建議

本研究的結果發現，在經過追蹤後，海洛因使用者持續留置在療 法中而從未退出的個案只有 25.4%，如何提升個案持續留置在美沙冬治 療是目前所需要面對的最大挑戰，而根據研究結果所發現的幾項影響 洛因使用者留置在療法中的因素，提出以下建議：

在本研究中，影響留置情形最顯著的因素為個案在初診至追蹤期 間是否曾經入監過，個案在接受美沙冬治療的過程中，若是遭受到判 刑入監，便必須中斷療法，但是，根據過去的研究顯示，個案在美沙 冬治療留置的時間越久，則治療的成效會越好，對個人、社會所產生 減少傷害的效果也會越好，相較於出監的海洛因使用者一年內再犯率 超過 50%，其再犯後入監服刑所必需負擔的費用將是由全民稅收支付，

反而造成了更多的社會成本的浪費，建議政府應針對海洛因使用者加 以除罪化，以避免社會成本的浪費、才能也讓海洛因使用者能夠持續 的接受治療、達到減少傷害的目的。

在美沙冬治療的可近性部分，在大都市的個案能夠有比較好的交

通便利性，無論是住家或是工作地點，離接受治療的醫療院所的交通 都比較方便，另外，在台北縣市的提供美沙冬門診服務的醫療院所共 合計 16 處，相較基隆、宜蘭縣共合計 5 處，高出許多，大都市的個案，

在選擇接受美沙冬治療的院所所在有較多的自由性，針對這樣的現象，

建議美沙冬的給藥方式可以藉由開立處方籤、由社區藥局定點給藥，

個案再定時回原就診醫院回診，以增加個案在接受美沙冬治療時的便 利性。

另外，在 HIV 篩檢結果部分，陽性個案的留置時間要顯著長於陰 性個案，由於 HIV 陽性個案並不需要負擔美沙冬的治療費用，接受治 療的經濟壓力較小，針對這部分，建議美沙冬治療可以納入健保給付 建議在推行美沙冬治療時，可以建立一套酬償機制，讓配合度好的個 案(如：長期皆按時服藥並未有中斷情形、尿液篩檢結果皆呈現陰性反 應。)可視情況減輕其接受美沙冬治療的經濟負擔，讓有意願接受美沙 冬治療的個案，在負擔醫療費用的部分可以減少壓力，提高參與的意 願與留置的時間。

另外，HIV 陽性個案，由於個案本身自覺 HIV 是容易致死的疾病，

較一般 HIV 陰性的個案會更注意自身的健康，也可能因此導致 HIV 陽 性個案對於接受美沙冬治療有更高的動機，而在醫療體制中，醫護人

員會對於 HIV 陽性個案有較多的關注，也被認為是 HIV 陽性個案有較 好的留置情形因素之一，建議醫護人員在面對 HIV 陰性以及年紀較輕 的個案，應該多給予關懷與輔導，以提昇年輕個案在美沙冬治療的留 置情形。

在美沙冬的日劑量部分，建議在初診的個案應根據美沙冬指引，

予以低於 30mg 的服藥日劑量，並持續評估個案服藥後的反應，以求海 洛因使用者在接受美沙冬治療後，能達到穩定而有效的服藥劑量。在 一個月時的服藥日劑量，雖然在本研究中，服藥劑量的高低對於留置 情形並未顯著差異，但針對在美沙冬劑量上，建議必須給予病患足夠 的美沙冬日劑量，才能有效的減少海洛因使用者的戒斷症狀以及對於 海洛因的渴求，降低個案因為對於美沙冬治療感到不如預期而退出治 療的情形。

參考文獻

許淑雲、王俊毅、江大雄、楊欣田、廖宏恩、林玠民 等（2007）。靜 脈注射藥癮者感染愛滋病毒之危險行為探討 。

疫情報導

，

23

（10），

549-560。

陳光輝、林志強、諶立中（2007）。海洛因成癮者之美沙酮替代療法。

http://www.fda.gov.tw/files/gov_home/98 年 11 月藥物濫用案 件暨檢驗

統計資料.pdf。引用日期：99 年 5 月 21 日。

衛生署疾病管制局 (2010a)。 美沙冬替代療法治療指引。

http://www.cdc.gov.tw/public/Attachment/93618332771.doc。

引用日

期：99 年 5 月 21 日。

衛生署疾病管制局 (2010b)。台灣地區感染人類免疫缺乏病毒者依危 險因子統計

表。

http://www.cdc.gov.tw/public/Attachment/01612104271.xls。引用 日期：99 年 5 月 21 日。

衛生署疾病管制局 (2008)。毒品病患愛滋減害試辦計畫。

http://www.cdc.gov.tw/public/Attachment/822614363671.doc 。 引用日

期：99 年 5 月 21 日。

Denning, P., Little, J. & Glickman, A.（2004）。

挑戰成癮觀點：

減害治

療模式

（謝菊英、蔡春美、管少彬譯）。臺北：張老師文化。

American Psychiatric Association（2007）。

DSM-IV-TR 精神疾病 診斷準則

手册（四版）

（孔繁鐘譯）。臺北：合記。（原著出版於 2007）

英文部分：

Aceijas, C., et al. (2004). Global overview of injecting drug use and HIV infection among injecting drug users.

