美沙酮维持治疗（MMT）门诊脱失相关因素分析及其应对策略探讨
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摘要
目的:探讨城市美沙酮维持治疗门诊影响脱失的相关因素,并针对性地提出策略和措施;以阻止目前MMT门诊脱失的发展态势和进一步提高MMT的效率,使毒品依赖者的替代治疗得到坚持和推广。
方法:选择江西省南昌市东湖区和西湖区各1个MMT社区门诊为研究现场。调查对象包括:2006年9月6日-2007年10月8日进入两个门诊接受治疗的所有对象计719人,门诊医务人员8人。通过问卷调查、个人深入访谈、查阅门诊工作记录等方法收集资料,据此获得脱失率等相关指标并进行描述性分析。在此基础上,运用Cox回归模型进行单因素及多因素分析,以筛选出可能影响MMT脱失的相关因素。据以上分析结果拟提出影响MMT的对策与措施。
结果:(1)南昌市2个MMT门诊719名受治者的调查提示,脱失185人,总脱失率为25.73﹪。在脱失者中维持治疗期间因偷吸或其他违法犯罪行为被强制戒毒或刑事拘留者97例,占52.43%;自称自然戒断毒瘾者22例,占11.89%;自称经济困难无力支付治疗费用者15例,占8.11%;因疾病等原因死亡者10例,占5.41%;综合因素,如外出或打工、生病住院、家庭事情耽搁、家属称不明原因等被取消治疗和放弃治疗者共41例,占22.16%。(2)定量研究的多因素Cox回归分析表明,年龄、性别、文化程度,美沙酮剂量、自愿戒毒次数、家庭与社会功能、美沙酮疗效及副作用、交通情况、以及对MMT工作认识不到位等22个变量与MMT门诊脱失有关。(3)定性访谈结果表明:维持治疗工作的认识不到位、经济困难、家庭和社会功能影响、美沙酮的疗效及副作用、外出或身体不适等综合原因造成脱失。
结论:(1)南昌市两个MMT门诊719名受治者调查提示总脱失率为25.73﹪,与相关报道比较居偏低水平;男性脱失率高于女性;文化程度越低者脱失率越高。(2)经多因素分析脱失率受多种因素影响,主要危险因素有:年龄偏小、男性、文化程度低;日平均剂量大、剂量波动大以及服药后出现皮疹;极少帮助家人做家务、很少把烦恼告诉家人、极少从密友得到支持和照顾以及与邻居关系差;认为门诊管理制度不严格以及治疗期间有偷吸或其他违法犯罪行为。主要保护因素有:治疗前戒毒次数多;美沙酮治疗后胃口改善;极少偷拿家里财物、因吸毒受到家人责备少以及从家人得到的照顾多。(3)针对减少或消除影响脱失危险因素主要应对策略和措施是在调整和不断完善工作策略的同时努力做到:加强社区防毒戒毒宣传、针对受治者开展健康教育和心理辅导;提高技术水平、加强门诊能力建设、拓展工作范围;完善和严格执行门诊管理制度、加强部门间合作;扩大MMT服务网络,完善转诊机制。
Objective: To explore the related factors which affect patients' dropout from methadone maintenance treatment in the clinics of cities, and to bring up the corresponding strategy and measures in order to prevent the developing situation of patients' dropout at present , and make the substituted therapy among heroin dependent people to be standed on and popularize. Methods: The MMT clinics of Donghu community and Xihu community are selected as the research spot. All of the 719 patients who entered the two clinics during the period from Sept. 6, 2006 to Oct. 8, 2007 and 8 medical personnels are selected as the target population . The data is colleted through the questionnaire survey, individual thorough interview and referring to the clinic jobs' records, according to which the correlation index such as dropout rate is obtained and the descriptive analysis is carried on. In the descriptive material's foundation, further does the analysis to the factors of the patients' dropout, namely carries on the single factor and the multi-factor analysis using the Cox proportional hazard regession model to screen the possible hazard factors which affect patients' dropout. The strategy and measures will be proposed according to the result of the above analysis. Results: (1) Among the 719 patients 185 cases dropped out from MMT in the two clinics of Nanchang , accounting for 25.73%. 97 ones out of all dropout cases is caught for using heroin again or conducting other crimes, accounting for 52.43%; 22 cases said being drugs free, accounting for 11.89%; 15 cases said can not afford for the treatment, accounting for 8.11%; 10 cases died because of diseases and so on, accounting for 5.41%; 41 cases were revoked qualification because of other reasons such as outgoing or hiring out for working, falling ill in hospital, delay for the family matter and their family member saying unknown cause, etc, accounting for 22.16%. (2) The quantitative survey using multi-factor Cox regression analysis screens 22 variables associated with affecting the patients' dropout from MMT, such as the age, the sex, the educational level, the does of methadone, the frequency of voluntary rehabilitation, the family and social function, the curative effect and side effect of methadone, the transportation situation, as well as the understanding to MMT, etc. (3) The results of qualitative interview indicate that the reasons affecting the patients' dropout include: the cognition to the work of MMT, the economic factors, the family and social