RAND Corporation, 1776 Main Street, Santa Monica, CA 90407, United States.
J Subst Abuse Treat. 2018 Jun;89:28-51. doi: 10.1016/j.jsat.2018.03.001. Epub 2018 Mar 13.
This systematic review synthesizes evidence on the effects of Medication-Assisted Treatment (MAT) for opioid use disorder (OUD) on functional outcomes, including cognitive (e.g., memory), physical (e.g., fatigue), occupational (e.g., return to work), social/behavioral (e.g., criminal activity), and neurological (e.g., balance) function. Five databases were searched from inception to July 2017 to identify English-language controlled trials, case control studies, and cohort comparisons of one or more groups; cross-sectional studies were excluded. Two independent reviewers screened identified literature, abstracted study-level information, and assessed the quality of included studies. Meta-analyses used the Hartung-Knapp method for random-effects models. The quality of evidence was assessed using the GRADE approach. A comprehensive search followed by 1411 full text publication screenings yielded 30 randomized controlled trials (RCTs) and 10 observational studies meeting inclusion criteria. The studies reported highly diverse functional outcome measures. Only one RCT was rated as high quality, but several methodologically sound observational studies were identified. The statistical power to detect differences in functional outcomes was unclear in most studies. When compared with matched "healthy" controls with no history of substance use disorder (SUD), in two studies MAT patients had significantly poorer working memory and cognitive speed. One study found MAT patients scored worse in aggressive responding than did "healthy" controls. A large observational study found that MAT users had twice the odds of involvement in an injurious traffic accident as non-users. When compared with persons with OUD not on MAT, one cohort study found lower fatigue rates among buprenorphine-treated OUD patients. No differences were reported for occupational outcomes and results for criminal activity and other social/behavioral areas were mixed. There were few differences among MAT drug types. A pooled analysis of three RCTs found a significantly lower prevalence of fatigue with buprenorphine compared to methadone, while a meta-analysis of the same RCTs found no statistical difference in insomnia prevalence. Three RCTs that focused on cognitive function compared the effects of buprenorphine to methadone; no statistically significant differences in memory, cognitive speed and flexibility, attention, or vision were reported. The quality of evidence for most functional outcomes was rated low or very low. In sum, weaknesses in the body of evidence prevent strong conclusions about the effects of MAT for opioid use disorder on functional outcomes. Rigorous studies of functional effects would strengthen the body of literature.
本系统评价综合了药物辅助治疗（MAT）治疗阿片类药物使用障碍（OUD）对认知（如记忆）、身体（如疲劳）、职业（如重返工作岗位）、社会/行为（如犯罪活动）和神经（如平衡）功能等功能结果的影响的证据。从建库到 2017 年 7 月，我们在五个数据库中检索了英文对照试验、病例对照研究和一组或多组队列比较研究，排除了横断面研究。两位独立的审查员筛选了确定的文献，提取了研究水平的信息，并评估了纳入研究的质量。荟萃分析采用 Hartung-Knapp 法进行随机效应模型分析。使用 GRADE 方法评估证据质量。全面检索后，对 1411 篇全文出版物进行了筛选，得到 30 项随机对照试验（RCT）和 10 项符合纳入标准的观察性研究。这些研究报告了非常多样化的功能结果测量。只有一项 RCT 被评为高质量，但也确定了一些方法合理的观察性研究。在大多数研究中，检测功能结果差异的统计能力尚不清楚。与没有物质使用障碍（SUD）病史的匹配“健康”对照组相比，在两项研究中，MAT 患者的工作记忆和认知速度明显较差。一项研究发现，MAT 患者的攻击反应得分高于“健康”对照组。一项大型观察性研究发现，MAT 用户发生伤害性交通事故的可能性是未使用者的两倍。与未接受 MAT 治疗的 OUD 患者相比，一项队列研究发现，丁丙诺啡治疗的 OUD 患者疲劳发生率较低。职业结果无差异，犯罪活动和其他社会/行为领域的结果参差不齐。MAT 药物类型之间差异不大。三项 RCT 的汇总分析发现，与美沙酮相比，丁丙诺啡的疲劳发生率显著降低，而对同一 RCT 的荟萃分析发现，失眠的患病率没有统计学差异。三项专注于认知功能的 RCT 比较了丁丙诺啡与美沙酮的效果，报告记忆、认知速度和灵活性、注意力或视力没有统计学差异。大多数功能结果的证据质量被评为低或极低。总之，证据的局限性使得无法对 MAT 治疗 OUD 对功能结果的影响得出强有力的结论。对功能影响的严格研究将加强文献体系。
