was associated with the participants' average weekly alcohol intake. 5 Politis, I., Basbas, S., Papaioannou, P. (2013). "Exploring the effects of attitudinal and perception characteristics on drinking and driving non-compliant behaviour." Accid Anal Prev In press. The objective of this paper is to examine a number of factors (observed and latent) that might have a causal effect on drinking and driving (D & D) behaviour. Face-to-face surveys were conducted among patrons at bars and cafeterias and 305 valid questionnaires were filled. A confirmatory factor analysis was performed so as to identify the latent constructs and a mixed structural equation model was developed. From the analysis it came up that non-compliant behaviour of D & D is limited at older ages, also associated with high levels of income and car availability. Though men are consuming more alcohol, women seem to be more prone in driving under influence (DUI) of alcohol. Furthermore, it was found that people who strongly support the examined interventions in the study (e.g. better enforcement, more traffic safety campaigns, stricter penalties), are more unlikely to drive after drinking compare to those who have some objections. Finally, it was not found any statistically significant relation between individuals' level of awareness and D & D behaviour. 11

Ενότητα Δεύτερη Ναρκωτικά 12

1. Ε Π Ι Δ Η Μ Ι Ο Λ Ο Γ Ι Α Ξενόγλωσση Βιβλιογραφία 1 Bogt, T. T., Looze, M., Molcho, M., Godeau, E., Hublet, A., Kokkevi, A., Kuntsche, E., Gabhainn, S., Franelic, I. P., Simons-Morton, B., Sznitman, S., Vieno, A., Vollebergh, W., Pickett, W. (2013). "Do societal wealth, family affluence and gender account for trends in adolescent cannabis use? A 30 country cross-national study." Addiction in press. Aims: To examine cross-national changes in frequent adolescent cannabis use (40+ times consumed over life-time at age 15) over time and relate these trends to societal wealth, family affluence and gender. Design: Data from three cycles (2002, 2006, 2010) of the Health Behaviour in School-aged Children (HBSC) Study were used for cross-sectional and trend analyses of adolescent cannabis use. Setting: Representative surveys in 30 European and North American countries. Participants: A total of 160 606 15-year-old students. Measurements: Respondents' life-time cannabis use, demographics, family affluence (FAS) and frequency of peer contacts were measured individually. Indicators of wealth (gross domestic product per capita, GDP) and perceived availability of cannabis were obtained from national public data bases. Findings: The frequency of life-time cannabis use decreased over time among adolescents in Europe and North America, particularly in western European countries and the United States (relative risk (RR)= 0.86: confidence interval (CI) 0.79-0.93). This trend was not observed consistently in rapidly developing countries in eastern, central and southern Europe. Over time (2002-10), cannabis use became: (i) less characteristic of high GDP countries in contrast to lower GDP countries (RR=0.74: CI 0.57-0.95); (ii) less characteristic of youth from high FAS families in contrast to youth from low FAS families (RR=0.83: CI 0.72-0.96); and (iii) characterized by an increasing gender gap, i.e. consumption was higher among males (RR 1.26: CI 1.04-1.53). Perceived availability of cannabis and peer contacts remained strong predictors of frequent cannabis use. Conclusions: Among 30 European and North American countries, cannabis use appears to have 'trickled down' over time, with developing countries taking on the former (heavier) use pattern of richer countries, and less affluent youth taking on the former (heavier) use pattern of more affluent youth. Cannabis use continues to be more common among adolescent males than females. 2 Frentz, D., Van DE Vijver, D., Abecasis, A., Albert, J., Hamouda, O., Jorgensen, L., Paraskevis, D. (2014). "Patterns of transmitted HIV drug resistance in Europe vary by risk group." PLoS One. 9(4): e94495. Background: In Europe, a continuous programme (SPREAD) has been in place for ten years to study transmission of drug resistant HIV. We analysed time trends of transmitted drug resistance mutations (TDRM), in relation to the risk behaviour reported. Methods: HIV-1 patients newly diagnosed in 27 countries from 2002 through 2007 were included. Inclusion was representative for risk group and geographical distribution in the participating countries in Europe. Trends over time were calculated by logistic regression. Results: From the 4317 patients included, the majority was men-having-sex-with-men- MSM (2084, 48%), followed by heterosexuals (1501, 35%) and injection drug users (IDU) (355, 8%). MSM were more often from Western Europe origin, infected with subtype B virus, and recently infected (<1 year) (p<0.001). The prevalence of TDRM was highest in MSM (prevalence of 11.1%), followed by heterosexuals (6.6%) and IDU (5.1% p<0.001). TDRM was predominantly ascribed to nucleoside reverse transciptase inhibitors (NRTI) with a prevalence of 6.6% in MSM, 3.3% in heterosexuals and 2.0% in IDU (p=0.001). A significant increase in resistance to non-nucleoside reverse transcriptase inhibitors (NNRTIs) and a decrease in resistance to protease inhibitors was observed in MSM (p=0.008 and p=0.006, respectively), but not in heterosexual patients (p=0.68 and p=0.14 respectively). Conclusions: MSM showed to have significantly higher TDRM prevalence compared to heterosexuals and IDU. The increasing NNRTI resistance in MSM is likely to negatively influence the therapy response of first line therapy, as most include NNRTI drugs. 13

