Weinrich M, Stuart M
Department of Neurology, University of Maryland, Baltimore, USA.
JAMA. 2000 Mar 8;283(10):1343-8. doi: 10.1001/jama.283.10.1343.
Under new proposed regulations, US physicians outside of traditional methadone clinics could prescribe methadone to patients with opioid dependence. No large-scale evaluations of US programs in which methadone maintenance is provided by primary care physicians are available, but primary care physicians in Scotland have participated in such programs on a large scale.
To review the history, operation, and outcome data on the efficacy and safety of 2 Scottish primary care-based opioid agonist treatment programs to derive lessons for the US context.
Naturalistic study of programs in Edinburgh and Glasgow, Scotland, with data obtained through site visits and interviews conducted in 1996 and 1998, as well as from published reports and retrospective analysis of electronic databases.
Proportions of injection drug users who were enrolled in the methadone maintenance programs, average methadone doses in the programs, and methadone-related deaths.
A total of 60% to 80% of injection drug users in Edinburgh and 41% to 73% of those in Glasgow were enrolled in methadone maintenance in 1998-1999. Dose levels are consistent with US recommendations (for Edinburgh in 1998, 61 mg; for Glasgow in 1994-1996, 54 mg). The Glasgow program required supervised consumption of methadone in community pharmacies for the first year and experienced significantly fewer methadone-related deaths than Edinburgh in 1997 (17 vs 30 deaths; P<.0001). Programs in both Edinburgh and Glasgow provided support to primary care physicians and achieved levels of general practitioner participation of 59% (1998) and 30% (1999), respectively.
The Scottish experience indicates that prescription of methadone in office-based settings can expand access to an important treatment modality. Primary care physicians safely prescribed methadone for maintenance treatment when provided with adequate support. Diversion of methadone was minimized by requiring supervised consumption in community pharmacies.
根据新提议的法规，美国传统美沙酮诊所以外的医生可以为阿片类药物依赖患者开具美沙酮处方。目前尚无对美国由初级保健医生提供美沙酮维持治疗项目的大规模评估，但苏格兰的初级保健医生已大规模参与此类项目。
回顾苏格兰两个基于初级保健的阿片类激动剂治疗项目的历史、运作及疗效和安全性的结果数据，以便为美国的情况提供经验教训。
对苏格兰爱丁堡和格拉斯哥的项目进行自然主义研究，数据通过1996年和1998年的实地考察和访谈获得，以及来自已发表报告和电子数据库的回顾性分析。
参加美沙酮维持治疗项目的注射吸毒者比例、项目中的平均美沙酮剂量以及与美沙酮相关的死亡人数。
1998 - 1999年，爱丁堡60%至80%的注射吸毒者以及格拉斯哥41%至73%的注射吸毒者参加了美沙酮维持治疗。剂量水平与美国的建议一致（1998年爱丁堡为61毫克；1994 - 1996年格拉斯哥为54毫克）。格拉斯哥项目在第一年要求在社区药房监督服用美沙酮，1997年与美沙酮相关的死亡人数明显少于爱丁堡（17例对30例死亡；P<0.0001）。爱丁堡和格拉斯哥的项目都为初级保健医生提供了支持，全科医生的参与率分别达到59%（1998年）和30%（1999年）。
苏格兰的经验表明，在门诊环境中开具美沙酮处方可以扩大获得一种重要治疗方式的途径。在获得充分支持的情况下，初级保健医生能够安全地开具美沙酮用于维持治疗。通过要求在社区药房监督服用美沙酮，美沙酮的转移被降至最低。
