德国的阿片类依赖替代治疗(英文)

经过漫长而激烈的争论,德国于1987年首次引进了美沙酮维持治疗。最初,由于入治标准严格,接受治疗的人数很少,但自1990年后接受治疗的人数迅速上升,到2005年底已有61 000人。在德国每位全科医生只要完成了成瘾医学的培训都允许为阿片类成瘾病人开具替代治疗药物。目前德国有2700个全科医生在为阿片类药物成瘾病人开具处方。每位参加维持治疗的病人需接受社会心理治疗。研究结果和实践经验表明,病人从美沙酮维持治疗中获得了实质性的好处,他们的身心健康得到了改善。美沙酮维持治疗的留治率高(65% -85%),对HIV和肝炎的评估和坚持治疗十分重要;在促进病人回归社会方面也是极其重要的因素;在降低药物相关伤害方面如:减少共患疾病、死亡和预防感染性疾病具有重要的作用。有10%的人在长期的治疗过程中戒掉了毒品。虽然丁丙诺啡正在显示其重要性,但是美沙酮仍是主要的替代药物。在农村,参加美沙酮维持治疗仍是难题。虽然一致认为工作是治疗的正性因素,但对病人来说就业机会很少。德国监狱的替代治疗采用不同的准入和治疗模式。准入治疗不协调,参加治疗的人数很少。无论如何,在德国替代治疗在为药物使用者提供的卫生医疗系统中发挥了重要作用。     

Adherence to HIV treatment among IDUs and the role of opioid substitution treatment (OST)

In the era of highly effective anti-retroviral therapy (ART), data show a significant difference in treatment outcomes between injecting drug users (IDUs) and non-IDUs. Factors that may contribute to suboptimal treatment outcomes in IDUs include delayed access to ART, competing comorbid diseases, psychosocial barriers and poor long-term adherence to ART. This review describes and compares several studies on adherence to ART and its correlates in HIV-infected individuals in general, then IDUs and finally those IDUs on opioid substitution treatment (OST). It highlights how ongoing drug use or OST can modify the pattern of these correlates. The aim is to extend all the experience acquired from these studies in order to optimise both access to care and adherence in those countries where HIV infection is mainly driven by IDUs and where ART and OST are only starting to be scaled up. The role of OST in fostering access to care and adherence to ART together with the promising results achieved to date using modified directly observed therapy (DOT) programs for patients taking methadone, allow us to emphasize the efficacy of a comprehensive care model which integrates substance dependence treatment, psychiatric treatment, social services, and medical treatment. The review concludes by suggesting areas of future research targeted at improving the understanding of both the role of perceived toxicity and patient-provider relationship for patients on ART and OST.     

Medical service use and financial charges among opioid users at a public hospital

We examined the prevalence of drug use related infectious complications among opioid using or dependent individuals and service charges associated with medical care received over a 2-year period at a public hospital. A computerized medical record review was used to identify 3147 individuals with diagnoses related to opioid use or dependence. Forty-nine percent of these patients were treated for bacterial infections and 30% presented for treatment of medical problems arising from the effects of the drugs themselves (e.g. drug withdrawal, overdoses, and drug-induced psychiatric symptoms). Mean charges were $13393 for these patients, nearly 2.5 times the average per patient charges for non-opioid using patients during the study period. Patients with diagnoses related to opioid use or dependence comprised 2% of the total patient population for this period, yet accounted for 5% of total charges. Homeless patients were less likely to have used ambulatory services and were more likely than non-homeless patients to have used emergency and inpatient services. Early detection of patients with opioid use or dependence problems, coupled with effective strategies to engage them in ambulatory preventive services, could allow interventions to reduce morbidity and associated charges in this patient population. The findings suggest that health care providers and policy makers consider policies that promote ambulatory care use among opioid users seeking medical care through the public health care system.     

Patterns of Abstinence or Continued Drug Use Among Methadone Maintenance Patients and Their Relation to Treatment Retention

The efficacy and effectiveness of methadone maintenance treatment (MMT) in the medical management of opioid addiction has been well-established, but treatment outcomes are compromised by the continued use of licit and illicit drugs during MMT. The present study examined the relationship between in-treatment illicit drug use and retention and dropout of 604 MMT patients in Washington, D.C. Sixty-eight percent of patients did not test positive for an unprescribed drug during the study period. Of patients who tested positive for an illicit drug during the baseline period, 55% tested positive for cocaine, 44% for opiates, 23% for THC, 20% for benzodiazepines, 7% for PCP, and 4% for amphetamines. Those testing positive were three times more likely to leave treatment than those who did not test positive. Testing positive for one drug doubled the rate of attrition; testing positive for multiple drugs quadrupled the risk of attrition. Non-prescribed opioid or benzodiazepine use was a predictor of MMT dropout, but prescribed opioid or benzodiazepine use was not. Continued illicit drug use poses significant risk for subsequent premature termination of MMT. Assertive clinical management of continued illicit drug use could provide mechanisms to enhance MMT retention and long-term recovery outcomes.     

