Guichard Anne, Lert France, Brodeur Jean-Marc, Richard Lucie
Inserm, U687, F-94410, Saint-Maurice, France.
Soc Sci Med. 2007 Jun;64(12):2578-93. doi: 10.1016/j.socscimed.2007.02.049. Epub 2007 Apr 17.
The French system for drug substitution, or maintenance treatment, established in 1996, differs from the often strict conditions attached to methadone clinics in other countries. Because of the predominant role of general practitioners and the flexible prescription rules for Subutex in France, the relationship between the physician and the drug user becomes a central element in the treatment. This article deals with the expectations that these users have of the physician, and their perception of his or her attitude towards them. In order to identify possible reasons for the absence of treatment compliance and of Subutex misuse, it focuses on the users' assessment of the physician's response to the problems they report. This study, based on a diversified convenience sample of 28 persons (19 men, 9 women) in treatment, showed 4 patterns of relationships between physicians and users, which differed in their focus: (1) closely focused on the posology of the prescription; (2) compliance with the prescribed regimen is the main issue in a relationship dominated by the physician; (3) an alliance between the physician and the user who is acknowledged as a person, and (4) a instrumental solely on the part of the user, who comes to procure a free, legal drug from a doctor's office. In all four case types, users had difficulty reporting other drug use or intravenous Subutex injection within this relationship, in which the stigma attached to drug dependence seems to reappear. Moreover, the lack of clarity about the treatment objectives and the time frame of the consultation limits the users' ability to integrate the treatment into their lives and to commit themselves to it. The heterogeneity and fragility of the users' situations, and the treatment objectives require regular assessment during contact with the physician. This constant reappraisal of the situation with the physician should help to optimize the treatment and avoid the hiatus that can generate or continue "misuse."
法国于1996年建立的药物替代或维持治疗体系，与其他国家美沙酮诊所通常附带的严格条件有所不同。由于法国全科医生的主导作用以及苏泊酮灵活的处方规定，医生与吸毒者之间的关系成为治疗的核心要素。本文探讨了这些吸毒者对医生的期望，以及他们对医生对待自己态度的看法。为了找出治疗依从性缺失和苏泊酮滥用的可能原因，研究聚焦于吸毒者对医生对其所报告问题的回应的评估。这项基于28名接受治疗者（19名男性，9名女性）的多样化便利样本的研究，显示了医生与吸毒者之间存在4种关系模式，其关注点各不相同：（1）紧密关注处方剂量；（2）在以医生为主导的关系中，遵守规定疗程是主要问题；（3）医生与被视为人的吸毒者之间结成联盟；（4）吸毒者仅仅出于获取免费合法药物的目的而利用医生。在所有这四种情况中，吸毒者在这种关系中难以报告其他药物使用情况或苏泊酮静脉注射情况，在这种关系中，与药物依赖相关的污名似乎再次出现。此外，治疗目标不明确以及咨询时间框架不清晰，限制了吸毒者将治疗融入其生活并全身心投入治疗的能力。吸毒者情况的异质性和脆弱性以及治疗目标，要求在与医生接触期间进行定期评估。与医生对情况的这种持续重新评估应有助于优化治疗，并避免可能导致或延续“滥用”的脱节情况。