function, the curative effect and side effect of methadone, as well as synthetic reasons such as outgoing or being ill. Conclusion: (1) The survey to the 719 patients displays that the dropout rate of the two MMT clinics is 25.73﹪,which occupies the somewhat low level with the related report ; the rate of the male is higher than that of the female; and the lower the educational level is, the higher the dropout rate is. (2) The multi-analysis shows many kinds of factor affect the dropout rate, and the primary hazard factors exist: The age being young, the male, the lower educational level; the daily average dosage being big, the dosage fluctuating greatly and presenting the skin rash; extremely little helping the family member to do the housework, very little telling the family member the worry, extremely little obtaining the support and attendance from the close friend and the neighborhood being difference; considering the service control system not strict, using drug again or conducting other criminal during treatment period. The main protection factors exist: the times of rehabilitation being more before treatment; appetite improving after treatment; extremely little stealing the belongings in family, being blamed for taking drugs and obtaining many attendance from the family member. (3) The main strategy and measures in view of reducing or eliminating the hazard factor which affect the dropout rate is striving to achieve the follows together with adjusting and unceasingly consummating the work strategy: To strengthen the anti-drug and rehabilitation propaganda in the community and develop the health education and psychological counseling; Improve the technical level, strengthen the construction of the clinics' ability and outreach efforts scope; Perfect and fulfils exactly the service control system, strengthen the cooperation between departments; Expand the service network of MMT and perfect the extension mechanism.
方法:选择江西省南昌市东湖区和西湖区各1个MMT社区门诊为研究现场。调查对象包括:2006年9月6日-2007年10月8日进入两个门诊接受治疗的所有对象计719人,门诊医务人员8人。通过问卷调查、个人深入访谈、查阅门诊工作记录等方法收集资料,据此获得脱失率等相关指标并进行描述性分析。在此基础上,运用Cox回归模型进行单因素及多因素分析,以筛选出可能影响MMT脱失的相关因素。据以上分析结果拟提出影响MMT的对策与措施。
结果:(1)南昌市2个MMT门诊719名受治者的调查提示,脱失185人,总脱失率为25.73﹪。在脱失者中维持治疗期间因偷吸或其他违法犯罪行为被强制戒毒或刑事拘留者97例,占52.43%;自称自然戒断毒瘾者22例,占11.89%;自称经济困难无力支付治疗费用者15例,占8.11%;因疾病等原因死亡者10例,占5.41%;综合因素,如外出或打工、生病住院、家庭事情耽搁、家属称不明原因等被取消治疗和放弃治疗者共41例,占22.16%。(2)定量研究的多因素Cox回归分析表明,年龄、性别、文化程度,美沙酮剂量、自愿戒毒次数、家庭与社会功能、美沙酮疗效及副作用、交通情况、以及对MMT工作认识不到位等22个变量与MMT门诊脱失有关。(3)定性访谈结果表明:维持治疗工作的认识不到位、经济困难、家庭和社会功能影响、美沙酮的疗效及副作用、外出或身体不适等综合原因造成脱失。
结论:(1)南昌市两个MMT门诊719名受治者调查提示总脱失率为25.73﹪,与相关报道比较居偏低水平;男性脱失率高于女性;文化程度越低者脱失率越高。(2)经多因素分析脱失率受多种因素影响,主要危险因素有:年龄偏小、男性、文化程度低;日平均剂量大、剂量波动大以及服药后出现皮疹;极少帮助家人做家务、很少把烦恼告诉家人、极少从密友得到支持和照顾以及与邻居关系差;认为门诊管理制度不严格以及治疗期间有偷吸或其他违法犯罪行为。主要保护因素有:治疗前戒毒次数多;美沙酮治疗后胃口改善;极少偷拿家里财物、因吸毒受到家人责备少以及从家人得到的照顾多。(3)针对减少或消除影响脱失危险因素主要应对策略和措施是在调整和不断完善工作策略的同时努力做到:加强社区防毒戒毒宣传、针对受治者开展健康教育和心理辅导;提高技术水平、加强门诊能力建设、拓展工作范围;完善和严格执行门诊管理制度、加强部门间合作;扩大MMT服务网络,完善转诊机制。
Objective: To explore the related factors which affect patients' dropout from methadone maintenance treatment in the clinics of cities, and to bring up the corresponding strategy and measures in order to prevent the developing situation of patients' dropout at present , and make the substituted therapy among heroin dependent people to be standed on and popularize. Methods: The MMT clinics of Donghu community and Xihu community are selected as the research spot. All of the 719 patients who entered the two clinics during the period from Sept. 6, 2006 to Oct. 8, 2007 and 8 medical personnels are selected as the target population . The data is colleted through the questionnaire survey, individual thorough interview and referring to the clinic jobs' records, according