行为列联管理在美沙酮维持治疗者中的疗效:一项随机对照研究(英文)

Efficacy of contingency management in improving retention and compliance to methadone maintenance treatment:a random controlled study

背景为了应对海洛因依赖的严重后果,我国开展了美沙酮维持治疗(methadone maintenance treatment,MMT)项目,但是MMT依从性差。目的评估在美沙酮维持治疗中行为列联管理(contingency management,CM)对阿片类药物依赖者的作用。假设在上海市常规MMT项目基础上结合以奖励机制为基础的CM干预共12周,可提高MMT治疗依从性和增加操守程度。方法来自于3个自愿戒毒MMT门诊的160名海洛因依赖者被随机分入常规治疗组(MMT,n=80)和干预组(MMT+CM,n=80),在前12周每周评估患者的服药行为并进行尿液的毒品检测,随后在第16、20和24周分别进行上述评估检测。结果干预组和常规治疗组完成12周治疗的比例都很高,分别为87.5%和86.2%。12周中,两组服用美沙酮的平均天数差异无统计学意义[70(2.9)d与71(2.7)d],两组未吸海洛因的最长时间(分别为7.4周与6.5周)以及尿检阴性的次数(分别为7.9次与7.6次)也没有明显差异。同样,根据24周的分析提示两组间差异也无统计学意义。用成瘾严重程度指数评估成瘾程度,24周内两组完成随访者的成瘾严重程度都显著下降,但是两组间比较同样无明显差异。结论在我国上海的MMT门诊,以奖励机制为基础的行为列联管理干预并未起到提高治疗依从性和促进保持操守的作用。这与西方研究结果不同。究其原因,一是基线依从性高(86%),二是CM项目提供的奖励相对少。在CM项目中奖励是与场景相关的,因而需要对场景进行仔细的分析,了解在特定场景采用什么特定的奖励措施,以便鼓励目标人群改变行为。

Background:Compliance with methadone maintenance treatment (MMT) in China is poor.Objective:To evaluate the effects of adjunctive contingency management (CM) on the efficacy of methadone maintenance treatment(MMT) in patients with opioid dependence.Hypothesis:A 12-week prize-based contingency management (CM) intervention can increase the retention and compliance of heroin abusers to standardized MMT programs in Shanghai.Methods:160 heroin-dependent patients from three voluntary MMT clinics in Shanghai were randomly assigned to a treatment as usual group (MMT,n=80) and an intervention group (MMT+CM,n=80).Daily use of methadone was recorded and urine drug tests were conducted weekly during the first 12 weeks and then at week 16,week 20 and week 24.Results:The 12-week retention rates for the intervention (MMT+CM) and treatment-as-usual (MMT) groups were both quite high:87.5% and 86.2%,respectively.The average durations of using methadone in the two groups were equal (70 days versus 71 days,respectively).There was a non-significant increase in the mean longest drug-free period (7.4 weeks versus 6.5 weeks) and in the mean number of negative urine tests (7.9 versus 7.6).Secondary analysis of the 24-week outcomes (12 weeks after termination of the adjunctive CM treatment) also found no significant differences between the groups.Among those who remained in the program the severity of addiction as assessed by the Addiction Severity Index decreased dramatically over the 24 weeks but,again,there were no significant differences in the addiction measures between those in the intervention group and those in the treatment-as-usual group.Conclusion:Prize-based CM is not effective in improving the retention and compliance of heroin abusers to MMT in Shanghai.The main reasons for failure to replicate western studies were the unexpectedly high baseline rates of compliance in this sample (86%) and the relatively weak financial incentives provided by the CM program.CM programs are context dependent so a careful preliminary situational analysis is needed to determine their potential effectiveness at a particular site and to identify the types of incentives (prizes) that will effectively encourage behavioral change in the target participants.