- 學位論文
海洛因使用者多向度評估:渴癮、腦部形態學與功能性連結
Multi-dimensional Assessments for Heroin Users: Craving, Brain Morphology and Brain Functional Connectivity
摘要
海洛因是一種成癮性極高，以致於全球廣泛濫用的非法物質，而海洛因使用疾患是一種慢性且容易復發的腦部疾患，我們嘗試以物質渴求及腦部型態學改變與腦功能性連結的觀點，來討論海洛因成癮的本質。 第一個部分檢視中文版成癮藥物渴望問卷 (Desire for Drugs Questionnaire-Chinese Mandarin version, DDQ-CM) 的信效度、於臨床評估海洛因使用者對於海洛因渴求程度之適用性與接受美沙冬替代療法臨床預後指標的關聯。我們邀集314位接受美沙冬替代療法的靜脈注射海洛因使用者接受問卷填寫與訪談。以DDQ-CM及視覺類比量表(visual analog scale) 評估當前海洛因渴求嚴重度；以中文版依賴程度量表(Chinese version of the Severity of Dependence Scale)、藥物使用疾患確認測驗-衍伸版(Drug Use Disorders Identification Test-Extended)、中文版憂鬱症流行病學研究中心量表(The Chinese version of the Center for Epidemiologic Studies-Depression Scale) 分別評估過去海洛因使用的嚴重度，海洛因使用態度及改變海洛因使用行為的準備程度以及憂鬱狀態。研究顯示原始因素結構應用於DDQ-CM尚在合適範圍，但在次量表的同步效度檢測僅 “慾望與意圖”(Desire and Intention) 及 “負增強”(Negative Reinforcement) 次量表達標，但未支持 “克制”(Control)次量表 。同時，DDQ-CM 在“慾望與意圖”Desire and Intention及“負增強” Negative Reinforcement 次量表量測之渴癮程度與海洛因成癮的嚴重程度、對於海洛因使用正向與負向態度以及憂鬱程度呈現正相關，但與準備改變海洛因使用行為的程度呈現負相關。 第二部分應用功能性核磁共振造影，檢視30位接受美沙冬替代療法之海洛因使用者與30位教育程度、年齡配對的對照組相較，在背外側前額葉皮層(dorsolateral prefrontal cortex ;DLPFC) 之腦部灰質容積(gray matter volume ;GMV) 及靜態腦部功能性連結(resting-state functional connectivity; rsFC) 之改變。受試者於靜止休息狀態下接受以3-Tesla General Electric MR scanner 做磁振造影，並以spoiled gradient echo 及gradient-recalled echo planar imaging sequences做影像學處理與分析。結果顯示，與對照組相較，海洛因使用者在右側背外側前額葉皮層(DLPFC)的腦部灰質容積(GMV)較低，進一步分析海洛因使用者右側背外側前額葉皮層(DLPFC)的靜態腦功能性連結(rsFC)，顯示其DLPFC兩大腦半前間的功能性連結在控制右側背外側前額葉皮層(DLPFC)的腦部灰質容積(GMV)大小後，亦顯得較弱。背外側前額葉皮層(DLPFC)在多種認知功能與行為決策佔有重要角色，臨床提供海洛因使用者戒癮服務時，應注意相關認知功能缺損與臨床症狀表現的連結。
並列摘要
Because of its high addictive property, heroin is one of the most worldwide used illicit drugs. Heroin use disorder is considered as a chronic relapsing brain disorder and creates a major public health problem. We tried to explore the entity of heroin use disorder with two perspectives by different means. The first part of the study aimed to examine the psychometrics of the Desire for Drug Questionnaire-Chinese Mandarin version (DDQ-CM) and its clinical utility of assessing craving for heroin measured among heroin users with methadone maintenance treatment (MMT). Self-reported craving for heroin use was measured on the DDQ-CM and visual analog scale among 314 intravenous heroin users receiving MMT. Self-reported heroin dependence, attitude toward heroin use, readiness to change heroin use, and depression were collected. The results revealed that although the original three-factor model was acceptable for applying the DDQ-CM for heroin users with MMT, only the concurrent validity of the subscales of Desire and Intention and Negative Reinforcement was supported but not that of Control. Meanwhile, the levels of craving on the subscales of Desire and Intention and of Negative Reinforcement on the DDQ-CM were positively associated with the levels of heroin dependence, positive and negative attitudes toward heroin use, and depression, but negatively associated with readiness to change heroin use. The Second part of this study evaluated the alteration of gray matter volume (GMV) and its resting-state functional connectivity (rsFC) over the dorsolateral prefrontal cortex (DLPFC) among male heroin users. Thirty heroin-dependent men undergoing methadone maintenance therapy and 30 educational-level- and age-matched male controls were recruited for this study. To assess their GMV and rsFC, the participants were evaluated using spoiled gradient echo and gradient-recalled echo planar imaging sequences with 3-Tesla General Electric MR scanner under resting state. The results showed that the heroin-dependent men had lower GMV over the right DLPFC in comparison with the controls. Further evaluation of the rsFC of the right DLPFC revealed a marked decrease in interhemispheric DLPFC connectivity among those with heroin dependence under control of head movement and GMV of the right DLPFC. As the DLPFC plays an imperative role in various domains of cognitive function, service providers for heroin users should consider the impacts of possible DLPFC-related cognitive deficits on treatment effectiveness.