美沙冬替代療法對於海洛因成癮者藥物濫用信念及社會功能之成效分析

背景：台灣近年來愛滋病感染人數急遽增加，自民國73年至民國96年12底止，台灣地區感染愛滋病毒的通報個案數累積已超過1萬5千人，其中藥癮者佔38.54%，居所有危險因子的首位。經分析原因發現，海洛因（heroin）藥癮者共用針具是感染愛滋病毒的主因。爲因應愛滋疫情擴大，行政院衛生署於民國94年12月開始推動「毒品病患愛滋減害試辦計畫」，美沙冬替代療法（Methadone Maintenance Treatment）得以由國外引進台灣。惟愛滋疫情雖已獲初步控制，但海洛因成癮的危害絕不止愛滋疫情之失控，毒品於治安、經濟、社會及家庭之影響，其衝擊層面不亞於愛滋病，甚至帶來更嚴重的後果。值此美沙冬替代療法甫於國內施行之初，社會及輿論對其治療概念尚一知半解，恐會影響我國毒品防制政策之執行。故本研究對美沙冬替代療法之成效進行探討及分析，並提出建議，以供相關單位參考。目的：探討海洛因成癮者之藥物濫用信念偏差及社會適應功能障礙，並分析美沙冬替代療法之成效。方法：採類實驗設計（quasi-experimental design）的研究方法進行，共分兩組，介入組為自民國96年1月至96年12月間於某區域醫院精神科門診接受美沙冬替代療法之海洛因成癮者，比較組為自民國96年1月至96年12月間因違反毒品危害防制條例於某地檢署接受保護管束處分之海洛因成癮者。先以Microsoft Excel 2000將資料編碼建檔，根據研究架構與研究假設進行統計及分析，探討海洛因成癮者之特殊人口學特徵包括：年齡層、教育程度、婚姻狀況及就業狀況，特殊之藥物濫用行為包括藥物濫用史及前科次數等。兩組分別以濫用藥物信念量表及社區生活適應量表進行前測及後測，前後測間隔時間為三個月。濫用藥物信念量表部份，依總分及「效果期待」、「自貶依毒」、「低估毒癮」三個分量表進行前後測組內比較分析。社區生活適應量表部份，依總分及「人際關係」、「成就表現」、「時間分配」、「家庭生活」、「性格適應」進行前後測組內比較分析，並比較介入組與比較組兩組間的差異，以分析美沙冬替代療法之成效。統計分析方法是以統計套裝軟體SPSS for Windows 12.0 中文版進行描述性統計及推論性統計。結果：本研究以海洛因成癮者為研究樣本，共蒐集了81人為介入組樣本，34人為比較組樣本，其中介入組有14人比較組有13人因問卷塡答資料缺漏、重複答題或未完成問卷後測者排除，總計有效樣本介入組共計67人，比較組共計21人。介入組之平均開始使用海洛因年齡為25.25±6.07歲，比較組為28.05±10.93歲；介入組之平均海洛因使用年數為11.40±6.15年，比較組為12.57±4.72年；介入組之平均毒品前科次數為1.97±1.54次，比較組為4.00±2.15次。兩組之基本人口學特徵及藥物濫用史經檢定無明顯差異，惟兩組之毒品前科數具顯著性差異，故於統計推論過程中以控制該變項的方式進行。介入組與比較組分別以配對樣本t檢定（paired t test）檢定各組前後測之信念得分變化。效果期待信念：介入組p<0.0001，比較組p=0.480。自貶依毒信念：介入組p<0.0001，比較組p=0.355。低估毒癮信念：介入組p<0.0001，比較組p=0.940。濫用藥物信念總分：介入組p<0.0001，比較組p=0.511。於社區生活適應部份：人際關係：介入組p<0.0001，比較組p=0.506。成就表現：介入組p<0.0001，比較組p=0.658。時間分配：介入組p<0.0001，比較組p=0.803。家庭生活：介入組p<0.0001，比較組p=0.083。性格適應：介入組p<0.0001，比較組p=0.366。社區生活適應總分：介入組p<0.0001，比較組p=0.740。介入組與比較組之組間比較以重複量數雙因子變異數分析（repeated measures two-way ANOVA）進行組間前後測交互作用統計分析，其結果於濫用藥物信念部份，p<0.0001，顯示美沙冬替代療法之介入，可改善海洛因成癮者之藥物濫用信念偏差，濫用藥物信念的三個分量表部份：效果期待信念（p<0.0001），自貶依毒信念（p<0.0001），低估毒癮信念（p<0.0001）。於社區生活適應部份，p=0.001，顯示美沙冬替代療法之介入，可改善海洛因成癮者之社會適應功能，社區生活適應量表的五個題項部份：人際關係（p=0.240），成就表現（p=0.010），時間分配（p=0.001），家庭生活（p=0.006），性格適應（p=0.014）。結論與建議：研究結果顯示：海洛因成癮者通常都從年輕時即開始使用毒品，一旦成癮，其使用年數往往超過10年，且海洛因成癮後戒除不易，極易復發，個案常有多次毒品前科。海洛因成癮者所面對的生理、心理障礙及其對整體社會國家所產生之公衛、經濟及治安的衝擊層面甚廣。建議我國之健保政策應將藥癮之治療納入給付項目，導正社會大眾對藥癮疾病的誤解，減少對藥癮者的排斥，避免因過度研究藥癮的道德問題而引起對立，並持續編列預算補助「美沙冬替代療法」，以降低進入治療的門檻及提高治療的普及率為目標，提供藥癮者可近性高的諮詢及治療平台。研議以「美沙冬替代療法」作為毒品犯之緩刑及假釋的強制司法處遇措施，設置「毒品處遇法庭」，推動「以社區為基礎」之毒品戒治模式，以提高戒治成效，並減少國家資源的浪費，以期建立遠離毒害的健康社會。

