评估完成 OAT 诱导和长期保留的决定因素：加拿大不列颠哥伦比亚省的一项基于人群的研究。
Assessing the determinants of completing OAT induction and long-term retention: A population-based study in British Columbia, Canada.
机构信息
Centre for Health Evaluation and Outcome Sciences, Vancouver, British Columbia, Canada.
Centre for Health Evaluation and Outcome Sciences, Vancouver, British Columbia, Canada; Faculty of Health Sciences, Simon Fraser University, Vancouver, British Columbia, Canada.
出版信息
J Subst Abuse Treat. 2022 Feb;133:108647. doi: 10.1016/j.jsat.2021.108647. Epub 2021 Oct 26.
BACKGROUND
Pharmacological treatments for opioid use disorder are essential, life-saving medications, yet successful induction of them and long-term retention on them is limited in many settings. Induction into opioid agonist treatment (OAT) features the highest risk of mortality throughout the treatment course, and greatest risk of discontinuation. We aimed to identify determinants of completing OAT induction and, among those completing induction, time to OAT discontinuation in British Columbia (BC), Canada.
METHODS
We conducted a retrospective study using linked population-level health administrative databases to capture all individuals in BC receiving at least one OAT dispensation from January 1, 2008, to September 30, 2018. We constructed covariates capturing client demographics, clinical history, and characteristics of the treatment episode and the primary prescribing physician. We estimated a two-part model to identify determinants of the probability of completing induction using a generalized linear mixed model with logit link and the time to OAT discontinuation among those completing induction using a Cox proportional hazards frailty model.
RESULTS
We observed 220,474 OAT episodes (73.9% initiated with methadone, 24.7% with buprenorphine, and 1.4% with slow-release oral morphine) among 45,608 individuals over the study period. Less than 60% of all OAT episodes completed induction (59.0% for methadone episodes, 56.7% for buprenorphine/naloxone, 41.0% for slow-release oral morphine) and half of all episodes that completed induction reached the minimum effective dosage (51.0% for methadone episodes [60 mg/day], 48.2% for buprenorphine/naloxone [12 mg/day], 59.4% for slow-release oral morphine [240 mg/day]). In multiple regression analysis, the adjusted odds of completing induction with buprenorphine improved over time, exceeding that of methadone in 2018: 1.46 (1.40, 1.51). For those who completed induction, buprenorphine use was associated with shorter times to discontinuation throughout the study period, but the estimated rate of discontinuation decreased over time (adjusted hazard ratio, vs. methadone in 2008: 2.50 (2.35, 2.66); in 2018: 1.79 (1.74, 1.85)).
CONCLUSION
We found low rates of completing OAT induction and, for those who did complete it, low rates of reaching the minimum effective dose.
背景
阿片类药物使用障碍的药物治疗是必不可少的救命药物，但在许多情况下，成功诱导和长期维持治疗的效果有限。在整个治疗过程中，阿片类激动剂治疗（OAT）的诱导阶段风险最高，停药风险最大。我们旨在确定在不列颠哥伦比亚省（BC）完成 OAT 诱导的决定因素，以及在完成诱导的人群中，OAT 停药的时间。
方法
我们使用链接的人群水平健康管理数据库进行了一项回顾性研究，以捕获 2008 年 1 月 1 日至 2018 年 9 月 30 日期间在 BC 接受至少一次 OAT 配药的所有个体。我们构建了包含客户人口统计学、临床病史以及治疗期和主要处方医生特征的协变量。我们使用广义线性混合模型（对数链接）估计了一个两部分模型，以确定完成诱导的概率的决定因素，并使用 Cox 比例风险脆弱模型估计了在完成诱导的人群中 OAT 停药的时间。
结果
在研究期间，我们观察到 45608 名个体中的 220474 个 OAT 发作（73.9%以美沙酮起始，24.7%以丁丙诺啡起始，1.4%以缓释口服吗啡起始）。少于 60%的所有 OAT 发作完成了诱导（美沙酮发作的 59.0%，丁丙诺啡/纳洛酮的 56.7%，缓释口服吗啡的 41.0%），并且一半的发作完成了诱导达到了最低有效剂量（美沙酮发作的 51.0%[60mg/天]，丁丙诺啡/纳洛酮的 48.2%[12mg/天]，缓释口服吗啡的 59.4%[240mg/天]）。在多元回归分析中，丁丙诺啡完成诱导的调整后几率随着时间的推移而提高，在 2018 年超过了美沙酮：1.46（1.40，1.51）。对于那些完成诱导的人，丁丙诺啡的使用与整个研究期间停药时间较短有关，但估计的停药率随时间下降（与 2008 年的美沙酮相比，调整后的危险比：2.50（2.35，2.66）；2018 年：1.79（1.74，1.85））。
结论
我们发现 OAT 诱导完成率较低，对于那些完成诱导的人，达到最低有效剂量的比例也较低。
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