3 Gigi, E., Sinakos, E., Sykja, A., Androulakis, G., Tanis, C., Stayridou, V., Tsirogianni, E., Zouridakis, K., Bellou, A., Orfanou, E., Raptopoulou-Gigi, M. (2013). "Epidemiology, clinical data and treatment of viral hepatitis in a large cohort of intravenous drug users." J Addict Med 7(1): 52-57. Objectives: The aim of this study was to evaluate retrospectively the prevalence of hepatitis B virus (HBV) and hepatitis C virus (HCV) infection, epidemiological parameters, and the clinical data from the antiviral treatment of hepatitis C in a large cohort of intravenous drug users (IDUs) followed-up from 1994 until 2008. Patients and Methods: A total of 1179 former IDUs followed up either in the liver unit or in the context of a substitution program organization were included in this study. A retrospective chart review was prepared to retrieve data on the patients' demographic characteristics, the prevalence of viral hepatitis, and information on HCV treatment. Results: The prevalence of HBsAg positive was 5%. A substantial number of patients were anti-hcv positive (847/1170, 73%), 189 were lost to follow-up, 526 (80%) were HCV RNA positive and 132 (20%) had a self-limited disease. The most prevalent genotype was 3 (59.7%). Twenty-five percent of the study population received antiviral treatment against HCV infection. Patients seen in the Liver Unit were more likely to receive antiviral treatment. The sustained virological response (SVR) was 80% with patients treated with pegylated interferon and ribavirin having a significantly higher SVR rate. Conclusions: Our results show that (a) the majority of IDUs in Greece have chronic hepatitis C and the prevalent genotype is 3, (b) patients who complete therapy have SVR rates similar to those without drug-dependence, and (c) since IDUs constitute the core of the hepatitis C epidemic and the main route of HCV transmission, efforts to treat these patients should be made. 4 Hatzakis, A., Damme, P. V., Alcorn, K., Gore, C., Benazzouz, M., Berkane, S., Buti, M., al., e. (2013). "The state of hepatitis B and C in the Mediterranean and Balkan countries: Report from a summit conference." Journal of Viral Hepatitis 20(s2): 1-20. The burden of disease due to chronic viral hepatitis constitutes a global threat. In many Balkan and Mediterranean countries, the disease burden due to viral hepatitis remains largely unrecognized, including in high-risk groups and migrants, because of a lack of reliable epidemiological data, suggesting the need for better and targeted surveillance for public health gains. In many countries, the burden of chronic liver disease due to hepatitis B and C is increasing due to ageing of unvaccinated populations and migration, and a probable increase in drug injecting. Targeted vaccination strategies for hepatitis B virus (HBV) among risk groups and harm reduction interventions at adequate scale and coverage for injecting drug users are needed. Transmission of HBV and hepatitis C virus (HCV) in healthcare settings and a higher prevalence of HBV and HCV among recipients of blood and blood products in the Balkan and North African countries highlight the need to implement and monitor universal precautions in these settings and use voluntary, nonremunerated, repeat donors. Progress in drug discovery has improved outcomes of treatment for both HBV and HCV, although access is limited by the high costs of these drugs and resources available for health care. Egypt, with a highest burden of hepatitis C in the world, provides treatment through its National Control Strategy. Addressing the burden of viral hepatitis in the Balkan and Mediterranean regions will require national commitments in the form of strategic plans, financial and human resources, normative guidance and technical support from regional agencies and research. 5 Linardakis, M., Smpokos, E., Papadaki, A., Komninos, I., Tzanakis, N., E., Philalithis, A. (2013). "Prevalence of multiple behavioral risk factors for chronic diseases in adults aged 50+, from eleven European countries - the SHARE study (2004)." Prev Med 57(3): 168-172. Objective: To estimate the prevalence and the associations between multiple behavioral risk factors (MBRFs) for chronic diseases in European adults. Method: Data from 26,743 individuals, aged 50+ years, participating in the Survey of Health, Ageing and Retirement in Europe (SHARE) (2004/05) were used. MBRFs included physical inactivity, high body weight, smoking habits and risky alcohol consumption. Estimations were based on weights according to the complex sampling design. Results: In total, 71.2% of individuals were physically inactive, while 59.8% had high body weight. 53.4% had 2+MBRFs, while males presented higher prevalence of MBRF clusters than females (P<0.001). Females displayed lower odds of increased alcohol consumption (OR=0.16, P<0.001) 14

