Fischer Benedikt, Keates Annette, Bühringer Gerhard, Reimer Jens, Rehm Jürgen
Centre for Applied Research in Mental Health and Addictions (CARMHA), Faculty of Health Sciences, Simon Fraser University, Vancouver, Canada; Social and Epidemiological Research Department, Centre for Addiction and Mental Health (CAMH), Toronto, Canada; Department of Psychiatry, University of Toronto, Toronto, Canada.
Addiction. 2014 Feb;109(2):177-81. doi: 10.1111/add.12224. Epub 2013 May 20.
This paper aims to identify possible system-level factors contributing to the marked differences in the levels of non-medical prescription opioid use (NMPOU) and prescription opioid (PO)-related harms in North America (i.e. the United States and Canada) compared to other global regions.
Scientific literature and information related to relevant areas of health systems, policy and practice were reviewed and integrated.
We identified several but different factors contributing to the observed differences. First, North American health-care systems consume substantially more Pos-even when compared to other high-income countries-than any other global region, with dispensing levels associated strongly with levels of NMPOU and PO-related harms. Secondly, North American health-care systems, compared to other systems, appear to have lesser regulatory access restrictions for, and rely more upon, community-based dispensing mechanisms of POs, facilitating higher dissemination level and availability (e.g. through diversion) of POs implicated in NMPOU and harms. Thirdly, we note that the generally high levels of psychotrophic drug use, dynamics of medical-professional culture (including patient expectations for 'effective treatment'), as well as the more pronounced 'for-profit' orientation of key elements of health care (including pharmaceutical advertising), may have boosted the PO-related problems observed in North America.
Differences in the organization of health systems, prescription practices, dispensing and medical cultures and patient expectations appear to contribute to the observed inter-regional differences in non-medical prescription opioid use and prescription opioid-related harms, although consistent evidence and causal analyses are limited. Further comparative examination of these and other potential drivers is needed, and also for evidence-based intervention and policy development.
本文旨在确定与其他全球区域相比，导致北美（即美国和加拿大）非医疗处方阿片类药物使用（NMPOU）水平及处方阿片类药物（PO）相关危害存在显著差异的可能的系统层面因素。
对与卫生系统、政策及实践相关领域的科学文献和信息进行了综述与整合。
我们确定了几个导致观察到的差异的不同因素。首先，北美医疗保健系统消耗的处方阿片类药物比其他任何全球区域都多得多——即使与其他高收入国家相比也是如此，其配药水平与NMPOU水平及PO相关危害密切相关。其次，与其他系统相比，北美医疗保健系统对处方阿片类药物的监管准入限制似乎更少，且更多地依赖基于社区的处方阿片类药物配药机制，这促进了与NMPOU及危害相关的处方阿片类药物的更高传播水平和可得性（例如通过转移）。第三，我们注意到精神药物的普遍高使用水平、医学专业文化动态（包括患者对“有效治疗”的期望），以及医疗保健关键要素（包括药品广告）更明显的“营利性”导向，可能加剧了在北美观察到的与处方阿片类药物相关的问题。
卫生系统组织、处方实践、配药、医学文化及患者期望方面的差异似乎导致了观察到的非医疗处方阿片类药物使用及处方阿片类药物相关危害的区域间差异，尽管一致的证据和因果分析有限。需要对这些及其他潜在驱动因素进行进一步的比较研究，也需要基于证据的干预措施和政策制定。