關鍵字

海洛因成癮；藥物濫用信念；社會功能；美沙冬替代療法

並列摘要

Background: An increasing number of people have become infected with HIV/AIDS in recent years. Between 1984 and 2007, more than 15,000 AIDS cases were reported. Among them, cases related to drug addiction accounted for 38.54%, making it the number one risk factor. Analysis reveals that heroin addicts who share needles comprise the majority of people becoming infected with HIV. To tackle the spread of AIDS, the Department of Health (DOH) in December 2005 launched a “Pilot Program of AIDS Harm Reduction to Drug Abuser” and introduced Methadone Maintenance Treatment (MMT). Though we are now able to control the spread of AIDS to a certain extent, the harm caused by heroin addiction is no less devastating than losing the battle against AIDS. The impact that drugs have on public security, the economy, society and families is no less than that of AIDS, with even worse consequences. MMT is still new to Taiwan, and the fact that most people are unfamiliar with this treatment may have a negative impact on the implementation of the country’s drug policies. Consequently, this study discusses and analyzes the effectiveness of MMT, with suggestions put forward for reference by relevant government agencies. Objective: This study discusses and analyzes irrational beliefs toward heroin addicts and their social function disability, as well as the effectiveness of MMT. Methods: The study was conducted using a quasi-experimental design. The subjects were divided into two groups – intervention and comparison groups. Those in the intervention group (G1) were heroin addicts receiving MMT at the psychiatric outpatient department of a regional hospital between January and December of 2007, and those in the comparison group (G2) were heroin addicts in the custody of a district prosecutors’ office in the same period for violating the drug abuse prevention statute. Our first step was to code data and create files using Microsoft Excel 2000. Then we compiled statistics and analyzed them based on our study framework and hypotheses to identify the drug addicts’ special demographic attributes, such as age, level of education, marital and employment statuses, and drug abuse behavior such as drug abuse history and previous convictions. Two separate questionnaires were filled out by subjects in both groups to quantify their beliefs toward drug abusing and social function at the beginning and the end of three-month period. The questionnaire for quantifying the subjects’ beliefs toward drug abuse comprises three parts – expectancy, self-abasement with drug dependence and underestimation of drug addiction. Results obtained at the beginning and end of three-month period of the same group were compared and analyzed. And the questionnaire for quantifying the subjects’ social function consists of five parts – interpersonal relations, achievements, time allocation, family life and flexibility. Results obtained at the beginning and end of three-month period of the same group were also compared and analyzed. In addition, results obtained from the two groups were compared to find out their differences in order to evaluate the effectiveness of the MMT. In this study, the Chinese version of the statistics application SPSS 12.0 for Windows was used to compile descriptive and deductive statistics. Results: There were 81 subjects in G1 and 34 in G2. 