丁丙诺啡辅助美沙酮维持治疗疗效观察

目的：探讨丁丙诺啡辅助美沙酮维持治疗效果。方法：对云南省曲靖市麒麟区美沙酮维持治疗的患者因客观原因不能进行美沙酮治疗给予丁丙诺啡替代治疗情况进行分析。结果：治疗组比对照组分别高22．5％和19．16％,降低脱失,脱失率低15％,能杜绝使用其他非法药（毒）品。结论：在维持患者因客观原因不能服用美沙酮时,丁丙诺啡辅助治疗能显著提高患者的依从性、提高尿吗啡阴性率。     

Cost-utility analysis of methadone maintenance treatment: a methodological approach

Economic considerations influence the substance user treatment system. These considerations influence who gets treatment and for how long, as well as determining what services they receive and in what setting. Current medical literature argues that maintenance treatment reduces risk-taking behavior, such as injection drug use and needle sharing. Treatment also reduces the mortality associated with abuse of opiates by injection and can cause decreases in costs incurred by the criminal justice system and social services agencies. This suggests the need for complex economic evaluations of a maintenance treatment to find out the optimum treatment program. This paper describes methods of economic evaluation in health care and reviews the methodology of cost-utility analysis in economic evaluations of methadone maintenance treatment.     

Therapeutic drug monitoring in methadone maintenance: choosing a matrix

Methadone maintenance is the premier pharmacological treatment for opioid addiction, but it is rarely informed by evidence-based practice guidelines for dosage monitoring and adjustment. Such guidelines are crucial because the pharmacokinetics of methadone vary greatly among patients, and this variation may account for differences in treatment outcome. We review the pharmacokinetics of methadone and factors that may alter it (including drug interactions, disease states, and idiosyncratic differences among patients). Also reviewed are prospects for therapeutic drug monitoring (TDM) of methadone in plasma, urine, sweat, and saliva. Due to its ease of collection and its presumed representation of the bioavailable free-fraction of methadone, saliva may be a promising matrix. However, saliva methadone concentrations are influenced by salivary pH, and future studies are needed to determine how to control for that. Administrative, medical, and social implications of methadone TDM are briefly discussed.     

Patients in methadone maintenance treatment who inject methadone syrup: a preliminary study

An increased awareness of the injection of methadone syrup has been appreciated by methadone treatment clinicians and Needle Exchange outlets which distribute large-volume syringes. This study aimed to identify patterns of use by methadone injectors, and the reasons and perceived risks of this behaviour. Nineteen of 36 attendees at a needle exchange who stated they had injected methadone over the previous 3 months completed a structured interview. Results found a majority were methadone clinic patients. Forty-two percent injected three times a week or more. This practice continued in 58%, despite reported difficult venous access. Subjects' concerns included accelerating vein damage and possible toxicity of syrup additives. Reasons for injecting included immediate drug effect (80%) and 'needle-fixation' (47%). It is concluded that methadone clinic staff need to be aware of such patients who may require additional treatment approaches, and that methadone formulations should minimize harmful consequences if injected. [Robinson GM, Kemp R, Lee C, Cranston D. Patients in methadone maintenance treatment who inject methadone syrup: a preliminary study. Drug Alcohol Rev 2000;19:447-450]     

Buprenorphine versus methadone maintenance: a cost-effectiveness analysis

This article presents the cost-effectiveness results of a randomised controlled trial conducted in two Australian cities. The trial was designed to assess the safety, efficacy and cost-effectiveness of buprenorphine versus methadone in the management of opioid dependence. The trial utilised a flexible dosing regime that was tailored to the clinical need of the patients, with high maximum doses, using the marketed formulation, under double-blind conditions. A total of 405 subjects were randomised to a treatment at one of three specialist outpatient drug treatment centres in Adelaide and Sydney, Australia. The perspective of the cost-effectiveness analysis was that of the service provider and included costs relevant to the provision of treatment. The primary outcome measure used in the economic analysis was change in heroin-free days from baseline to the sixth month of treatment. Treatment with methadone was found to be both less expensive and more effective than treatment with buprenorphine, which suggests methadone dominates buprenorphine. However, statistical testing found that the observed difference between the cost-effectiveness of methadone and buprenorphine treatments was not statistically significant. The results of this study provide useful policy information on the costs and outcomes associated with the use of methadone and buprenorphine and indicate that buprenorphine provides a viable alternative to methadone in the treatment of opioid dependence.     