Addiction Severity Index in a chronic pain sample receiving opioid therapy

The treatment of chronic pain with opioids remains controversial. Physicians are concerned about addiction and drug diversion, and there is limited empirical information on the use of opioids in patients with chronic pain. This report presents data on the Addiction Severity Index (ASI) collected in a sample of patients (N = 908) receiving opioids from their primary care physicians. The ASI provides clinically important information about patients receiving opioid therapy. The ASI consists of seven subscales, including medical, alcohol, drug, employment/support, legal, family/social, and psychiatric domains. Clinically relevant findings include high ASI medical score (0.87), high psychiatric severity score (0.27), lifetime treatment of alcohol problems (reported by 22% of men), prior delirium tremens (5.6%), prior treatment for drug problems (10.1%), prior drug overdose (12.1%), and drunk-driving citations (28%); 40.3% of women had serious suicidal thoughts, and 23.8% had suicide attempts. The ASI provides important information that can help primary care physicians manage patients with chronic pain who are receiving opioid therapy.     

Treatment of intravenous drug users with AIDS: the role of methadone maintenance

Methadone maintenance programs are treating increasing numbers of HIV-infected IVDUs. Methadone treatment offers the opportunity to constructively intervene in the lives of these patients by helping to prevent the further spread of AIDS and by providing medical, psychiatric, and social services. The need for expanded AIDS services presents a serious challenge to methadone programs. These programs will need added resources as well as new and more flexible treatment techniques to meet this challenge.     

Characteristics of older opioid maintenance patients

The aging "baby boomer" population has higher rates of substance use than previous cohorts and is predicted to put increased demands on substance abuse treatment services; however, little is known about older illicit drug abusers. This study compared 41 older (age 50-66 years) and 26 younger (age 25-34 years) opioid maintenance patients on psychiatric, substance use, medical, general health, demographic, and psychosocial characteristics using standardized instruments. The health of both groups was compared to age and sex-matched U.S. population norms. Both groups had high rates of lifetime psychiatric and substance abuse/dependence diagnoses, and poor general health compared to population norms. The older group began using illicit substances significantly later in life, and had significantly more medical problems and worse general health than the younger group. The inevitable increasing medical morbidity and physical limitations of an increasingly large older population with substance use problems will challenge treatment providers and planners. Low rates of positive urine opioid tests occurred for both older and younger patients without age-specific services.     

Characteristics of methadone maintenance treatment patients prescribed opioid analgesics

ABSTRACT

Background: Opioid analgesic use and disorders have dramatically increased among the general American population and those receiving methadone maintenance treatment (MMT). Most research among MMT patients focuses on opioid analgesics misuse or disorders; few studies focus on MMT patients prescribed opioid analgesics. We describe demographic, clinical, and substance use characteristics of MMT patients prescribed opioid analgesics and compare them with MMT patients not prescribed opioid analgesics. Methods: We conducted a cross-sectional secondary data analysis using screening interviews from a parent study. From 2012 to 2015, we recruited adults from 3 MMT Bronx clinics. Questionnaire data included patterns of opioid analgesic use, substance use, comorbid illnesses, and demographic characteristics. Our main dependent variable was patients' report of currently taking prescribed opioid analgesics. To compare characteristics between MMT patients prescribed and not prescribed opioid analgesics, we conducted chi-square tests, t tests, and Mann-Whitney U tests. Results: Of 611 MMT patients, most reported chronic pain (62.0%), hepatitis C virus (HCV) infection (52.1%), and current use of illicit substances (64.2%). Of the 29.8% who reported currently taking prescribed opioid analgesics, most misused their opioid analgesics (57.5%). Patients prescribed (versus not prescribed) opioid analgesics were more likely to report human immunodeficiency virus (HIV) infection (adjusted odds ratio [aOR] = 1.6, 95% confidence interval [CI]: 1.1–2.3) and chronic pain (aOR = 7.6, 95% CI: 4.6–12.6). Conclusion: Among MMT patients primarily in 3 Bronx clinics, nearly one third reported taking prescribed opioid analgesics. Compared with patients not prescribed opioid analgesics, those prescribed opioid analgesics were more likely to report chronic pain and HIV infection. However, between these patients, there was no difference in illicit substance use. These findings highlight the complexity of addressing chronic pain in MMT patients.     