14 questionnaires handed in by subjects in G1 and 13 by those in G2 were considered invalid and excluded from the study, leaving 67 valid questionnaires in G1 and 21 in G2. The average age at which the subjects began using heroin was 25.25±6.07 in G1 and 28.05±10.93 in G2, for an average of 11.40±6.15 and 12.57±4.72 years, respectively. The average number of previous conviction per subject was 1.97±1.54 in G1 and 4.00±2.15 in G2. There are no obvious differences between the two groups in terms of demographic attributes and drug abuse history. However, an examination of previous convictions reveals a noticeable difference between them. Consequently, the variable was placed under control throughout the deduction process. Paired t test was utilized in both groups to measure the difference in the points scored between the beliefs toward drug abuse questionnaires filled out at the beginning and end of three-month period. In terms of beliefs toward drug abuse, the results are: expectancy – G1: p<0.0001, G2: p=0.480; self-abasement with drug dependence – G1: p<0.0001, G2: p=0.355; and underestimation of drug addiction – G1: p<0.0001, G2: p=0.940, with the combined score being G1: p<0.0001, G2: p=0.511. As far as social function are concerned, the results are: interpersonal relations – G1: p<0.0001, G2: p=0.506; achievements – G1: p<0.0001, G2: p=0.658; time allocation – G1: p<0.0001, G2: p=0.803; family life – G1: p<0.0001, G2: p=0.083; and flexibility – G1: p<0.0001, G2: p=0.366, with the combined score being G1: p<0.0001, G2: p=0.740. In addition, repeated measure two-way ANOVA was used to analyze the interaction between the two groups with questionnaires filled out at the beginning and end of each period. In terms of beliefs toward drug abuse, the score is: p<0.0001, indicating that subjects receiving MMT suffered less from beliefs toward drug abusing. The results obtained from the three parts of this questionnaire are: expectancy – p<0.0001, self-abasement with drug dependence – p<0.0001, and underestimation of drug addiction – p<0.0001. As far as social function are concerned, the score is p=0.001, indicating that subjects receiving MMT can improve their social function. The results obtained from the five parts of this questionnaire are: interpersonal relations – p=0.240, achievements – p=0.010, time allocation – p=0.001, family life – p=0.006, and flexibility – p=0.014. Conclusions and Suggestions: According to the study results, most of them began using drugs when they were young.Those who became addicted had used drugs for more than ten years. Once becoming addicted to heroin, it is very difficult to abstain. Even those who manage to abstain are prone to relapse, resulting in multiple drug convictions.Heroin addicts are faced with many physical and psychological problems, which have wide-ranging impacts on public hygiene, economy and security of society in general.It is suggested that the national health insurance pays for the treatment of drug addiction.The public should be educated to eliminate their misunderstandings about drug addiction and reduce the repulsion experienced by drug addicts. Efforts should be made to avoid paying too much attention to the ethical issues surrounding drug addiction to avoid polarization. The government should also continue to subsidize MMT in order to lower the threshold for the treatment and allow more drug abusers to receive MMT. A platform should be established to provide drug abusers with friendly consultations and caring treatment. The government is advised to consider obtaining drug offenders’ consent to receive MMT as a condition of granting probation or parole. It is also advised to set up drug courts and promote a community-based drug abstinence model in order to improve abstinence effectiveness, reduce waste of resources and establish a healthy society far away from drug hazards.