Srivastava Anita, Kahan Meldon, Nader Maya
Associate Professor in the Department of Family and Community Medicine at the University of Toronto in Ontario and a member of the St Joseph's Urban Family Health Team in Toronto.
Associate Professor in the Department of Family and Community Medicine at the University of Toronto and Medical Director of the Substance Use Service at Women's College Hospital in Toronto.
Can Fam Physician. 2017 Mar;63(3):200-205.
To advise physicians on which treatment options to recommend for specific patient populations: abstinence-based treatment, buprenorphine-naloxone maintenance, or methadone maintenance.
PubMed was searched and literature was reviewed on the effectiveness, safety, and side effect profiles of abstinence-based treatment, buprenorphine-naloxone treatment, and methadone treatment. Both observational and interventional studies were included.
Both methadone and buprenorphine-naloxone are substantially more effective than abstinence-based treatment. Methadone has higher treatment retention rates than buprenorphine-naloxone does, while buprenorphine-naloxone has a lower risk of overdose. For all patient groups, physicians should recommend methadone or buprenorphine-naloxone treatment over abstinence-based treatment (level I evidence). Methadone is preferred over buprenorphine-naloxone for patients at higher risk of treatment dropout, such as injection opioid users (level I evidence). Youth and pregnant women who inject opioids should also receive methadone first (level III evidence). If buprenorphine-naloxone is prescribed first, the patient should be promptly switched to methadone if withdrawal symptoms, cravings, or opioid use persist despite an optimal buprenorphine-naloxone dose (level II evidence). Buprenorphine-naloxone is recommended for socially stable prescription oral opioid users, particularly if their work or family commitments make it difficult for them to attend the pharmacy daily, if they have a medical or psychiatric condition requiring regular primary care (level IV evidence), or if their jobs require higher levels of cognitive functioning or psychomotor performance (level III evidence). Buprenorphine-naloxone is also recommended for patients at high risk of methadone toxicity, such as the elderly, those taking high doses of benzodiazepines or other sedating drugs, heavy drinkers, those with a lower level of opioid tolerance, and those at high risk of prolonged QT interval (level III evidence).
Individual patient characteristics and preferences should be taken into consideration when choosing a first-line opioid agonist treatment. For patients at high risk of dropout (such as adolescents and socially unstable patients), treatment retention should take precedence over other clinical considerations. For patients with high risk of toxicity (such as patients with heavy alcohol or benzodiazepine use), safety would likely be the first consideration. However, the most important factor to consider is that opioid agonist treatment is far more effective than abstinence-based treatment.
就针对特定患者群体推荐何种治疗方案向医生提供建议，这些方案包括基于禁欲的治疗、丁丙诺啡 - 纳洛酮维持治疗或美沙酮维持治疗。
检索了PubMed，并对基于禁欲的治疗、丁丙诺啡 - 纳洛酮治疗和美沙酮治疗的有效性、安全性及副作用情况的文献进行了综述。纳入了观察性研究和干预性研究。
美沙酮和丁丙诺啡 - 纳洛酮都比基于禁欲的治疗有效得多。美沙酮的治疗保留率高于丁丙诺啡 - 纳洛酮，而丁丙诺啡 - 纳洛酮的过量用药风险较低。对于所有患者群体，医生应推荐美沙酮或丁丙诺啡 - 纳洛酮治疗而非基于禁欲的治疗（一级证据）。对于治疗中断风险较高的患者，如注射用阿片类药物使用者，美沙酮优于丁丙诺啡 - 纳洛酮（一级证据）。注射阿片类药物的青少年和孕妇也应首先接受美沙酮治疗（三级证据）。如果首先开具丁丙诺啡 - 纳洛酮处方，而尽管丁丙诺啡 - 纳洛酮剂量已达到最佳，但戒断症状、渴望或阿片类药物使用仍持续存在，则应迅速将患者换用美沙酮（二级证据）。对于社会稳定的处方口服阿片类药物使用者，推荐使用丁丙诺啡 - 纳洛酮，特别是如果他们的工作或家庭事务使他们难以每天前往药房，如果他们患有需要定期初级护理的医疗或精神疾病（四级证据），或者如果他们的工作需要较高水平的认知功能或精神运动表现（三级证据）。对于美沙酮毒性高风险患者，如老年人、服用高剂量苯二氮䓬类药物或其他镇静药物的患者、酗酒者、阿片类药物耐受性较低的患者以及QT间期延长风险高的患者，也推荐使用丁丙诺啡 - 纳洛酮（三级证据）。
选择一线阿片类激动剂治疗时应考虑个体患者特征和偏好。对于中断风险高的患者（如青少年和社会不稳定患者），治疗保留应优先于其他临床考虑因素。对于毒性风险高的患者（如大量饮酒或使用苯二氮䓬类药物的患者），安全性可能是首要考虑因素。然而，要考虑的最重要因素是阿片类激动剂治疗远比基于禁欲的治疗有效。