Management of acute pain in methadone maintenance therapy in-patients

Methadone maintained treatment (MMT) patients may be given less opioid analgesia for acute pain than the general patient, due to requests for analgesia being misinterpreted as craving for drugs. Pain studies have showed that MMT patients have hyperalgesic responses and that cross-tolerance to opioids may be present, suggesting that they may need more analgesia than the non-MMT patient. This study compares the pain management of MMT patients and controls during an acute hospital stay. It is a retrospective study of MMT in-patients and controls matched for medical condition, age and gender, comparing the analgesia given and pain stated in hospital notes. Patients with a chronic pain condition were excluded. MMT patients and controls did not differ in relation to median morphine dose received or average number of pain reports per day, and only a small proportion of both groups engaged in drug-seeking behaviour. Behavioural problems were significantly more common among MMT patients (39% versus 5%, p < 0.001). The fact that the opioid doses were not significantly different between subjects and controls seems to contradict the experimental evidence that patients on methadone tend to be hyperalgesic. Alternatively, MMT patients may be hyperalgesic, and statistically equal levels of opioid analgesia given to both groups may indicate an effective under-treatment of pain in the hyperalgesic MMT group. Inadequate analgesia may contribute to both behavioural problems and premature discharge. Resolving these uncertainties will require prospective studies.     

Opioid detoxification with buprenorphine,clonidine, or methadone in hospitalized heroin-dependent patients with HIV infection

With the growing role of intravenous drug use in the transmission of HIV infection, HIV-infected patients frequently present with comorbid opioid dependence. Yet, few empirical evaluations of the efficacy and consequences of opioid detoxification medications in medically ill HIV-infected patients have been reported. In a randomized, double-blind clinical trial, we evaluated the impact of three medications on the signs and symptoms of withdrawal and on the pain severity in heroin-dependent HIV-infected patients (N=55) hospitalized for medical reasons on an inpatient AIDS service. Patients received a 3-day pharmacologic taper with intramuscular buprenorphine (n=21), oral clonidine (n=16), or oral methadone (n=18), followed by a clonidine transdermal patch on the fourth day. Observed and self-reported measures of opioid withdrawal and pain were taken 1-3 times daily for up to 4 days. Opiate administration used as medically indicated for pain was also recorded. Observer- and subject-rated opiate withdrawal scores decreased significantly following the first dose of medication and overall during treatment. Among all 55 subjects, self-reported and observer-reported pain decreased after treatment (on average observer-rated opioid withdrawal scale (OOWS) scores declined 5.6 units and short opioid withdrawal scale (SOWS) declined 4.8 units, P<0.001, for both) with no indication of increased pain during medication taper. There were no significant differences of pain decline and other measures of withdrawal between the three treatment groups. During the intervention period, supplemental opiates were administered as medically indicated for pain to 45% of the patients; only 34% of men versus 62% of women received morphine (P<0.05). These findings suggest buprenorphine, clonidine, and methadone regimens each decrease opioid withdrawal in medically ill HIV-infected patients.     

Co-occurring psychiatric symptoms and drug dependence or heavy drinking among HIV-positive people

This study sought to establish population-based estimates of the prevalence of co-occurring psychiatric symptoms and either or both drug dependence symptoms or heavy drinking among individuals who test positive for the human immunodeficiency virus (HIV) and to identify the factors associated with such comorbidity. Data from the HIV Cost and Services Utilization Study (HCSUS), a nationally representative sample of HIV-infected adults receiving medical care in the U.S. in 1996 (N = 2,864), were used to estimate the prevalence of comorbidity. Logistic regression was used to identify the independent influences of sociodemographic and HIV-related variables on comorbidity. The authors estimate that 13% of people with HIV receiving care in the U.S. in 1996 had co-occurring psychiatric symptoms and either or both drug dependence symptoms or heavy drinking. The odds of having a comorbid condition were higher for males, heterosexuals, and people with more HIV-related symptoms. The odds were lower for people living with AIDS, African Americans, people who were gay or sexually abstinent, those living with a spouse, those aged 50 years or older, and those with private insurance. Sixty-nine percent of those with a substance-related condition also had psychiatric symptoms; 27% of those with psychiatric symptoms also had a substance-related condition.     

