University of California-San Francisco, San Francisco General Hospital, San Francisco, CA, USA.
Am Fam Physician. 2019 Oct 1;100(7):416-425.
Opioid use disorder is highly prevalent and can be fatal. At least 2.1 million Americans 12 years and older had opioid use disorder in 2016, and approximately 47,000 Americans died from opioid overdoses in 2017. Opioid use disorder is a chronic relapsing condition, the treatment of which falls within the scope of practice of family physicians. With appropriate medication-assisted treatment, patients are more likely to enter full recovery. Methadone and buprenorphine are opioid agonists that reduce mortality, opioid use, and HIV and hepatitis C virus transmission while increasing treatment retention. Intramuscular naltrexone is not as well studied and is harder to initiate than opioid agonists because of the need to abstain for approximately one week before the first dose. However, among those who start naltrexone, it can reduce opioid use and craving. Choosing the correct medication for a given patient depends on patient preference, local availability of opioid treatment programs, anticipated effectiveness, and adverse effects. Discontinuation of pharmacotherapy increases the risk of relapse; therefore, patients should be encouraged to continue treatment indefinitely. Many patients with opioid use disorder are treated in primary care, where effective addiction treatment can be provided. Family physicians are ideally positioned to diagnose opioid use disorder, provide evidence-based treatment with buprenorphine or naltrexone, refer patients for methadone as appropriate, and lead the response to the current opioid crisis.
阿片类药物使用障碍的发病率很高，且可能致命。2016 年，至少有 210 万 12 岁及以上的美国人患有阿片类药物使用障碍，2017 年约有 4.7 万名美国人死于阿片类药物过量。阿片类药物使用障碍是一种慢性复发性疾病，其治疗属于家庭医生的实践范围。通过适当的药物辅助治疗，患者更有可能完全康复。美沙酮和丁丙诺啡是阿片类激动剂，可降低死亡率、阿片类药物使用量以及艾滋病毒和丙型肝炎病毒的传播，同时提高治疗保留率。肌肉内注射纳曲酮的研究较少，且由于需要在第一剂前大约一周内禁欲，因此比阿片类激动剂更难启动。然而，对于开始使用纳曲酮的患者，它可以减少阿片类药物的使用和渴望。为特定患者选择正确的药物取决于患者的偏好、当地阿片类药物治疗方案的可用性、预期效果和不良反应。药物治疗的中断会增加复发的风险；因此，应鼓励患者无限期继续治疗。许多患有阿片类药物使用障碍的患者在初级保健中接受治疗，在那里可以提供有效的成瘾治疗。家庭医生是诊断阿片类药物使用障碍、提供丁丙诺啡或纳曲酮循证治疗、酌情转介患者接受美沙酮治疗以及领导应对当前阿片类药物危机的理想人选。
