俄羅斯迫切需要阿片類激動劑治療
資料來源:www.thelancet.com/hiv Vol 10 September 2023
阿片類激動劑藥物,包括美沙酮 (methadone) 和丁丙諾啡 (buprenorphine),是治療阿片類藥物使用障礙的挽救生命的治療方法,可減少致命的過量用藥和全死因死亡率,改善照護存留率,並降低物質使用引起的感染性併發症的風險。使用阿片類藥物治療該疾病還與HIV 感染者抗反轉錄病毒治療 (ART) 依從性的提高和HIV 病毒抑制的增加以及C型肝炎以及侵襲性細菌和真菌感染患者預後的改善有關。
Jeffrey Samet 及其同事在《刺胳針HIV》中報導了LINC-II 試驗的結果,這是一項在俄羅斯進行的隨機對照開放試驗,比較了擴大接受ART、納曲酮(naltrexone,用於治療阿片類藥物使用障礙)和病例管理服務與未接受抗反轉錄病毒治療且患有阿片類藥物使用障礙的愛滋病毒感染者的當前照護標準。作者發現,在 12 個月的研究期間,接受干預的參與者在 12 個月時 HIV 病毒抑制的機率更高,照護存留率更高,並且 ART 覆蓋率更高。我們讚揚這項重要研究的作者,該研究強調了阿片類藥物使用障礙和愛滋病毒患者治療方面的差距,特別是考慮到在俄羅斯完成這項工作的固有困難。 LINC-II 試驗的結果強調了多學科照護在愛滋病毒治療中的重要性,特別是對於患有物質使用障礙的人。然而,將治療阿片類藥物使用障礙的藥物限制為納曲酮,而不是提供美沙酮或丁丙諾啡的治療,這兩種藥物被世衛組織視為基本藥物,並且是美國和世界其他地區的照護標準,從而無法挽救高危人群的生命並發揮治療高效作用。
正如作者所描述的,與世界其他大部分地區相比,俄羅斯的愛滋病毒流行在過去十年中迅速蔓延。這種流行病是由性傳播和注射相關傳播造成的,但由於持續的政策和計畫失敗而得以延續,包括缺乏減害計畫和教育活動,以及對吸毒的刑事定罪。同樣,有在俄羅斯,愛滋病毒和注射吸毒普遍存在恥辱。這些因素嚴重阻礙了對注射吸毒愛滋病毒感染者的照護,並顯示需要進一步宣傳和干預。作為專門從事阿片類藥物使用障礙患者工作的傳染病專家,我們親眼目睹了擴大阿片類藥物激動劑治療的可及性,對個人和社區層在面對阿片類藥物激動劑治療上的迫切需求之影響。隨著其他國家努力實施其他減害的策略,例如開設過量預防中心、提供安全供應或放寬美沙酮法規,這項研究的結果強調迫切需要確保在全球範圍內獲得阿片類藥物使用障礙的黃金標準治療。我們強烈鼓勵俄羅斯政策制定者考慮採取更加務實、以患者為中心、懲罰性較小的策略來解決藥物濫用和愛滋病毒傳播問題。
LINC-II 試驗和早期的 LINC 試驗的結果支持在俄羅斯擴大綜合照護和基於優勢的病例管理,用於治療愛滋病毒和阿片類藥物使用障礙,並顯示了潛在的前進方向,儘管目前缺乏機會,儘管其他工作已經顯示在線平台和其他創新方法在這種情況下提供減害服務的有用性,但如果沒有阿片類激動劑治療,這些舉措的成功將是有限的。我們讚揚作者這項引人注目的工作並提出,俄羅斯當前的社會政治不穩定,可能為重新考慮政策和解決圍繞愛滋病毒和阿片類藥物使用障礙治療帶來的恥辱提供了機會。我們希望 LINC-II 試驗的結果能夠帶來政策改變並消除結構性障礙,以確保俄羅斯人民能夠獲得循證的救命照護,從而遏制持續的愛滋病毒流行。
JR 是藥物政策聯盟的董事會成員、Jeffrey Samet 多項研究的數據和安全監測委員會成員(但不是 LINC 或 LINC-II),並獲得了生物醫學卓越研究中心 (COBRE) 阿片類藥物和過量用藥的資助(資助號 P20GM125507),他是普羅維登斯/波士頓愛滋病研究中心的一名教員(資助號P30AI042853),該中心促進了這項工作。 LH 和 NR 聲明不存在競爭利益。
*利亞·哈維、娜塔莎·瑞巴克、喬賽亞·里奇 lharvey@lifespan.org
美國羅德島普羅維登斯布朗大學沃倫阿爾珀特醫學院傳染病科(LH、NR、JR);美國羅德島普羅維登斯米里亞姆醫院健康與司法轉型中心(JR、LH );在美國羅得島州普羅維登斯羅德島醫院生物醫學卓越研究中心 (COBRE) 研究阿片類藥物和過量用藥(JR、LH)
The urgent need for opioid agonist treatment in Russia
www.thelancet.com/hiv Vol 10 September 2023
Opioid agonist medications, including methadone and buprenorphine, are life-saving treatments for opioid use disorder that reduce fatal overdose and all-cause mortality, improve retention in care, and reduce risk of infectious complications of substance use. Treatment with medications for opioid use disorder is also associated with increased antiretroviral therapy (ART) adherence and HIV viral suppression for people with HIV, as well as improved outcomes for patients with hepatitis C and invasive bacterial and fungal infections.