Predictors of methadone maintenance treatment utilization in a multisite cohort of illicit opioid users (OPICAN)

Although methadone maintenance treatment (MMT) has been a primary treatment response to illicit opioid use in Canada for decades, analytical treatment data are scarce. Using data from the multisite OPICAN cohort of illicit opioid and other drug users repeatedly assessed between 2002 (baseline) and 2005 (last follow-up [FU]), we (1) longitudinally examined characteristics associated with MMT uptake between baseline and FU and (2) cross-sectionally compared drug use patterns between cohort participants in MMT (n = 133) and those not in MMT (n = 400) at the last FU through bivariate and multivariate analyses (stepwise logistic regression). Significant baseline predictors of MMT uptake emerging in the logistic regression model included injection drug, heroin, as well as alcohol use, housing status, and Quebec City as a site. Furthermore, lower prevalence levels of opioid (e.g., morphine and OxyContin) and nonopioid (e.g., cocaine and crack) drug use as well as lower frequency of heroin use days were observed among MMT users. This study highlights potential factors relevant for improved MMT uptake and illustrates possible reductions of drug use related to MMT.     

A Randomized,Controlled Trial of the Efficacy of an Interoceptive Exposure-Based CBT for Treatment-Refractory Outpatients with Opioid Dependence

Many patients diagnosed with opioid dependence do not adequately respond to pharmacologic, psychosocial, or combination treatment, highlighting the importance of novel treatment strategies for this population. The current study examined the efficacy of a novel behavioral treatment focusing on internal cues for drug use (Cognitive Behavioral Therapy for Interoceptive Cues; CBT-IC) relative to an active comparison condition, Individual Drug Counseling (IDC), when added to methadone maintenance treatment (MMT) among those who had not responded to MMT. Participants (N=78) were randomly assigned to receive 15 sessions of CBT-IC or IDC as an adjunct to ongoing MMT and counseling. Oral toxicology screens were the primary outcome. Results indicated no treatment differences between CBT-IC and IDC and a small, significant reduction of self-reported drug use, but no change on toxicology screens. Tests of potential moderators, including sex, anxiety sensitivity, and coping motives for drug use, did not yield significant interactions. Among opioid-dependent outpatients who have not responded to MMT and counseling, the addition of IDC or CBT-IC did not result in additive outcome benefits. These results highlight the need for more potent treatment strategies for opioid dependence, particularly among those who do not fully respond to frontline treatment.     

美沙酮维持综合干预治疗对阿片类依赖者心理健康的影响

目的:研究美沙酮维持综合干预治疗对阿片类依赖者心理健康的影响。方法:随机对35例参加美沙酮维持治疗(MMT)的阿片类依赖者,在治疗前、治疗满一个月、治疗满两个月做症状自平量表(SCL-90)测评,用简明统计学处理器2.0进行计量资料t检验分析。结果:与治疗前相比,在治疗满一月后患者的SCL-90中的躯体化、强迫症状、人际关系敏感、抑郁、焦虑、敌对、恐怖、偏执、其他因子均降低,差异有高度显著性(P<0.01);精神病性因子差异有显著性(P<0.05);治疗满两个月与满一个月比较,强迫症状和抑郁因子差异具有高度显著性(P<0.01);躯体化、焦虑、敌对、恐怖、偏执、精神病性和其他因子差异无显著性(P>0.05)。结论:对阿片类药物依赖者进行MMT结合心理治疗、行为治疗和家庭治疗可以明显改善病人的心理健康水平,而且随着治疗时间的延长,效果会更好。     

Factors associated with mortality among heroin users after seeking treatment with methadone: A population-based cohort study in Taiwan

Data concerning factors associated with mortality among heroin users under methadone maintenance treatment (MMT) in the Han Chinese population are limited. This study examined mortality risk among heroin users after seeking treatment with methadone in a catchment area using a cohort of 1616 Taiwanese heroin users between October 2006 and December 2008. During the study period, 26 (1.6%) people died, with an all-cause mortality rate per 100 person years of 3.42. The primary cause of death among our patients was accidents, followed by suicide and drug overdose. Older age, HIV infection, psychiatric treatment history, and alcohol abuse/dependence were risk factors for all-cause mortality; remaining on MMT was protective for survival. Our findings suggest that although mortality is mainly associated with medical and psychiatric comorbidities, continuing with the MMT program is still an important predictor for survival.     

