鴉片類藥物和甲基安非他命：兩個危機的故事

資料來源：www.thelancet.com Vol 391 February 24, 2018；財團法人台灣紅絲帶基金會編譯

在美國與鴉片類藥物有關的死亡事件透過很多方式亳無節制的增加，目前已是最糟糕的時期。 2012年處方量達到2.55億次（每100人有81·3次），隨後下降了15％左右。然而因鴉片類藥物相關之死亡率繼續上升。在過量死亡嚴峻度的排名中，非法製造的芬太尼和類似物大幅的增加，在2016年聲稱有超過20,100名的美國人因其過量而死亡。天然和半合成鴉片類藥物如羥二氫可待因酮和嗎啡的死亡率仍然非常高（14,400名）。然而，儘管鴉片類藥物的危機爆發，但甲基安非他命其流行的過程已悄然由平靜期迅速地扭轉，現在已佔藥物過量死亡總數的11％。

   大量與鴉片類藥物有關的死亡人數絕對占據了全國對話的主導地位。但是，這一焦點可能會由藥物的大量使用和過量問題分散轉移至藥物的種類上。以前認為甲基安非他命和鴉片類藥物危機是獨特且各自影響不同的人群。但包括在威斯康新州和奧勒岡州在內的地方，新的模式隨著越來越多的人使用這兩種藥物顯示它們已經開始重疊。甲基安非他命和鴉片類藥物的使用具有破壞性，並伴隨著生產力的喪失、對家庭的有害影響，並在介入措施和治療上虹吸了大量的資源。它們也是促成醫療、執法、行業和政府政策間潛在衝突的多因素流行病。甲基安非他命和鴉片類藥物危機間的幾個緊密關聯，如其費用、控制以及後果等直到最近才受到審視。

    2005年，在甲基安非他命流行的高峰期，其經濟負擔高達483億美元。相比之下，Altarum健康研究公司在2018年2月的一份分析報告中估計，美國因鴉片類藥物危機的花費超過1兆美元，僅單單2017年就出現1,150億美元的估價。個人和私人部門的花費是巨大的，而這些經費數字依聯邦政府之預算規模並非微不足道的。儘管據報導政府正在尋求將阿片類藥物的資金增加至130億美元以用於預防和治療，但川普政府2019年在衛生和人類服務部的擬議預算總額僅為684億美元，許多專家認為這樣的編列太少且太晚了。儘管在2017年10月該項流行狀況已被宣佈為全國緊急情況，而總統的鴉片藥物委員會的呼籲卻僅是要求在邊界上阻礙藥品供應者，且由於未能有效地納入藥物政策相關的專家而被大幅地嘲笑。

過去對甲基安非他命控制上的努力對阿片類藥物相關的政策亦具有影響。在2012年，針對製藥公司的抗議活動，國會授權禁毒執法機構限制可用於合成甲基安非他命的含偽麻黃鹼的減充血劑之非處方銷售。藥物的取得受到了幾年的抑制，但也導致墨西哥生產的廉價、高質量的甲基安非他命現已淹沒市場。美國海關和邊境保護局報告甲基安非他命之緝獲量大幅增加，全國使用率已上升至4％左右。公共衛生對鴉片類藥物優先性的轉變使得甲基安非他命之市場蓬勃發展並為其再復發流行做好準備。

    透過處方和非法途徑向用戶提供，讓鴉片類藥物取得的途徑明顯更多元。例如，芬太尼是為合法使用而生產的，但中國薄弱的製造規範導致了非法出口。在沒有其他預防和治療選擇方案的情況下，加強美國邊境管制是一種短視的戰略，除了改變供應商的地理位置之外，也不太可能做得太多。製藥公司也必須對他們在此項危機中所應受譴責和策略部份所扮演的部份負起責任。除了積極向醫生宣傳錯誤信息之外，在2018年2月參議院的報告中之詳盡證據，亦顯示對倡導團體宣傳“鴉片類藥物友好信息”的財務誘因。大多數州現在已經制定了限制鴉片類藥物處方的立法，但充足的資金和強有力的遊說努力已經使製藥商不受影響。