and higher odds of physical inactivity (OR=1.47, P<0.001) than males. Individuals who lived alone, compared to living with a partner and those with more, compared to fewer education years, exhibited a significantly higher and lower, respectively, mean MBRF score (P<0.001). Conclusion: The prevalence of MBRFs was considerably high in this sample of European adults, while not living alone and having higher education may prove protective. These findings could be used for the design of primary healthcare programs by health professionals. 6 Malliori, M., Golna, C., Souliotis, K., Hatzakis, A. (2013). "Managing opioid dependence treatment and controlling for HIV incidence among injecting drug users in Greece: a case study of optimism in the face of adversity." Addiction 108(6): 1174-1175. 7 Metallidis, S., Tsachouridou, O., Skoura, L., Zebekakis, P., Chrysanthidis, T., Pilalas, D., Bakaimi, I., Kollaras, P., Germanidis, G., Tsiara, A., Galanos, A., Malisiovas, N., Nikolaidis, P. (2013). "Older HIV-infected patients. An underestimated population in northern Greece: Epidemiology, risk of disease progression and death." Int J Infect Dis 17(10): 883-891. Objectives: HIV prevalence among older people is on the increase. The aim of this study was to evaluate the epidemiological and clinical features at diagnosis and survival of older patients. Methods: This was a retrospective analysis of the data of 558 newly diagnosed antiretroviral-naïve patients between January 1998 and December 2008. Patients were divided into two groups according to their age at diagnosis: 50 years (n=103) and 18-49 years (n=455). Results: The most common risk factor for older patients was heterosexual contact (p<0.013). Older patients were more likely to suffer from hypertension (33.0% vs. 5.1%, p<0.0005), cardiovascular disease (20.4% vs. 2.9%, p<0.0005), neurological disorders (11.7% vs. 5.5%, p=0.02), renal dysfunction (12.6% vs. 5.3%, p=0.01), and infections (66.0% vs. 49.7%, p=0.003) than their younger counterparts, and to have more hospital admissions during follow-up (47.5% vs. 19.6%, p<0.0005). Older patients had a shorter survival time (p<0.0005). A statistically significant increase in CD4+ cell number through time was observed in both groups (p<0.0005). Younger patients reached higher magnitudes of absolute numbers of CD4+ cells during follow-up (p<0.0005) after the initiation of antiretroviral therapy. The total number of patients with clinical AIDS from baseline throughout the study period was also higher in the older age group (35.9% vs. 25.0%). Conclusions: HIV-infected people aged 50 years differ in epidemiological and clinical features to younger HIV-infected people. The issue of increasing prevalence of HIV infection is a matter of concern due to existing comorbidities, which probably lead to higher mortality rates and faster progression to clinical AIDS. 8 Nerantzis, C., Couvaris, C., Pastromas, S., Marianou, S., Boghiokas, I., Koutsaftis, F. (2013). "Histological findings of the atrioventricular conductive system in street heroin addicts, victims of sudden unexpected death." Journal of Forensic Sciences 58(s1): 99-104. A study of the atrioventricular (AV) conducting tissue was considered necessary for the examination of probable histologic changes that could justify the arrhythmias observed in street-heroin addicts. Postmortem coronary angiography and microscopic examination were performed in 50 heroin addicts (group A) and in 50 nonaddicts (group B), all male 16-40 years old. In group A, fatty and/or fibrous tissue replaced the AV node in 50% of cases while in group B in 14%. The main bundle was replaced by fatty and/or fibrous tissue in 44% in group A cases and 10% in group B. Intimal proliferation and fibromuscular dysplasia of the AV arteries in group A were correspondingly 26% and 14% and in group B 6% and 2%. Inflammation with focal and/or diffuse concentration of round cells of the AV node was detected in 54% in group A. These findings could explain a possible arrhythmia mechanism in this population. 9 Nikolopoulos, G., Tsiodras, S., Botsi, C., Malliori, M., Kremastinou, T. (2014). "HIV surveillance and injecting drug users in Greece." The Lancet 383(9918): 693-694. 10 Sarafis, P., Igoumenidis, M., Tsounis, A. (2013). "Exposure of HIV-positive sex workers in Greece." The Lancet 13(8): 649-650. 15

