Changing Outdated Methadone Regulations That Harm Pregnant Patients.
Changing Outdated Methadone Regulations That Harm Pregnant Patients.
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DOI：
10.1097/adm.0000000000000720
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发表时间：
2021-04-01
影响因子：
5.5
通讯作者：
von Klimo MC
中科院分区：
文献类型：
--
作者：
McCarthy JJ;Jones HE;Terplan M;Rudolf VP;von Klimo MC
自 1974 年以来，尽管人们对阿片类药物使用障碍 (OUD) 的性质以及药物在其治疗中的作用的理解取得了进展，但美沙酮法规变化甚微。当时，大多数 OUD 患者被认为患有反社会人格障碍，法规旨在对药物获取进行最大程度的控制。无论距离、儿童保育和其他社会责任如何，都需要连续几个月去六到七天的诊所就诊。除非满足严格和公式化的条件，否则不允许将药物带回家。尽管成瘾医学拒绝了“犯罪”范式，转而将 OUD 作为一种可治疗的疾病，但美沙酮法规并没有跟上科学的步伐。怀孕的特点是超快速的代谢状态，但法规禁止使用每日分剂量的美沙酮来维持稳定。这导致母体/胎儿阿片类药物戒断反复发作，以及其他胎儿生理异常。干扰剂量方案调整会阻碍最佳结果。此外，美沙酮诊所大多位于城市，农村地区的患者无法获得美沙酮诊所的服务。当阿片类药物危机爆发时，这导致了过高的发病率和死亡率。当 Covid-19 到来时，仅仅扩大过度拥挤的城市诊所的容量就造成了传染威胁。孕妇（以及有孩子的父母）被迫在危险条件下协商剂量。修订后的美沙酮系统必须提供局部、灵活且规模有限的治疗，以控制病毒传染风险。这种监管变化最容易通过改变对孕妇产生不利影响的法规来启动。
Methadone regulations have changed minimally since 1974, despite advances in the understanding of the nature of opioid use disorder (OUD) and the role of medications in its treatment. At that time, most patients with OUD were considered to have anti-social personality disorders and the regulations aimed to exert maximal control over medication access. Six or seven day clinic attendance is required for months, regardless of distance, or childcare and other social responsibilities. Take home medications are not allowed unless rigid and formulaic conditions are met. While addiction medicine has rejected the ‘criminal’ paradigm in favor of OUD as a treatable medical disorder, methadone regulations have not kept pace with the science. Pregnancy is characterized by an ultra-rapid metabolic state, but regulations prevent the use of daily divided doses of methadone to maintain stability. This results in repeated episodes of maternal/fetal opioid withdrawal, as well as other fetal physiologic abnormalities. Interference with dose regimen adjustments prevents optimal outcomes. Further, methadone clinics are mostly urban, leaving patients in rural areas without access. This led to excessive morbidity and mortality when the opioid crisis hit. The response of merely expanding capacity in overcrowded urban clinics created a contagion menace when Covid-19 arrived. Pregnant women (and parents with children) were forced to negotiate dosing in dangerous conditions. A revised methadone system must provide treatment that is local, flexible, and limited in size to manage viral contagion risks. This regulatory change can most easily be started by changing regulations that adversely affect pregnant women.