Opioid agonist treatment and fatal overdose risk in a state-wide US population receiving opioid use disorder services
Opioid agonist treatment and fatal overdose risk in a state-wide US population receiving opioid use disorder services
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DOI：
10.1111/add.14991
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发表时间：
2020-02-24
期刊：
影响因子：
6
通讯作者：
Saloner, Brendan
中科院分区：
文献类型：
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作者：
Krawczyk, Noa;Mojtabai, Ramin;Saloner, Brendan
背景与目的：随机对照试验的证据表明，美沙酮和丁丙诺啡药物治疗可减少阿片类药物使用并提高治疗留存率。然而，与非药物治疗相比，此类药物在降低美国常规护理环境下接受治疗的患者群体的过量用药风险方面所起的作用鲜为人知。本研究比较了专科护理环境中药物治疗与非药物治疗患者的过量用药死亡率。
设计：回顾性队列研究，使用与死亡记录相关联的全州治疗数据。采用生存分析在事件发生时间框架内分析数据。
地点：2015年1月1日至2016年12月31日期间，美国马里兰州由757家提供者在公共资助的门诊专科治疗项目中提供的服务。
参与者：2015 - 2016年因阿片类药物使用障碍初次诊断而进入门诊专科治疗项目的共48274名成年人。
测量：主要暴露因素为药物治疗（美沙酮/丁丙诺啡）时间、药物治疗后的时间、接受非药物治疗的时间以及非药物治疗后的时间。主要结局是治疗期间和治疗后的阿片类药物过量死亡。使用考克斯比例风险回归计算风险比。根据患者的性别、年龄、种族、居住地区、婚姻和退伍军人状况、就业、无家可归情况、主要使用的阿片类药物、心理健康治疗、被捕情况和刑事司法转诊等信息调整倾向得分权重。
结果：研究人群中有371例阿片类药物过量死亡。与非药物治疗期间相比，药物治疗期间阿片类药物过量死亡的风险大幅降低[调整后的风险比（aHR）= 0.18，95%置信区间（CI）= 0.08 - 0.40]。从非药物治疗出院后的时期（aHR = 5.45，95% CI = 2.80 - 9.53）和药物治疗出院后的时期（aHR = 5.85，95% CI = 3.10 - 11.02）与非药物治疗期间相比，风险相似且大幅升高。
结论：在马里兰州接受阿片类药物专科治疗的患者中，与未接受治疗的时期相比，治疗期间对过量用药有保护作用。在治疗期间，美沙酮和丁丙诺啡与非药物治疗相比，过量死亡风险显著降低，但在治疗停止后则不然。
Background and aims Evidence from randomized controlled trials establishes that medication treatment with methadone and buprenorphine reduces opioid use and improves treatment retention. However, little is known about the role of such medications compared with non-medication treatments in mitigating overdose risk among US patient populations receiving treatment in usual care settings. This study compared overdose mortality among those in medication versus non-medication treatments in specialty care settings.Design Retrospective cohort study using state-wide treatment data linked to death records. Survival analysis was used to analyze data in a time-to-event framework.Setting Services delivered by 757 providers in publicly funded out-patient specialty treatment programs in Maryland, USA between 1 January 2015 and 31 December 2016.Participants A total of 48 274 adults admitted to out-patient specialty treatment programs in 2015-16 for primary diagnosis of opioid use disorder.Measurements Main exposure was time in medication treatment (methadone/buprenorphine), time following medication treatment, time exposed to non-medication treatments and time following non-medication treatment. Main outcome was opioid overdose death during and after treatment. Hazard ratios were calculated using Cox proportional hazard regression. Propensity score weights were adjusted for patient information on sex, age, race, region of residence, marital and veteran status, employment, homelessness, primary opioid, mental health treatment, arrests and criminal justice referral.Findings The study population experienced 371 opioid overdose deaths. Periods in medication treatment were associated with substantially reduced hazard of opioid overdose death compared with periods in non-medication treatment [adjusted hazard ratio (aHR) = 0.18, 95% confidence interval (CI) = 0.08-0.40]. Periods after discharge from non-medication treatment (aHR = 5.45, 95% CI = 2.80-9.53) and medication treatment (aHR = 5.85, 95% CI = 3.10-11.02) had similar and substantially elevated risks compared with periods in non-medication treatments.Conclusions Among Maryland patients in specialty opioid treatment, periods in treatment are protective against overdose compared with periods out of care. Methadone and buprenorphine are associated with significantly lower overdose death compared with non-medication treatments during care but not after treatment is discontinued.