Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK.
National Drug and Alcohol Research Centre, UNSW Sydney, Sydney, NSW, Australia.
Lancet Psychiatry. 2021 Apr;8(4):301-309. doi: 10.1016/S2215-0366(20)30538-1. Epub 2021 Feb 25.
BACKGROUND: Opioid agonist treatment (OAT) reduces many of the harms associated with opioid dependence. We use mathematical modelling to comprehensively evaluate the overall health benefits of OAT in people who inject drugs in Perry County (KY, USA), Kyiv (Ukraine), and Tehran (Iran). METHODS: We developed a dynamic model of HIV and hepatitis C virus (HCV) transmission, incarceration, and mortality through overdose, injury, suicide, disease-related and other causes. The model was calibrated to site-specific data using Bayesian methods. We evaluated preventable drug-related deaths (deaths due to HIV, HCV, overdose, suicide, or injury) averted over 2020-40 for four scenarios, added incrementally, compared with a scenario without OAT: existing OAT coverage (setting-dependent; community 4-11%; prison 0-40%); scaling up community OAT to 40% coverage; increasing average OAT duration from 4-14 months to 2 years; and scaling up prison-based OAT. OUTCOMES: Drug-related harms contributed differentially to mortality across settings: overdose contributed 27-47% (range of median projections) of preventable drug-related deaths over 2020-40, suicide 6-17%, injury 3-17%, HIV 0-59%, and HCV 2-18%. Existing OAT coverage in Tehran (31%) could have a substantial effect, averting 13% of preventable drug-related deaths, but will have negligible effect (averting <2% of preventable drug-related deaths) in Kyiv and Perry County due to low OAT coverage (<4%). Scaling up community OAT to 40% could avert 12-24% of preventable drug-related deaths, including 13-22% of overdose deaths, with greater effect in settings with significant HIV mortality (Tehran and Kyiv). Improving OAT retention and providing prison-based OAT would have a significant additional effect, averting 27-51% of preventable drug-related deaths. INTERPRETATION: OAT can substantially reduce drug-related harms, particularly in settings with HIV epidemics in people who inject drugs. Maximising these effects requires research and investment into achieving higher coverage and provision and longer retention of OAT in prisons and the community. FUNDING: UK National Institute for Health Research, US National Institute on Drug Abuse.
背景：阿片类激动剂治疗（OAT）可减少与阿片类药物依赖相关的许多危害。我们使用数学模型全面评估了在佩里县（美国肯塔基州）、基辅（乌克兰）和德黑兰（伊朗）注射毒品人群中 OAT 的整体健康益处。
方法：我们开发了一个 HIV 和丙型肝炎病毒（HCV）传播、监禁和因过量、伤害、自杀、疾病相关和其他原因导致的死亡率的动态模型。该模型使用贝叶斯方法针对特定地点的数据进行了校准。我们评估了在四个情景下，2020 年至 2040 年期间可以预防的药物相关死亡（因 HIV、HCV、过量、自杀或伤害导致的死亡），并将这些情景与没有 OAT 的情景进行了比较：现有的 OAT 覆盖率（取决于环境；社区为 4-11%；监狱为 0-40%）；将社区 OAT 覆盖率提高到 40%；将平均 OAT 持续时间从 4-14 个月延长至 2 年；扩大监狱内 OAT。
结果：药物相关危害对不同环境下的死亡率有不同的影响：过量占 2020 年至 2040 年期间可预防药物相关死亡的 27-47%（中位数预测范围），自杀占 6-17%，伤害占 3-17%，HIV 占 0-59%，HCV 占 2-18%。在德黑兰（31%），现有的 OAT 覆盖率可能会产生重大影响，可预防 13%的药物相关死亡，但在基辅和佩里县（<4%），由于 OAT 覆盖率较低（<4%），影响可忽略不计（可预防的药物相关死亡减少<2%）。将社区 OAT 覆盖率提高到 40%，可预防 12-24%的药物相关死亡，包括 13-22%的过量死亡，在 HIV 死亡率较高的地区（德黑兰和基辅）效果更大。提高 OAT 保留率并提供监狱内 OAT 将产生重大的额外影响，可预防 27-51%的药物相关死亡。
解释：OAT 可显著降低药物相关危害，特别是在注射毒品人群中有 HIV 流行的地区。为了最大限度地发挥这些效果，需要研究和投资，以实现更高的覆盖率，并在监狱和社区中提供和延长 OAT 的保留率。
资助：英国国家卫生研究院，美国国立药物滥用研究所。
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