A risk-benefit analysis of methadone maintenance treatment.

Methadone maintenance treatment for heroin (diamorphine) addiction has been extensively researched. There is consistent evidence that while in treatment, heroin addicts are at a lower risk of death, are less involved in crime, and feel and function better than while using heroin. Despite the research evidence supporting methadone treatment, there remains widespread public scepticism about this form of treatment. This scepticism is frequently expressed in terms of the perceived risks of methadone treatment. The perceived risk that methadone treatment may maintain people in an addicted lifestyle is not supported by research literature. The risks of treatment include an increased risk of death during induction into treatment, and risks of diversion of drugs to the black market. For some patients, adverse effects of methadone pose a problem and the availability of new pharmacotherapies may provide useful options for these patients. Risks can be reduced and benefits increased by directing greater attention to the quality of treatment.     

Screening for major depression among alcoholics: an application of receiver operating characteristic analysis

When comparing several screening tests designed to detect the same disease, methodological problems arise in determining which is most accurate. We have previously demonstrated that receiver operating characteristic (ROC) methodology can provide a set of statistical procedures which allow for objective comparisons of screening tests. In this report, ROC methodology is brought to a different substantive area: the detection of clinical depression among treated alcoholics. In a sample of hospitalized alcoholics, we compared the accuracies of several commonly used screening tests for depressive disorders, as well as comparing each of these with a screening test for anxiety disorders. No test offered a statistically significant advantage over any other, and all did poorly in detecting clinically diagnosed major depression. The performance of the screening tests was worst when the non-depressed comparison group included subjects with remitted disorder, but was still poor when the comparison group did not include such potentially 'noisy' subjects. Factors contributing to the difficulty of screening for clinical depression are discussed, as well as suggestions for improvements in future screening efforts.     

Contingency management in a methadone maintenance treatment program

A contingency management program was developed for in-patients induced on methadone in a methadone maintenance treatment program. Before the behavioural program started, data were collected during a 4 week base-line period. After the program had been running for one week there was an “accidental reversal” during 3 weeks, and then a 12 weeks period with the program. During the program points were given contingent on target behaviours. The points gave access to privileges such as leave, passes and visitors. The target behaviours increased in frequency during the program, decreased during the “accidental reversal” and increased again when the program was reinstated.     

Screening for current drug use disorders in alcoholics: an application of receiver operating characteristic analysis

The major objectives of the present study were 2-fold: (1) to demonstrate the superiority of receiver operating characteristic (ROC) methodology in the comparison of screening tests that yield continuous values; and (2) to identify the best screening indicator of current drug use disorders in alcoholics. We evaluated the ability of the screening tests to detect drug use disorder (DUD) according to the research diagnostic criteria. Results showed that the language of addiction - drug version and the reasons for drug use (RDU) screening tests offered excellent detectability for current DUD. The accuracy of both tests was reduced as the result of broadening the clinical spectrum in the comparative group. Implications of these findings to the neglected topic of clinical and co-morbid spectrums in screening test evaluation is presented. Issues surrounding the use of psychiatric diagnoses as standards, assessment of efficacy, the role of screening in defining subthreshold disorder, and the use of biochemical screening as an adjunct to the questionnaire approach are also discussed.     

Pharmacokinetics of methadone in methadone maintenance treatment: Characterization of therapeutic failures

Deuterated methadone (M-d3) and GC-MS analysis were used to study the steady state pharmacokinetics of methadone (M) in eight patients reported as therapeutic failures in a methadone maintenance treatment programme. The patients were compared to an unselected group of 12 patients stabilized on M for 25 days. During one dosage interval a pulse dose of M-d3 was administered intravenously instead of the oral M-dose (M-d0). The pharmacokinetic parameters, half-life in the beta-phase (t1/2 beta), volume of distribution during the postdistributive phase (Vd beta) and during steady state (Vdss) were determined as well as the body (ClS) and renal (ClR) clearances of M. Pronounced differences in Vd beta and Vdss were found between the two groups. The therapeutic failures had a smaller Vd beta and Vdss 3.09 +/- 0.96 1/kg and 2.74 +/- 0.96 1/kg vs 4.56 +/- 1.00 1/kg and 4.20 +/- 0.78 1/kg in the control group. The differences were due to changes between the groups in the volume of the central compartment. Differences between the groups were also found in t1/2 beta - 24.5 +/- 2.6 h in the therapeutic failures and 34.0 +/- 7.0 h (p less than 0.001) in the comparison group. However, the change in t1/2 beta was probably a consequence of the change in Vd beta, as the body clearance of M was similar in the two groups - 104 +/- 36 ml/min vs 111 +/- 36 ml/min. The smaller volume of distribution could lead to unacceptably high fluctuation of M in the central compartment, and withdrawal symptoms during the latter part of the dosage interval.(ABSTRACT TRUNCATED AT 250 WORDS)     