Drug abuse, methadone treatment, and health services use among injection drug users with AIDS

This paper compares health care use across subgroups of injection drug users (IDUs) with AIDS, as defined by current drug abuse status and participation in methadone maintenance treatment (MMT), using surveillance-identified IDU status and health care claims data. Merged Medicaid and AIDS surveillance data were analyzed using ordinary least squares regression, simple logistic regression and multinomial logistic regression. Consistent MMT was more likely among women, Whites and older subjects. Monthly total expenditures and inpatient expenditures were significantly lower for IDUs in MMT than for IDUs with claims indicative of current drug abuse. Consistent participation in MMT was associated with a higher probability of antiretroviral use and, among antiretroviral users, more consistent use of antiretrovirals. Merged administrative data sets can be an important data source that illuminate the relationships among drug abuse, drug treatment, and HIV-related health care. For AIDS-infected IDUs, consistent MMT may lower barriers to receipt of appropriate HIV-related health care and reinforce adherence to medical recommendations.     

Injection opioid use as a predictor of treatment outcomes among methadone-maintained opioid-dependent patients

BackgroundInjection opioid use is associated with more severe health and psychosocial consequences relative to non-injection use, but few studies have examined whether injection use is associated with methadone maintenance treatment outcomes. The present study examined differential MMT outcomes among opioid injectors and non-injectors.MethodsData were extracted from the clinic charts of opioid-dependent MMT patients (N = 290; n = 115 injectors) enrolled in a university-affiliated, urban MMT clinic. Injection status was examined as a predictor of short- (3-month opioid, cocaine, benzodiazepine and cannabis urine drug screens) and long- (days retained in treatment) term MMT outcomes.ResultsBivariate analyses revealed injection users were less likely to be African American and to have completed high school, were more likely to have started heroin use before age 21, to report having hepatitis C, to report a baseline cocaine use disorder, and had higher methadone doses at 3-months into treatment. Injection status significantly predicted a greater proportion of cocaine-positive urine drug screens in the first 3 months of treatment, but did not significantly predict opioid, benzodiazepine or cannabis drug screens, or length of treatment retention.ConclusionThis is one of a handful of studies to examine injection status as a predictor of MMT outcomes. Injection status is associated with cocaine use early in treatment, which has implications for the focus of treatment.     

Hepatitis C Treatment Eligibility and Comorbid Medical Illness in Methadone Maintenance (MMT) and Non-MMT Patients: A Case-Control Study

ABSTRACT

Comorbid medical illness is common in patients with chronic hepatitis C (HCV) infection and in methadone treatment (MMT) patients, yet little is known about the impact of medical illness on HCV treatment eligibility. Medical illness and HCV treatment eligibility were compared in a case-control study of 80 MMT patients entering an HCV treatment trial and 80 matched non-MMT patients entering HCV treatment in a gastroenterology clinic. 91% of MMT and 85% of non-MMT patients had chronic medical conditions. Despite similar medical severity ratings, a significantly higher proportion (77%) of non-MMT patients were eligible for HCV treatment than were MMT patients (56%) (p < .01). Specific comorbid medical and psychiatric illness led to ineligibility in only 18% of MMT and 16% of non-MMT patients. However, failure to complete the medical evaluation process was significantly (p < .001) more likely to cause ineligibility among MMT patients (19%) than non-MMT patients (0%).     

Response to methadone maintenance treatment of opiate dependent patients with and without significant pain

BACKGROUND: Both clinicians and researchers have expressed doubt that opiate dependent patients with significant pain can be effectively treated in methadone maintenance treatment (MMT) programs; however, little research exists on this topic. Patients who report significant pain in the month preceding entry to MMT present with a distinct and more severe pattern of polysubstance use, medical and psychosocial problems than do those without pain. The present study investigated the 1-year treatment outcomes of MMT patients with opiate dependence and pain. METHODS: Analyses were based on a national sample of 200 patients presenting in MMT programs for treatment of opiate dependence. Substance use and related problems were measured at treatment entry and 12 months later. Patients reported pain severity over the month preceding treatment entry. RESULTS: Compared to patients without significant pain, patients who reported significant pain at baseline (n = 103) showed similar substance-related functioning, but poorer psychosocial functioning at 1 year. CONCLUSIONS: Patients with and without significant pain experience comparable reductions in substance use when provided with standard care in MMT programs. However, additional medical and/or mental health treatment is needed for their pain and other problems.