加拿大更安全的阿片類藥物供應計畫幫助那些面臨過量服用風險的人
資料來源:Carolyn Crist / 2022 年 9 月 27 日 / Medscape / 財團法人台灣紅絲帶基金會編譯
根據新數據,加拿大多倫多附近的更安全的阿片類藥物供應 (SOS) 計畫似乎是一項安全有效的減少危害舉措。
一項分析顯示,該計畫與減少急診就診、住院和整體醫療保健成本有關。此外,在這些過量服用高風險的計畫參與者中沒有與阿片類藥物相關的死亡。
塔拉·戈麥斯博士
研究作者Tara Gomes 博士說:「在開始 SOS 計畫後,不僅醫院急診就診量立即下降,而且過量服用的風險也沒有改變,並且在 1 年的追蹤中沒有出現與阿片類藥物相關的死亡」。多倫多大學衛生政策、管理和評估學系之助理教授,亦是多倫多聖邁克爾醫院李嘉誠知識研究所的科學家,告訴Medscape 醫學新聞。
Gomes 是安大略省藥物政策研究網絡的首席研究員,該網絡是該省研究人員和藥物政策決策者之間的合作項目。
「這些變化在居住在同一個城市的一群相似的人身上並沒有被看到——因此接觸到同樣的非法藥物供應——但他們不是該計畫的一部分,這有助於強調這些變化是特定於參與SOS上的」, 她說。
該研究於 9 月 19 日發表在加拿大醫學協會雜誌上。
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醫院住院率降低
研究人員稱,2016 年至 2021 年期間,加拿大發生了超過 29,000 例與阿片類藥物相關的毒性死亡,這通常是由於藥物供應中芬太尼含量過高所致。作為回應,SOS 計畫已在多個省份啟動,包括安大略省倫敦社區內健康中心的第一個正式 SOS 計畫。作為該計畫的一部分,顧客被開具處方的類阿片類藥物作為芬太尼摻假藥物供應的替代品,並獲得健康和社會支持。
Gomes 及其同事對安大略省倫敦的居民進行了一項中斷時間序列分析 (an interrupted time series analysis),這些居民在 2016 年 1 月至 2019 年 3 月期間被診斷為阿片類藥物使用障礙,並有過與該診斷相關的醫療保健經歷。他們追踪了 82 名進入 SOS 的計畫參與者,以及根據人口統計學和臨床特徵匹配但未參加該計畫的 303 人的對照組。
研究小組關注人群的急診就診次數、住院人數、感染率和醫療保健費用。他們使用整合移動平均自我迴歸模型 (Autoregressive Integrated Moving Average models) 來評估啟動 SOS 計畫的效果,並比較人群在進入該計畫之前和之後一年的結果率。
對於參加該計畫的參與者,急診科就診率每 100 人下降了約 14 次。此外,每 100 人住院人數減少了約 5 人。與初級保健或門診藥物無關的醫療保健費用每人減少了約 922 美元。因感染而入院的比率基本保持不變;調查人員觀察到每 100 人的感染人數減少了約 1.6 人。
在加入該計畫後的一年裡,與前一年相比,SOS 顧客的急診科就診次數、住院人數、感染相關入院人數和總醫療費用顯著下降。
相反,在未參加該計劃的 303 人中,任何測量結果都沒有顯著變化。
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藥物費用增加
Gomes 及其同事指出,這些發現提供了初步證據,表明 SOS 計畫可以在藥物中毒和過量服用高風險人群可用的減害選擇中發揮作用。與此同時,許多問題仍然存在。
例如,儘管參加該計畫的人的總醫療保健費用下降了,但與藥物相關的費用卻增加了。大約 34% 的參與者感染了 HIV,69.5% 的人感染了C型肝炎病毒,28% 的人在進入計畫前一年出現了感染併發症。這一發現可能顯示參與者因吸毒而出現嚴重的醫療併發症,並且能夠尋求醫療保健服務。
「我們認為這是一個積極的發現,因為 SOS 顧客中 HIV 和C型肝炎的患病率非常高。HIV 和C型肝炎的治療可以挽救生命,但價格昂貴」,戈麥斯說。「因此,這些較高的藥物成本可能反映了這些感染的治療途徑得到改善,這可以大大改善人們的健康和生活質量,但從長遠來看也可以節省醫療系統的資金」。
Gomes 及其同事現在開始評估安大略省的其他 SOS 計畫。他們希望更好地了解可用的各種方法,並確定哪些模型可以最好地支持因吸毒而面臨高風險的人。
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有限的解決方案?