Nicotine maintenance for smokers in methadone treatment: a new direction

Patients of methadone maintenance treatment (MMT) exhibit an exceedingly high prevalence of tobacco use and disproportionately suffer from tobacco-related illnesses and mortality. A number of studies have sought to target MMT smokers with cessation interventions utilizing a variety of behavioral and pharmacological treatments. Such efforts have struggled to attain even modest rates of cessation at follow-up, suggesting a need for novel approaches. In an effort to accelerate this area of research, the current article proposes an alternative paradigm for MMT smokers: Nicotine Maintenance. The proposed model emphasizes five domains aimed at advancing the contextual fit between smoking cessation treatment and MMT: (1) A harm reduction and maintenance orientation; (2) a reconsideration of abstinence-oriented frameworks and techniques; (3) a longer-term perspective; (4) greater integration with the MMT treatment milieu; and (5) approaches that address the unique needs of MMT patients including shame, stigma, and the enhancement of treatment autonomy.     

Knowledge and stigma regarding methadone maintenance treatment among personnel of methadone maintenance treatment and non-methadone maintenance treatment addiction facilities in Israel

Stigma attached to methadone maintenance treatment is very common. The objective of the current article is to evaluate the presence of stigma and its relation to the extent of knowledge about methadone maintenance treatment. The authors conducted a survey among methadone maintenance treatment and non-methadone maintenance treatment addiction therapists from different treatment centers in Israel, including methadone maintenance treatment clinics (Ministry of Health) and non-methadone maintenance treatment addiction facilities (Ministry of Social Services), using an anonymous questionnaire about methadone maintenance treatment stigma and knowledge. There were 63 therapists from methadone maintenance treatment clinics (63%) and 46 therapists from the social services department (SSD) non-methadone maintenance treatment addiction facilities (9.2%) who responded. Methadone maintenance treatment versus social services department personnel were older (42.7 ± 12.8 versus 37.5 ± 8.2 years; p = 0.03), with fewer females (48 versus 75%; p = 0.006), and 50% were social workers compared to 100% social workers in the SSD group (p < 0.0005). Stigma score was lower among methadone maintenance treatment personnel compared to the social services department personnel (3 ± 2.5 versus 5.0 ± 3.5; p = 0.0001), while the knowledge score about methadone maintenance treatment was higher among the methadone maintenance treatment personnel (10.3 ± 2.9 versus 7.7 ± 2.8; p < 0.0005). The difference in both the stigma and knowledge scores remained significant after controlling for age, gender, and profession. There was a negative correlation between the stigma and knowledge scores among both the methadone maintenance treatment (R = –0.5, p < 0.0005) and the social services department personnel (R = –0.33, p = 0.03). These results revealed a significant correlation between the presence of stigma and the extent of education and knowledge about methadone maintenance treatment, with ignorance and stigma against methadone maintenance treatment being more pronounced among social services department personnel. An educational intervention, especially among social services department personnel, may benefit people who use opioids and improve the overall quality of treatment for opioid addiction in Israel.     

Treatment failure and methadone dose in a public methadone maintenance treatment programme in Geneva

The aim of this study was to identify predictors of treatment failure in a methadone maintenance treatment programme in Geneva. All patients (n=149) starting treatment between May 1993 and May 1995 were followed until end of treatment or 31st July 1996. The proportion of depressed patients decreased significantly over time, as did the proportion of those injecting illegal drugs. The overall treatment failure was 21%. The probability of treatment failure was higher for women than for men (RR 2.2, P=0.03) and decreased in successive cohorts. There was no correlation between the methadone dose at 2 months and treatment outcome, probably because doses were individualised and the associated level of psycho-social services high.     

