加拿大多伦多大学Jennifer Wyman团队研究了阿片类激动剂治疗带回家剂量增加与阿片类药物过量、治疗中断和停药之间的相关性。2022年3月1日出版的《美国医学会杂志》发表了这项成果。

在疫情期间，修改后的阿片类激动剂治疗（OAT）指南允许处方者增加带回家的剂量，以维持治疗。这是否与过量用药风险增加有关尚不明确。

为了评估在疫情早期增加OAT的带回家剂量是否与治疗维持和阿片类药物相关伤害有关，2020年3月21日，研究组在加拿大安大略省进行了一项回顾性倾向加权队列研究，共招募21297名参与者。2020年3月22日至2020年4月21日，研究组评估了OAT带回家剂量频率的变化，并对个体进行了长达180天的观察，以评估结果（最后一次随访日期，2020年10月18日）。

根据OAT类型和基线带回家剂量频率（每日分配的美沙酮和5-6剂带回家的美沙酮、每日分配的丁丙诺啡/纳洛酮和5-6剂带回家的丁丙诺啡/纳洛酮），暴露定义为疫情第一个月内4个队列中每个队列的延长带回家剂量。主要结局为阿片类药物过量、OAT中断和OAT中止。

在16862名美沙酮接受者与4435名丁丙诺啡/纳洛酮接受者中，中位年龄为38至42岁，29.1%至38.2%为女性。在每天服用美沙酮的5852名参与者中，开始服用带回家的剂量与阿片类药物过量、停药和治疗中断的风险降低显著相关。在每日服用丁丙诺啡/纳洛酮的662名参与者中，暴露组之间的任何结局均无显著差异。

在每周接受OAT的个体中（11010名接受美沙酮，3773名接受丁丙诺啡/纳洛酮），与带回家剂量不变相比，延长美沙酮带回家剂量与OAT中断与停药的风险显著相关，延长丁丙诺啡/纳洛酮带回家剂量与治疗中断风险降低显著相关。其他主要结局在各组之间没有显著差异。

研究结果表明，加拿大安大略疫情期间，在一些接受阿片类激动剂治疗的患者亚群中，发放更多的带回家的阿片类激动剂治疗剂量与治疗中断率和停药率显著相关，在6个月的随访中，与阿片类药物相关的过量用药没有显著增加。

附：英文原文

Title: Association Between Increased Dispensing of Opioid Agonist Therapy Take-Home Doses and Opioid Overdose and Treatment Interruption and Discontinuation

Author: Tara Gomes, Tonya J. Campbell, Sophie A. Kitchen, Ria Garg, Nikki Bozinoff, Siyu Men, Mina Tadrous, Charlotte Munro, Tony Antoniou, Dan Werb, Jennifer Wyman

Issue&Volume: 2022/03/01

Abstract:

Importance  During the COVID-19 pandemic, modified guidance for opioid agonist therapy (OAT) allowed prescribers to increase the number of take-home doses to promote treatment retention. Whether this was associated with an increased risk of overdose is unclear.

Objective  To evaluate whether increased take-home doses of OAT early in the COVID-19 pandemic was associated with treatment retention and opioid-related harm.

Design, Setting, and Participants  A retrospective propensity-weighted cohort study of 21297 people actively receiving OAT on March 21, 2020, in Ontario, Canada. Changes in OAT take-home dose frequency were assessed between March 22, 2020, and April 21, 2020, and individuals were observed for up to 180 days to assess outcomes (last date of follow-up, October 18, 2020).

Exposures  Exposure was defined as extended take-home doses in the first month of the pandemic within each of 4 cohorts based on OAT type and baseline take-home dose frequency (daily dispensed methadone, 5-6 take-home doses of methadone, daily dispensed buprenorphine/naloxone, and 5-6 take-home doses of buprenorphine/naloxone).

Main Outcomes and Measures  Primary outcomes were opioid overdose, interruption in OAT, and OAT discontinuation.

Results  Among 16862 methadone and 4435 buprenorphine/naloxone recipients, the median age ranged between 38 and 42 years, and 29.1% to 38.2% were women. Among individuals receiving daily dispensed methadone (n=5852), initiation of take-home doses was significantly associated with lower risks of opioid overdose (6.9% vs 9.5%/person-year; weighted hazard ratio [HR], 0.73 [95% CI, 0.56-0.96]), treatment discontinuation (51.0% vs 63.6%/person-year; weighted HR, 0.80 [95% CI, 0.72-0.90]), and treatment interruption (19.0% vs 23.9%/person-year; weighted HR, 0.80 [95% CI, 0.67-0.95]) compared with no change in take-home doses. Among individuals receiving daily dispensed buprenorphine/naloxone (n=662), there was no significant difference in any outcomes between exposure groups. Among individuals receiving weekly dispensed OAT (n=11010 for methadone; n=3773 for buprenorphine/naloxone), extended take-home methadone doses were significantly associated with lower risks of OAT discontinuation (14.1% vs 19.6%/person-year; weighted HR, 0.72 [95% CI, 0.62-0.84]) and interruption in therapy (5.1% vs 7.4%/person-year; weighted HR, 0.69 [95% CI, 0.53-0.90]), and extended take-home doses of buprenorphine/naloxone were significantly associated with lower risk of interruption in therapy (9.5% vs 12.9%/person-year; weighted HR, 0.74 [95% CI, 0.56-0.99]) compared with no change in take-home doses. Other primary outcomes were not significantly different between groups.

Conclusions and Relevance  In Ontario, Canada, during the COVID-19 pandemic, dispensing of increased take-home doses of opioid agonist therapy was significantly associated with lower rates of treatment interruption and discontinuation among some subsets of patients receiving opioid agonist therapy, and there were no statistically significant increases in opioid-related overdoses over 6 months of follow-up. These findings may be susceptible to residual confounding and should be interpreted cautiously.

DOI: 10.1001/jama.2022.1271

Source: https://jamanetwork.com/journals/jama/article-abstract/2789543