卑斯省溫哥華大學社會醫學的博士後研究員、卑斯省藥物濫用中心研究科學家 Andrew Ivsins 博士在評論 Medscape 的這項研究時說:「這是一項重要的研究,也是第一個以前從未存在的透過建立與醫療保健系統的聯繫來展示安全供應如何提供幫助的研究」。
安德魯·艾夫辛斯博士
Ivsins 沒有參與這項研究,他研究了溫哥華周圍的安全供應計畫。他和同事發現,在這些計畫的參與者中,街頭非法購買藥物的使用減少了,從而改善了健康狀況。
「安全供應根本地,是在最基礎的水準上,對北美劇毒藥品供應和中毒危機失控上的反應」,他說。「這是一個有爭議的問題,但它非常有意義,如果殺死人們的是劇毒藥物,我們需要找到一種方法來提供一種不會殺死他們的選擇」。
Marie-Eve Goyer 博士
「到目前為止,更安全的供應主要用於減少使用非法阿片類藥物者的危害,包括死亡率和發病率。但如果我們真的想降低與不受監管的藥物供應上嚴重污染相關的風險,更安全的供應計畫將有需要擴展到所有可能非法銷售的物質」,蒙特婁爾大學家庭醫學助理教授 Marie-Eve Goyer 醫學博士告訴 Medscape Medical News。
Goyer 沒有參與這項研究,他在魁北克進行了關於藥物替代療法的研究。她發現,許多省份現在都在報告新型強效苯二氮卓類 (benzodiazepines) 藥物正在被使用或污染芬太尼的現象,這需要採取更廣泛的方法來解決藥物過量危機。
「讓我們意識到,針對要解決由污名化、刑事定罪和壓制性公共政策構成的流行病,更安全的處方供應只是一種非常醫學化(且有限)的解決方案」,她說。「如果法律沒有真正的改變,我們將繼續看到我們的人民每天都在死亡」。
該研究由安大略省衛生處和加拿大衛生研究院資助。 Gomes 獲得了支持這兩個小組研究的資助,其他作者也獲得了與倫敦社區間健康中心相關的支持或費用。 Ivsins 和 Goyer 則沒有披露任何相關的財務上關係。
參考文獻:
CMAJ。 2022 年 9 月 19 日發布。全文
Carolyn Crist 是一名健康和醫學記者,負責報導 Medscape、MDedge 和 WebMD 的最新研究。
Safer Opioid Supply Program in Canada Helps Those Who Face Overdose Risks
Carolyn Crist / September 27, 2022 / Medscape Medical News © 2022
The Safer Opioid Supply (SOS) Program near Toronto, Canada, appears to be a safe and effective harm-reduction initiative, according to new data.
An analysis indicates that the program is associated with a reduction in emergency department visits, hospitalizations, and overall healthcare costs. In addition, there were no opioid-related deaths among participants who were at high risk of overdose.
Dr Tara Gomes
“Not only did hospital engagements decline immediately after starting SOS programs, but also the risk of overdose did not change, and there were no opioid-related deaths in the 1-year follow-up,” study author Tara Gomes, PhD, an assistant professor of health policy, management, and evaluation at the University of Toronto and a scientist at the Li Ka Shing Knowledge Institute of St. Michael’s Hospital in Toronto, told Medscape Medical News.
Gomes is the lead principal investigator of the Ontario Drug Policy Research Network, a collaboration between researchers and drug policy decision-makers in the province.
“These changes were not seen in a group of similar individuals who lived in the same city — so were exposed to the same illicit drug supply — but who were not part of this program, helping to reinforce that these changes are specific to SOS participation,” she said.
The study was published in the Canadian Medical Association Journal on September 19.
Hospital Admissions Declined
More than 29,000 opioid-related toxicity deaths occurred in Canada between 2016 and 2021, often as a result of high levels of fentanyl in the drug supply, according to the investigators. In response, SOS programs have been launched in several provinces, including the first formal SOS program at the London InterCommunity Health Centre in Ontario. As part of the program, clients are prescribed pharmaceutical opioids as an alternative to the fentanyl-adulterated drug supply and are given health and social supports.