Optimizing long-term response to methadone maintenance treatment: a 152-week follow-up using higher-dose methadone

We report the clinical course over 152 weeks of 245 patients in methadone maintenance treatment: 144 high dose (HD) patients (> or = 100 mg/d, mean 211 mg/d), and 101 control (C) patients (< 100 mg/d, mean 65 mg/d). After 152 weeks the mean methadone doses were 284.9 mg/d (range 13-1100 mg/d) and 94.0 mg/d (range 10-500 mg/d), respectively. Overall retention in treatment was 59% over the 152 weeks, with the HD group having significantly better retention (61.1% vs. 46.3%) and lower rates of positive urine toxicologies (16.0% vs. 36.6%). Mortality was statistically the same for the HD group (2/144, 1.4%) and the C group (2/101, 1.9%) over the 152-week period. We conclude that doses of methadone exceeding 100 mg/d are safe and effective in long-term maintenance treatment. We attribute the favorable outcomes we report to a model of treatment that emphasizes medication management in the treatment of opioid addiction.     

Counseling issues in methadone maintenance treatment.

This article reviews some of the issues and dilemmas faced by methadone maintenance treatment (MMT) programs counselors. The context in which MMT occurs sets the tone and constraints within which clinicians must find ways to be effective; negative attitudes and tensions with regulatory agencies have a strong impact. Coexisting disorders, particularly depression and thought disorders, are discussed and special medication considerations are noted. Counselor collaboration on medical issues, and dosing policies and practices are explored, as well as the clinical approach to tapering off methadone. The article examines helpful clinical strategies when clients continue to use heroin or other drugs, and explores psychological issues that frequently occur, women's issues, and problems that may arise when patients have human immunodeficiency virus-spectrum disease. It also reconsiders the role of family therapy. Several innovative and promising psychoeducational approaches are described and the potential integration of MMT with 12-Step programs is addressed. Recommendations are offered for training and supervision.     

权变管理理论在美沙酮维持治疗中的应用

<正>权变管理理论(contingency management theory)是20世纪60年代末70年代初在美国经验主义学派基础上发展起来的管理理论。权变理论认为,在组织管理中要根据组织所处的环境和内部条件的发展变化随机应变,没有什么一成不变的、普遍适用的、最好的管理理论和方法。     

Development of a brief treatment instrument for routine clinical use with methadone maintenance treatment clients: the methadone treatment index

Routine measurement of treatment outcome between clinician and client in alcohol and drug user treatment services is an important quality improvement initiative. It is particularly important for clients receiving long-term treatment such as methadone maintenance treatment, as fluctuations in substance use, functioning, and health are to be expected. Although there are a number of standardized alcohol and drug user treatment outcome instruments available for research and clinical use, a key challenge is to develop clinical instruments that will actually be used routinely in busy practice settings by a range of staff. Such instruments need to be brief, acceptable to staff and clients, easy to use, provide immediate feedback, and meet adequate psychometric requirements. This report describes development work undertaken in three studies of the Methadone Treatment Index (MTI). The MTI is a brief instrument comprising measures of recent substance use, aspects of social and behavioral functioning, and physical and psychological health. The MTI was designed in consultation with clinicians and clients for use in monitoring treatment progress with clients receiving methadone maintenance treatment. Key findings were that the MTI was acceptable to clients, produced clinically relevant information, and has satisfactory psychometric properties, although it was not used to measure change in this study. Further evaluation of the MTI on a longitudinal basis is supported.     

Urine testing in methadone maintenance treatment: applications and limitations

We consider here the applications and limitations of urine testing schedules used in methadone maintenance treatment programs. We show that for patients attending clinic daily, any practical testing schedule will only reliably detect those who are using heroin or other illicit drugs very frequently (e.g., daily). For patients with take-home privileges no testing schedule can effectively detect either skipped doses or use of illicit drugs. Consequently, whether for patients attending clinic daily or for patients with take-home privileges, some programs, as measured by urine test results, may actually be less successful than they appear to be.     

The effectiveness of methadone maintenance treatment: an overview

This paper reviews the evidence for the effectiveness of methadone maintenance as used in the treatment of opioid dependence. Findings from randomized controlled trials and observational studies suggest that methadone maintenance reduces heroin use, crime, injection-related risk behaviours and premature mortality among people dependent on opioids. The research further suggests that two aspects of treatment are important in ensuring this effectiveness. Methadone treatment is more effective when higher doses (>50 mg) are employed and, overall, the evidence suggests that a treatment goal of successful maintenance on methadone rather than total abstinence is appropriate. The importance of ancillary services in treatment outcome is less clear and is the subject of current research and debate.