鴉片類藥物成癮者對美沙冬及丁基原啡因/納洛酮舌下錠維持治療選擇之現況及看法

Current status and views of Methadone and Buprenorphine/Naloxone Maintenance Treatment in Patients with Opioid-Addiction

梁雅莉(YA-LI LIANG)

指導教授 ： 林英琦

高雄醫學大學/藥學院/藥學系碩士在職專班/碩士(2018年)

摘要

研究背景
　　鴉片類藥品使用者若共用針頭行為有感染愛滋病毒的風險。疾管署為減少感染愛滋病毒或其他傳染疾病的風險而辦理替代治療。替代治療使用藥品包含美沙冬(Methadone)及丁基原啡因/納洛酮(Buprenorphine/Naloxone)舌下錠(後簡稱舌下錠)兩種。美沙冬藥物免自費但需每天到醫院服，而舌下錠雖需部分自付費用但可帶回家不用每天到院服用，考量交通及工作成本，舌下錠對藥癮者可能是更經濟的選擇；又舌下錠相較於美沙冬有更好的安全性和戒除藥癮效果，但國內臨床上觀察病患對舌下錠接受度不如預期，因此想藉由了解在臨床上治療個案對兩項藥品的選用意願及看法，找出影響個案選擇替代性治療，提供未來替代治療推行參考。

實驗方法
　　研究採用自填問卷調查方式，包含對於藥癮者的基本資料、物質使用史、治療史及對於美沙冬及舌下錠藥品分別的了解及認知量表。受試者為南部三家醫院參與替代治療之鴉片類藥物成癮者。

結果
　　自106年5月至107年3月於三家醫院鴉片類藥物成癮者替代治療門診及給藥專區問卷調查回收問卷310份，7位因執行問題扣除，完成問卷調查有303位。其中目前服用美沙冬有285位，服用舌下錠者18位。男性佔81.8%居多，平均年齡46.8歲，教育程度以國高中為主，有工作者佔76.4%。受試者中212人(70.0%)無服用舌下錠經驗，91人(30.0%)有服用舌下錠經驗，同時有服用美沙冬及舌下錠經驗者88人(29.0%)；在同時有服用美沙冬及舌下錠經驗者88人中，目前替代治療藥物服用美沙冬者73人(83.0%)，服用舌下錠者15人(17.0%)。相對於舌下錠，同時有服用美沙冬及舌下錠經驗者中較多人認為美沙冬可以有效地停止海洛因戒斷症狀、會停止對海洛因的渴望。然而，較多受試者認為美沙冬比舌下錠會完全阻斷海洛因的效果、會讓受試者非常想睡、美沙冬比舌下錠更難停止服用而導致成癮、也認為只是換成用另一種成癮物質。相對來說，服用舌下錠者認為別人會覺得使用舌下錠比起美沙冬不算是有藥癮的人。

結論
　　多數藥癮者選擇服用美沙冬為替代治療的藥物，而且認為美沙冬比舌下錠效果好且較安全。然而就藥理機轉而言，舌下錠較美沙冬安全性高且會使再使用海洛因比較沒有感覺，較能停止對海洛因的渴望。可能是國內藥癮者對於舌下錠的認識不足及使用方法不正確使多數人傾向於接受美沙冬。透過衛教正確觀念及教導舌下錠正確用法，可能提高替代治療舌下錠使用率。

關鍵字

鴉片類藥物成癮治療 ； 美沙冬替代治療 ； 丁基原啡因替代治療

並列摘要

Background:
Opioid users are at risk of human immunodeficiency virus (HIV) infection if they share needles. Methadone and Buprenorphine/Naloxone sublingual tablets are maintenance treatments to reduce illicit drug use and the spread of HIV infections or other infectious diseases. Methadone could only be taken at the hospital, while the sublingual tablets could be taken at home. Although using the sublingual tablets is a self-pay treatment comparing to the free Methadone, it is a more cost-effective alternative to the drug addicts considering the cost of both transportation and labor. However, most participants of maintenance treatment in Taiwan choose Methadone. The goal of this study is to survey patients’ understanding and views on the two medications to find out the reasons that contributes to the patient’s decision to change to the sublingual tablets. The results of the study may offer insights for implementing replacement treatments in the future.

Methods:
Questionnaire containing basic characteristics, history of substance abuse, treatment history and a 5-point Likert scale for questions on the participants' understanding and views of the two medicines. Participants in the maintanence therapy were recruited from three hospitals in southern Taiwan.

Results:
From May 2017 until March 2018, a total of 310 questionnaires were collected. Seven subject was excluded. Of the 303 subjects in the study, 285 subjects were currently under Methadone therapy, and 18 subjects were under Buprenorphine therapy. Most subjects are male (81.8%) and average aged 46.8 years old. Their education levels are mostly at high schools. About 76% of subjects have a job. 212 subjects (70%) don’t have the experience on Buprenorphine and 91 subjects (30%) have the experience on Buprenorphine. There were only 88 subjects (29%) have the experience on both Methadone and Buprenorphine, which include 73 subjects who are currently on Methadone (83.0%) and 15 subjects currently on Buprenorphine (17.0%). Most subjects think Methadone can prevent withdrawal symptoms and stop their desire of heroin more effectively than Buprenorphine. They also think Methadone was harder to stop using, and consider taking Methadone is just swapping one addiction for another. However, subjects wrongly think that Methadone can top the effect of heroin. By contrast, subjects in Buprenorphine group think that others would not consider Buprenorphine user a drug addict.

Conclusions:
A majority of the opiate addicts considered Methadone to be more effective than Buprenorphine despite pharmacologically Buprenorphine is safer and more likely to control their desire to heroin. Educations on the maintanence therapy and their usage may increase the prevalence of the sublingual tablets use in mainanence treatments.

並列關鍵字

Maintanence treatment ； Methadone ； BuprenorphineMethadone, Buprenorphine

參考文獻

Bonhomme, J., Shim, R. S., Gooden, R., Tyus, D., & Rust, G. (2012). Opioid addiction and abuse in primary care practice: a comparison of methadone and buprenorphine as treatment options. Journal of the National Medical Association, 104, 342.

Connock, M., Juarez-Garcia, A., Jowett, S., Frew, E., Liu, Z., Taylor, R., . . . Roberts, T. (2007). Methadone and buprenorphine for the management of opioid dependence: a systematic review and economic evaluation.

Dunn, K. E., Finan, P. H., Tompkins, D. A., Fingerhood, M., & Strain, E. C. (2015). Characterizing pain and associated coping strategies in methadone and buprenorphine-maintained patients. Drug and alcohol dependence, 157, 143-149.

Fareed, A., Vayalapalli, S., Casarella, J., Amar, R., & Drexler, K. (2010). Heroin anticraving medications: a systematic review. The American journal of drug and alcohol abuse, 36(6), 332-341.

Pinto, H., Maskrey, V., Swift, L., Rumball, D., Wagle, A., & Holland, R. (2010). The SUMMIT trial:: a field comparison of buprenorphine versus methadone maintenance treatment. Journal of substance abuse treatment, 39(4), 340-352.