Gomes and colleagues conducted an interrupted time series analysis of residents in London, Ontario, who had received a diagnosis of opioid use disorder and had had a healthcare encounter related to the diagnosis between January 2016 and March 2019. They followed 82 participants who entered the SOS program, as well as a comparison group of 303 people who were matched on the basis of demographic and clinical characteristics but who did not participate in the program.
The research team focused on the population’s numbers of emergency department visits, hospital admissions, infection rates, and healthcare costs. They used autoregressive integrated moving average models to evaluate the effect of starting the SOS program and to compare the population’s outcome rates in the year before and after entering the program.
For participants who entered the program, the rate of emergency department visits declined by about 14 visits per 100 people. In addition, hospital admissions declined by about five admissions per 100 people. Healthcare costs that weren’t related to primary care or outpatient medications declined by about $922 per person. The rate of hospital admission for infections remained about the same; the investigators observed a decline of about 1.6 infections per 100 people.
In the year after entry into the program, emergency department visits, hospital admissions, infection-related admissions, and total healthcare costs declined significantly among SOS clients, compared with the year before.
Conversely, there were no significant changes in any of the measured outcomes among the 303 people who didn’t participate in the program.
Medication Costs Increased
Gomes and colleagues noted that the findings provide preliminary evidence that SOS programs can play a role in the harm-reduction options available to those who are at high risk of drug poisoning and overdose. At the same time, many questions remain.
For instance, although total healthcare costs declined among those enrolled in the program, the medication-related costs increased. About 34% of participants had HIV, 69.5% had hepatitis C virus infection, and 28% had infectious complications in the year before entering the program. This finding may indicate that the participants had serious medical complications resulting from their drug use and were able to seek healthcare services.
“We interpret that to be a positive finding, because of the very high prevalence of HIV and hepatitis C in the SOS clients. Treatments for HIV and hepatitis C are lifesaving but expensive,” said Gomes. “Therefore, these higher medication costs are likely reflective of improved access to treatments for these infections, which can greatly improve people’s health and quality of life but also save the healthcare system money over the longer term.”
Gomes and colleagues are now beginning to evaluate other SOS programs across Ontario. They hope to better understand the various approaches that are available and determine which models can best support people who face high risks because of drug use.
A Limited Solution?
Commenting on the study for Medscape, Andrew Ivsins, PhD, a postdoctoral fellow in social medicine at the University of British Columbia in Vancouver and a research scientist at the British Columbia Centre on Substance Abuse, said, “This is an important study and one of the first to show how safe supply can help by building connections to the healthcare system that didn’t exist previously.”
Dr Andrew Ivsins
Ivsins, who wasn’t involved with this study, has researched safe supply programs around Vancouver. He and colleagues found that among participants in these programs, the use of illicit street-purchased drugs decreased, which led to improved health and wellness.
“Safe supply is fundamentally, at the most basic level, a response to the highly toxic drug supply and out-of-control poisoning crisis in North America,” he said. “It’s a contentious issue, but it makes so much sense that if what’s killing people is highly toxic drugs, we need to find a way to provide an option that doesn’t kill them.”
Dr Marie-Eve Goyer
“Up to now, safer supply has mostly been used to reduce harms, including mortality and morbidity, in persons using illicit opioids. But if we really want to lower the risk linked to heavy contamination of the unregulated drug supply, safer supply programs will have to be extended to all substances potentially sold illegally,” Marie-Eve Goyer, MD, an assistant professor of family medicine at the University of Montreal, told Medscape Medical News.
Goyer, who wasn’t involved with this study, has conducted research about substance replacement therapy in Quebec. She found that many provinces are now reporting on new potent designer benzodiazepines that are being used or that are contaminating fentanyl, which calls for a broader approach to address the drug overdose crisis.
“Let’s realize that safer supply prescription is a very medicalized (and limited) solution to an epidemic that is made of stigma, criminalization, and repressive public policies,” she said. “Without true changes in the law, we will continue to see our people dying every day.”
The study was funded by grants from the Ontario Ministry of Health and the Canadian Institutes of Health Research. Gomes has received grants to support the research of both groups, and other authors has received support or fees related to the London InterCommunity Health Centre. Ivsins and Goyer have disclosed no relevant financial relationships.
CMAJ. Published September 19, 2022. Full text
Carolyn Crist is a health and medical journalist who reports on the latest studies for Medscape, MDedge, and WebMD.