to which the correlation index such as dropout rate is obtained and the descriptive analysis is carried on. In the descriptive material's foundation, further does the analysis to the factors of the patients' dropout, namely carries on the single factor and the multi-factor analysis using the Cox proportional hazard regession model to screen the possible hazard factors which affect patients' dropout. The strategy and measures will be proposed according to the result of the above analysis. Results: (1) Among the 719 patients 185 cases dropped out from MMT in the two clinics of Nanchang , accounting for 25.73%. 97 ones out of all dropout cases is caught for using heroin again or conducting other crimes, accounting for 52.43%; 22 cases said being drugs free, accounting for 11.89%; 15 cases said can not afford for the treatment, accounting for 8.11%; 10 cases died because of diseases and so on, accounting for 5.41%; 41 cases were revoked qualification because of other reasons such as outgoing or hiring out for working, falling ill in hospital, delay for the family matter and their family member saying unknown cause, etc, accounting for 22.16%. (2) The quantitative survey using multi-factor Cox regression analysis screens 22 variables associated with affecting the patients' dropout from MMT, such as the age, the sex, the educational level, the does of methadone, the frequency of voluntary rehabilitation, the family and social function, the curative effect and side effect of methadone, the transportation situation, as well as the understanding to MMT, etc. (3) The results of qualitative interview indicate that the reasons affecting the patients' dropout include: the cognition to the work of MMT, the economic factors, the family and social function, the curative effect and side effect of methadone, as well as synthetic reasons such as outgoing or being ill. Conclusion: (1) The survey to the 719 patients displays that the dropout rate of the two MMT clinics is 25.73﹪,which occupies the somewhat low level with the related report ; the rate of the male is higher than that of the female; and the lower the educational level is, the higher the dropout rate is. (2) The multi-analysis shows many kinds of factor affect the dropout rate, and the primary hazard factors exist: The age being young, the male, the lower educational level; the daily average dosage being big, the dosage fluctuating greatly and presenting the skin rash; extremely little helping the family member to do the housework, very little telling the family member the worry, extremely little obtaining the support and attendance from the close friend and the neighborhood being difference; considering the service control system not strict, using drug again or conducting other criminal during treatment period. The main protection factors exist: the times of rehabilitation being more before treatment; appetite improving after treatment; extremely little stealing the belongings in family, being blamed for taking drugs and obtaining many attendance from the family member. (3) The main strategy and measures in view of reducing or eliminating the hazard factor which affect the dropout rate is striving to achieve the follows together with adjusting and unceasingly consummating the work strategy: To strengthen the anti-drug and rehabilitation propaganda in the community and develop the health education and psychological counseling; Improve the technical level, strengthen the construction of the clinics' ability and outreach efforts scope; Perfect and fulfils exactly the service control system, strengthen the cooperation between departments; Expand the service network of MMT and perfect the extension mechanism.
