Lee Joshua D, Grossman Ellie, DiRocco Danae, Gourevitch Marc N
New York University School of Medicine, New York, NY, USA.
J Gen Intern Med. 2009 Feb;24(2):226-32. doi: 10.1007/s11606-008-0866-8. Epub 2008 Dec 17.
Buprenorphine can be used for the treatment of opioid dependence in primary care settings. National guidelines recommend directly observed initial dosing followed by multiple in-clinic visits during the induction week. We offered buprenorphine treatment at a public hospital primary care clinic using a home, unobserved induction protocol.
Participants were opioid-dependent adults eligible for office-based buprenorphine treatment. The initial physician visit included assessment, education, induction telephone support instructions, an illustrated home induction pamphlet, and a 1-week buprenorphine/naloxone prescription. Patients initiated dosing off-site at a later time. Follow-up with urine toxicology testing occurred at day 7 and thereafter at varying intervals. Primary outcomes were treatment status at week 1 and induction-related events: severe precipitated withdrawal, other buprenorphine-prompted withdrawal symptoms, prolonged unrelieved withdrawal, and serious adverse events (SAEs).
Patients (N = 103) were predominantly heroin users (68%), but also prescription opioid misusers (18%) and methadone maintenance patients (14%). At the end of week 1, 73% were retained, 17% provided induction data but did not return to the clinic, and 11% were lost to follow-up with no induction data available. No cases of severe precipitated withdrawal and no SAEs were observed. Five cases (5%) of mild-to-moderate buprenorphine-prompted withdrawal and eight cases of prolonged unrelieved withdrawal symptoms (8% overall, 21% of methadone-to-buprenorphine inductions) were reported. Buprenorphine-prompted withdrawal and prolonged unrelieved withdrawal symptoms were not associated with treatment status at week 1.
Home buprenorphine induction was feasible and appeared safe. Induction complications occurred at expected rates and were not associated with short-term treatment drop-out.
丁丙诺啡可用于基层医疗环境中阿片类药物依赖的治疗。国家指南建议直接观察初始剂量，随后在诱导周期间进行多次门诊就诊。我们在一家公立医院的基层医疗诊所采用在家自行诱导的方案提供丁丙诺啡治疗。
参与者为符合门诊丁丙诺啡治疗条件的阿片类药物依赖成年人。初次就诊时，医生会进行评估、教育、提供诱导期电话支持指导、一份图文并茂的在家诱导手册以及为期1周的丁丙诺啡/纳洛酮处方。患者随后在其他地点开始服药。在第7天及之后以不同间隔进行尿毒理学检测随访。主要结局指标为第1周的治疗状态以及与诱导相关的事件：严重戒断反应、其他丁丙诺啡引发的戒断症状、戒断症状持续未缓解以及严重不良事件（SAE）。
患者（N = 103）主要为海洛因使用者（68%），但也有处方阿片类药物滥用者（18%）和美沙酮维持治疗患者（14%）。在第1周结束时，73%的患者继续接受治疗，17%提供了诱导期数据但未返回诊所，11%失访且无诱导期数据。未观察到严重戒断反应和严重不良事件病例。报告了5例（5%）轻度至中度丁丙诺啡引发的戒断反应以及8例戒断症状持续未缓解病例（总体为8%，美沙酮转换为丁丙诺啡诱导者中为21%）。丁丙诺啡引发的戒断反应和戒断症状持续未缓解与第1周的治疗状态无关。
在家进行丁丙诺啡诱导是可行的且似乎是安全的。诱导期并发症发生率符合预期，且与短期治疗中断无关。