In May 2012, on the Attorney General's order, the police publicised photos and identity details of 18 women working illegaly as sex workers in Athens, Greece, who had been arrested and found to be HIV positive. The rationale for this decision was presumably protection of the public people who had had sexual intercourse with these sex workers might recognise them and seek medical advice and HIV testing, whereas people who pay for sex could avoid contact with these particular workers. Five of the sex workers were prosecuted for intentional grievous harm-ie, transmission of the HIV. The case draw media attention and sparked controversy for a brief period, but was forgotten amid pressing problems related to the economic crisis. On March 11, 2013, the five women were acquitted, but this news did not make headlines. Some important ethical issues were raised, which need to be adequately addressed both in Greece and internationally. Sex work in Greece is legal and regulated. Sex workers must register at their local prefecture and carry a medical card that is updated every 2 weeks. However, fewer than 1.000 women are estimated to be legally employed as sex workers, whereas roughly 20.000 women, mostly of foreign origin, are thought to be engaged in illegal sex work. Greece is not unique in this regard-by and large, the sex industry evades control worldwide. Notwithstanding the diversity of sex work settings and its many problematic aspects, such as human trafficking, sex workers' health has gained the attention of policy makers, which is shown by a growing body of published guidelines and strategies. Is the aim of these strategies to protect sex workers or to protect public health via protection of sex workers? If the outcome is the same either way, does the intent make a difference? The Greek authorities' handling of the 18 HIVpositive sex workers shows an obvious difference between the two aims. Researchers from other countries have already pointed out that public health officials are concerned less about the health of sex workers than about that of the sex workers' clients or the larger community. The public health response to sex workers is often one sided. In breach of key principles set by WHO, the rights of the 18 sex workers to privacy, confidentiality and anonymity were not respected, and no effort was made to target sex work as a whole-eg, clients, third parties, rather than sex workers only. With regard to criminal transmission of HIV, UN guidelines stat that people living with HIV/AIDS should be authorised to demand that their identity and privacy be protected in legal proceedings in which information about these matters will be raised. Exposure and criminalisation further marginalise vulnerable groups, such as illegal sex workers, without addressing the real problem-ie, protection of public health. People who pay for sex, should take appropriate caution without waiting for the state to inform them about the HIV status of specific sex workers. Furthermore, as UNAIDS officials have pointed out, prosecution of sex workers for intentional grievous harm raises many objections about inappropriate application of criminal law, especially when people who pay for sex have the social and economic power to insist upon condom use. A consistent policy of promotion of health care and prevention strategies for sex workers (in agreement with WHO and UN guidelines) and targeting of the sex industry as a whole is needed. The Greek authorities' negative treatment of HIV-positive sex workers can serve only as a bad example. 11 Sarafis, P., Tsounis, A. (2014). "Debt burden of Greece and HIV among injecting drug users." The Lancet 14(3): 180-181. 12 Skapinakis, P., Bellos, S., Koupidis, S., Grammatikopoulos, I., Theodorakis, P., Mavreas, V. (2013). "Prevalence and sociodemographic associations of common mental disorders in a nationally representative sample of the general population of Greece." BMC Psychiatry 13: 163. Background: No study in Greece has assessed so far the full range of common mental disorders using a representative sample of the population from both mainland and insular regions of the country. The aim of the present paper was to present the results of the first such study. Methods: The study was carried out between 2009-2010 in a nationally representative sample of 4894 individuals living in private households in Greece. Common mental disorders in the past week were assessed with the revised Clinical Interview Schedule (CIS-R). We also assessed alcohol use disorders (using AUDIT), smoking and cannabis use. Results: 14% of the population (Male: 11%, Female: 17%) was found to have clinically significant psychiatric morbidity according to the scores on the CIS-R. The prevalence (past seven days) of specific common mental disorders was as follows: Generalized Anxiety Disorder: 4.10% (95% CI: 3.54, 4.65); Depression: 2.90% (2.43, 3.37); Panic Disorder: 1.88% (1.50, 2.26); Obsessive-Compulsive Disorder: 1.69% (1.33, 2.05); All Phobias: 2.79% (2.33, 3.26); Mixed anxiety-depression: 2.67% (2.22, 3.12). Harmful alcohol use was reported by 12.69% of the population (11.75, 13.62). Regular smoking was reported by 39.60% of 16