引文
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[2] 詹初航.我国艾滋病疫情有进一步蔓延的趋势[J].中国卫生,2006,12:33
[3] 龙正元,吴祖英,杜波等.538 例海洛因成瘾者美沙酮维持治疗情况[J].中国药物依赖性 杂志,2006, 15 (1) :38-40
[4] 梁涛,刘恩武,乌正赉等.美沙酮维持治疗及其在中国的开展[J].中华护理杂志,2007, 4(4):361-363
[5] 董建群.AIDS美沙酮社区维持治疗工作的难点和策略[J].中国艾滋病性病,2003, 9(1): 4O-42.
[6] 武俊龙,吴尊友.美沙酮维持治疗的有效性及其影响因素[J].中国艾滋病性病,2004, 10(1):69-70
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[12] 陈康林,郝春,阮玉华等.海洛因成瘾者社区美沙酮维持治疗脱失和保持的定性研究[J].中国药物滥用防治杂志,2006,12(6):315-319
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[21] 郝春,胡薇,阮玉华等.社区美沙酮维持治疗对海洛因成瘾者性行为影响的初步研究. 中国艾滋病性病,2006,12(4):307-310
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[2] 詹初航.我国艾滋病疫情有进一步蔓延的趋势[J].中国卫生,2006,12:33
[3] 龙正元,吴祖英,杜波等.538 例海洛因成瘾者美沙酮维持治疗情况[J].中国药物依赖性 杂志,2006, 15 (1) :38-40
[4] 梁涛,刘恩武,乌正赉等.美沙酮维持治疗及其在中国的开展[J].中华护理杂志,2007, 4(4):361-363
[5] 董建群.AIDS美沙酮社区维持治疗工作的难点和策略[J].中国艾滋病性病,2003, 9(1): 4O-42.
[6] 武俊龙,吴尊友.美沙酮维持治疗的有效性及其影响因素[J].中国艾滋病性病,2004, 10(1):69-70
[7] Ward J,Hall W ,Mattick RP.Role of methadone treatment in opiod dependence[J]. Lancet,1999,353(9148):221-226
[8] Joseph H,Stanelif S,Lansgrod J.Methadone Maintenance Treatment(MMT):A Review of Historical and Clinical Issues[J].Mt Sinai J Med,2000,67(5-6):347-364
[9] 苗翠英.戒毒药物美沙酮[J].刑事技术,2005,1:61-6
[10] Bertschy G. Methadone maintenance treatment: an update [J]. Eur Arch Psychiatry Clin Neurosci, 1995, 245(2): 114-124.
[11] Kerr T, Marsh D, Li K, et al. Factors associated with methadone maintenance therapy use among a cohort of polysubstance using injection drug users in Vancouver. Drug Alcohol Depend. 2005, 80(3): 329-35
[12] 陈康林,郝春,阮玉华等.海洛因成瘾者社区美沙酮维持治疗脱失和保持的定性研究[J].中国药物滥用防治杂志,2006,12(6):315-319
[13] 卫生部,公安部,国家食品药品监督管理局.关于印发《海洛因成瘾者社区药物维持治疗试点工作暂行方案》的通知.卫疾控发 [2003] 37 号
[14] 海洛因成瘾者社区药物维持治疗试点国家工作组.海洛因成瘾者社区药物维持治疗试点文件汇编.2004 年 11 月:147-177
[15] 龚幼龙.社会医学[M].北京:人民卫生出版社,2001 年 1 月第 1 版第 3 次印刷:75-88
[16] 沈福民.流行病学原理与方法[M].上海:复旦大学出版社,2001 年 8 月第 1 版第 1 次印刷:224-229
[17] 郭崧.美沙酮维持治疗方案.中国药物依赖性杂志,2001,10(2):91-94
[18] Loowinson JH,ed Substance abuse,a comprehensive textbook 3rd ed.Baltimore:Willlams and W ilkins.1997.405-415.
[19] 刘建波,地力夏提·亚合甫,李凡.美沙酮维持治疗保持时间及其影响因素的Cox回归分析.中国艾滋病性病,2007,13(2):160-161
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