    當地方公共衛生當局、急診室和急救人員因鴉片類藥物所造成數千人的過早死亡而疲於奔命時，因此當面對第二次甲基安非他命流行波開始時，前景可能比預期更加可怕。甲基安非他命和阿片類藥物的合併使用增加了藥品注射和愛滋病毒傳播的可能性，特別是在公共衛生資源嚴重靠徵稅的美國地區。如果不仔細考慮過去的努力所帶來的不良後果，且以有限的範圍和資金承諾提供治療和介入措施，這些危機就會融合，絕望的寒冬將會持續下去。

Opioids and methamphetamine: a tale of two crises

資料來源：www.thelancet.com Vol 391 February 24, 2018

The unchecked acceleration of opioid-related deaths in the USA is, by many measures, the worst of times. Prescriptions peaked in 2012 at more than 255 million(81·3 per 100 persons), then subsequently declined by about 15%. Yet the rate of opioid-related deaths has continued to rise. In the grim ranking of overdose deaths,illegally manufactured fentanyl and analogues have made the most drastic gains, claiming over 20 100 Americans in 2016. Deaths from natural and semisynthetic opioids, such as oxycodone and morphine, remain exceedingly high (14 400). But while the opioid crisis has exploded, the lull in the methamphetamine epidemic has quietly and swiftly reversed course, now accounting for 11% of the total number of overdose deaths.

   The sheer number of opioid-related deaths has dominated the national conversation. However, that focus could distract from the larger issues of use and overdose across classes of drugs. The methamphetamine and opioid crises were previously considered distinct and affecting different populations. But in states including Wisconsin and Oregon, new patterns suggest they are beginning tooverlap as increasing numbers of people use both drugs. Methamphetamine and opioid use are destructive and associated with loss of productivity, deleterious effects on families, and siphon substantial resources for intervention and treatment. They are also multifactorial epidemics urged on by underlying conflicts among health-care, law enforcement, industry, and government policies. There are several strong connections between the methamphetamine and opioid crises that have only recently come under scrutiny—namely costs, control, and consequences.

    In 2005, at the peak of the methamphetamine epidemic, the economic burden was placed as high as US$48·3 billion. In comparison, a February, 2018 analysis by the health research firm Altarum estimated the opioid crisis in the USA has cost in excess of $1 trillion, with an estimated price tag of $115 billion for 2017 alone. Individual and private sector costs are enormous, but these are not trivial numbers in the scope of the federal budget. The Trump administration’s 2019 total proposed budget for Health and Human Services is only $68·4 billion, although it is reportedly seeking to expand opioid funding by $13 billion for prevention and treatment. Many experts have suggested that it is too little, too late. Although, the epidemic was declared a national emergency in October, 2017, the President’s Commission on opioids has led to little more than calls for a border wall to impede suppliers and has largely been derided for failing to meaningfully include drug policy experts.

    Previous control efforts with methamphetamine have relevant policy implications for opioids. In 2012, over the protests of pharmaceutical companies, Congress authorised the Drug Enforcement Agency to limit over-the-counter sales of decongestants containing pseudoephedrine used to synthesise methamphetamine.Availability was dampened for a few years, but cheap, highquality methamphetamine produced in Mexico has now flooded the market. US Customs and Border Protectionhave reported a massive increase in methamphetamine seizures and use nationally has risen to about 4%. The shift in public health priorities to opioids has left the methamphetamine market to flourish and primed for resurgence.

     Access to opioids is notably more varied, reaching users via prescription and illicit routes. Fentanyl, for example, is produced for legal uses, but weak manufacturing regulations in China have led to illicit exporting. Ramping up US border control in the absence of other prevention and treatment options is a myopic strategy that is unlikely to do much beyond shifting the geolocation of suppliers. Pharmaceutical companies must also be held accountable for the reprehensible and strategic part that they have played in the crisis. In addition to actively promoting misinformation to physicians, evidence, detailed in a February, 2018 Senate report, shows major financial inducements to advocacy groups to promulgate “opioid-friendly messaging”. Most states have now introduced legislation limiting opioid prescriptions, but well funded and powerful lobbying efforts have left drug makers untouched.

    As local public health authorities, emergency rooms, and first responders reel from the strain of the thousands of premature deaths caused by opioids, the outlook might be more dire than anticipated as a second methamphetamine wave begins. The co-use of methamphetamine and opioids increases the probable uptick in injection drug use and transmission of HIV, especially in the regions of the USA where public health resources are severely taxed. Without considering the consequences of past efforts and with limited bandwidth and funding pledged to provide intervention and treatment, these crises will merge, and the winter of despair will rage on.