In The Lancet HIV, Jeffrey Samet and colleagues3 report the results of the LINC-II trial, an open-label, randomised controlled trial in Russia comparing expanded access to ART, naltrexone (for treatment of opioid use disorder), and case management services versus the current standard of care among people with HIV with opioid use disorder who are not on ART. The authors found that participants who received the intervention had higher odds of HIV viral suppression at 12 months, better retention in care, and higher ART coverage over the 12-month study period. We commend the authors on this important study highlighting gaps in treatment for people with opioid use disorder and HIV, particularly in light of the inherent difficulties accomplishing this work in Russia. The results of the LINC-II trial highlight the importance of multidisciplinary care in the treatment of HIV, particularly for people with substance use disorders. However, limiting medication for opioid use disorder to naltrexone, rather than providing treatment with methadone or buprenorphine, which are considered essential medicines by WHO and are the standard of care in the USA and other parts of the world, withholds life-saving and highly effective treatment from this population at high risk.
As the authors describe, in contrast to much of the rest of the world, Russia has had a burgeoning HIV epidemic for the past decade. This epidemic has been driven by both sexual and injection-associated transmission but has been perpetuated by ongoing policy and programmatic failures, including a scarcity of harm reduction programmes and educational campaigns, as well as the criminalisation of drug use. Likewise, there is pervasive stigma around both HIV and injection drug use in Russia. These factors substantially impede care for people with HIV who inject drugs and suggest the need for further advocacy and intervention. As infectious disease specialists with expertise working with patients with opioid use disorder, we have seen firsthand the effect of expanding access to opioid agonist treatment on both an individual The urgent need for opioid agonist treatment in Russia and a community level. As other nations grapple with implementing other harm reduction strategies, such as opening overdose prevention centres, providing safe supplies, or liberalising methadone regulations, the results of this study underscore the urgent need to ensure access to the gold standard treatment for opioid use disorder worldwide. We strongly encourage Russian policy makers to consider a more pragmatic and patientcentred and less punitive strategy to address substance use and HIV transmission.
The results of the LINC-II trial, and the earlier LINC trial, support the expansion of integrated care and strengthsbased case management for the treatment of HIV and opioid use disorder in Russia and show a potential way forward, despite the current lack of access to opioid agonist treatment. Although other work has shown the usefulness of online platforms and other innovative approaches for the provision of harm reduction services in this setting, these initiatives will have limited success without access to opioid agonist treatment. We commend the authors on this compelling work and propose that the current sociopolitical instability in Russia might provide an opportunity to reconsider policies and address stigma surrounding treatment of HIV and opioid use disorder. We hope that the results of the LINC-II trial lead to policy change and the removal of structural barriers to ensure that people in Russia have access to evidence-based, life-saving care in order to stem the ongoing HIV epidemic.
JR serves on the board of directors of the Drug Policy Alliance, on the data and safety monitoring board of several studies of Jeffrey Samet (but not LINC or LINC-II), had received funding from COBRE Opioids and Overdose (grant number P20GM125507), and is a faculty member at the Providence/Boston Center for AIDS Research (grant number P30AI042853), which facilitated this work. LH and NR declare no competing interests.
*Leah Harvey, Natasha Rybak, Josiah Rich lharvey@lifespan.org
Division of Infectious Diseases, The Warren Alpert Medical School, Brown University, Providence, RI, USA (LH, NR, JR);The Center for Health and Justice Transformation, The Miriam Hospital, Providence, RI, USA (JR, LH); The Center of Biomedical Research Excellence (COBRE) COBRE on Opioid and Overdose at Rhode Island Hospital, Providence, RI, USA (JR, LH)