Is There a Need for Heroin Substitution Treatment in Vancouver's Downtown Eastside?
Is There a Need for Heroin Substitution Treatment in Vancouver's Downtown Eastside?
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DOI：
10.1007/bf03404152
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发表时间：
2011-03-01
影响因子：
4.3
通讯作者：
Conway, Brian
中科院分区：
文献类型：
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作者：
Kahan, Meldon;Srivastava, Anita;Conway, Brian
北美阿片类药物治疗倡议(NAOMI)是在温哥华和蒙特利尔进行的一项随机对照试验，比较海洛因成瘾者的海洛因替代疗法(HST)和美沙酮疗法(MT)。HST组的治疗保留率高于MT组，而非法海洛因使用率低于MT组。尽管这项研究设计得很严谨，但系统性的缺陷影响了对结果的解释。在MT组，剂量滴定缓慢，导致早期脱落率高。平均维持剂量是次优的。研究人员没有计算治疗期间的保留率；在试验结束时，服用MT的受试者比服用HST的受试者更多。危及生命的事件在HST组比MT组更常见。总体而言，与MT相比，HST唯一明显的优势是其更大的初始治疗吸引力，导致MT组中更多的人早期辍学。HST是为治疗难治性成瘾者而设计的，他们别无选择，只能在街头使用海洛因。然而，对于大多数Naomi受试者来说，最安全和最具成本效益的方法是综合MT或丁丙诺啡，以及最佳剂量、灵活的计划政策以及提供综合的初级保健和社会服务。考虑到HST的风险、成本和不确定的效果，这些经过验证的战略目前在温哥华市中心东区缺乏，应该在将本已不足的资源转移到HST之前实施。
The North American Opiate Medication Initiative (NAOMI) was a randomized controlled trial conducted in Vancouver and Montreal comparing heroin substitution treatment (HST) to methadone treatment (MT) for heroin addicts. The HST group had a higher treatment retention rate and lower illicit heroin use than the MT group. Despite the rigour with which the study was designed, systematic flaws have affected the interpretation of the results. In the MT arm, the dose was titrated slowly, contributing to the high early dropout rate. The mean maintenance dose was suboptimal. The investigators did not calculate on-treatment retention rates; by the end of the trial, more subjects were on MT than HST. Life-threatening events were more common in the HST than the MT group. Overall, the only clear advantage of HST over MT was its greater initial treatment attractiveness, resulting in more early drop-outs in the MT group.HST is intended for treatment-refractory addicts who have no other option but to use street heroin. Yet for most NAOMI subjects, the safest and most cost-effective approach is comprehensive MT or buprenorphine with optimal dosing, flexible program policies, and the provision of integrated primary care and social services. These proven strategies, currently lacking in Vancouver's Downtown Eastside, should be implemented before diverting already insufficient resources to HST, given its risks, cost and uncertain efficacy.