Gibson Amy E, Doran Christopher M, Bell James R, Ryan Anni, Lintzeris Nicholas
National Drug and Alcohol Research Centre, University of New South Wales, UNSW Randwick Campus, King Street, Randwick, NSW 2052, Australia.
Med J Aust. 2003 Jul 7;179(1):38-42. doi: 10.5694/j.1326-5377.2003.tb05417.x.
To compare outcomes, costs and incremental cost-effectiveness of heroin detoxification performed in a specialist clinic and in general practice.
Randomised controlled trial set in a specialist outpatient drug treatment centre and six office-based general practices in inner city Sydney, Australia.
115 people seeking treatment for heroin dependence, of whom 97 (84%) were reinterviewed at Day 8, and 78 (68%) at Day 91.
Participants were randomly allocated to primary care or a specialist clinic, and received buprenorphine for 5 days for detoxification, then were offered either maintenance therapy with methadone or buprenorphine, relapse prevention with naltrexone, or counselling alone.
Completion of detoxification, engagement in post-detoxification treatment, and heroin use assessed at Days 8 and 91. Costs relevant to providing treatment, including staff time, medication use and diagnostic procedures, with abstinence from heroin use on Day 8 as the primary outcome measure.
There were no significant differences in the proportions completing detoxification (40/56 [71%] primary care v 46/59 [78%] clinic), participating in postwithdrawal treatment (28/56 [50%] primary care v 36/59 [61%] clinic), reporting no opiate use during the withdrawal period (13/56 [23%] primary care v 13/59 [22%] clinic), and in duration of postwithdrawal treatment by survival analysis. Most participants in both groups entered postwithdrawal buprenorphine maintenance. On an intention-to-treat basis, self-reported heroin use in the month before the Day 91 interview was significantly lower than at baseline (27 days/month at baseline, 14 days/month at Day 91; P < 0.001) and did not differ between groups. Buprenorphine detoxification in primary care was estimated to be $24 more expensive per patient than treatment at the clinic. The incremental cost-effectiveness ratio reveals that, in this context, it costs $20 to achieve a 1% improvement in outcome in primary care.
Buprenorphine-assisted detoxification from heroin in specialist clinic and primary care settings had similar efficacy and cost-effectiveness. Buprenorphine treatment can be initiated safely in primary care settings by trained GPs.
比较在专科诊所和全科医疗中进行海洛因脱毒治疗的效果、成本及增量成本效益。
在澳大利亚悉尼市中心的一家专科门诊药物治疗中心和六家基层全科医疗诊所开展的随机对照试验。
115名寻求海洛因依赖治疗的患者，其中97名（84%）在第8天接受了再次访谈，78名（68%）在第91天接受了再次访谈。
参与者被随机分配至基层医疗或专科诊所，接受为期5天的丁丙诺啡脱毒治疗，之后可选择美沙酮或丁丙诺啡维持治疗、纳曲酮预防复发治疗或仅接受咨询。
脱毒完成情况、脱毒后治疗参与情况，以及在第8天和第91天评估的海洛因使用情况。以第8天戒除海洛因使用作为主要结局指标，计算提供治疗相关的成本，包括工作人员时间、药物使用和诊断程序。
在脱毒完成比例（基层医疗组40/56 [71%] 对比专科诊所组46/59 [78%]）、参与脱毒后治疗比例（基层医疗组28/56 [50%] 对比专科诊所组36/59 [61%]）、报告在脱毒期未使用阿片类药物的比例（基层医疗组13/56 [23%] 对比专科诊所组13/59 [22%]）以及通过生存分析得出的脱毒后治疗持续时间方面，两组间均无显著差异。两组中的大多数参与者都进入了脱毒后丁丙诺啡维持治疗阶段。在意向性治疗分析中，自我报告的在第91天访谈前一个月的海洛因使用量显著低于基线水平（基线时为每月27天，第91天时为每月14天；P < 0.001），且两组间无差异。据估计，基层医疗中丁丙诺啡脱毒治疗每名患者的费用比诊所治疗贵24美元。增量成本效益比显示，在此背景下，基层医疗中每实现1%的结局改善需花费20美元。
专科诊所和基层医疗环境中丁丙诺啡辅助的海洛因脱毒治疗具有相似的疗效和成本效益。经过培训的全科医生可在基层医疗环境中安全地启动丁丙诺啡治疗。