AIDS.

Ball, J.C., et al. (1988). Reducing the risk of AIDS through methadone maintenance treatment

. Journal of Health and Social Behaviour

,

29

(3), 214-26.

Beardsley, K., et al. (2003). Distance travelled to outpatient drug treatment and client retention.

Journal of Substance Abuse Treatment

,

25

(4), 279-85.

Beck, Wright, Newman, & Liese (1993).

Cognitive Therapy of Substance Abuse

. New York: Guilford.

Booth, R.E., Corsi, K.F., & Mikulich-Gilbertson S.K. (2004).

Factors associated with methadone maintenance treatment retention among street-recruited injection drug users.

Drug and Alcohol Dependence, 74

(2), 177-85.

Borisova, N.N. & Goodman, A.C. (2004). The effects of time and money prices on treatment attendance for methadone

maintenance clients

. Journal of Substance Abuse Treatment

,

26

(1)

,

345-52.

Burns, L., & Teesson, M. (2002). Alcohol use disorders comorbid with anxiety, depression and drug use disorders: Findings from the Australian National Survey of Mental Health and Well Being.

Drug and alcohol dependence, 68

(3), 299-307.

Brady, T., Salvucci, S., Sverdlov, L., Male, A., Kyeyune, H., Sikali, E., et al. (2005). Methadone dosage and retention:

an examination of the 60 mg/day threshold.

Journal of addictive diseases

,

24

(3), 23.

Callon, C., Wood, E., Marsh, D., Li, K., Montaner, J., & Kerr, T. (2006). Barriers and facilitators to methadone

maintenance therapy use among illicit opiate injection drug users in Vancouver.

Journal of opioid management

,

2

(1), 35-41.

Caplehorn, J., & Bell, J. (1991). Methadone dosage and retention of patients in maintenance treatment.

The Medical Journal of Australia

,

154

(3), 195.

Coviello, D.M., et al. (2004). The role of family history in addiction severity and treatment response.

Journal of

Substance Abuse Treatment, 26

(1), 303-13.

methadone maintenance treatment in two western states.

Journal of Behavioral Health Services & Research

,

32

(1), 43-60.

Flynn, P., Joe, G., Broome, K., Simpson, D., & Brown, B. (2003).

Recovery from opioid addiction in DATOS.

Journal of Substance Abuse Treatment

,

25

(3), 177-186.

Gibson, D., Flynn, N., & McCarthy, J. (1999). Effectiveness of methadone treatment in reducing HIV risk behavior and HIV seroconversion among injecting drug users.

Aids, 13

(14), 1807-1818. 

Gossop, M., Marsden, J., Stewart, D., & Treacy, S. (2001).

Outcomes after methadone maintenance and methadone

reduction treatments: two-year follow-up results from the National Treatment Outcome Research Study.

Drug and alcohol dependence

,

62

(3), 255-264.

Gossop, M., Stewart, D., Browne, N., & Marsden, J. (2002).

Factors associated with abstinence, lapse or relapse to heroin use after residential treatment: protective effect of coping responses.

Addiction

,

97

(10), 1259-1267.

Grella, C.E. & Wugalter, S.E. (1997). Predictors of Treatment Retention in Enhanced and Standard Methadone Maintenance Treatment for HIV Risk Reduction

. Journal of Drug Issues

,

27

(2), 203 - 225.

Hartel, D., Schoenbaum, E., Selwyn, P., Kline, J., Davenny, K., Klein, R., et al. (1995). Heroin use during methadone maintenance treatment: the importance of methadone dose and cocaine use.

American Journal of Public Health

, 85(1), 83-88.

Hser, Y., Evans, E., Huang, D., & Anglin, D. (2004). Relationship between drug treatment services, retention, and outcomes.

Psychiatric Services

, 55(7), 767-774.

International Harm Reduction Association. (2008). What is harm reduction? http://www.ihra.net/Whatisharmreduction

Retrived at May 21, 2010.

Keen, J., Rowse, G., Mathers, N., Campbell, M., & Seivewright,

patients retained in general practice reduce criminal conviction rates and time spent in prison?

The British Journal of General Practice, 50

(450), 48-49.

Kelly, J., Finney, J., & Moos, R. (2005). Substance use disorder patients who are mandated to treatment: Characteristics, treatment process, and 1-and 5-year outcomes.

Journal of Substance Abuse Treatment

, 28(3), 213-223.

Kerr, T., et al., (2005). Factors associated with methadone maintenance therapy use among a cohort of polysubstance using injection drug users in Vancouver

. Drug and Alcohol Dependence, 16,

16.

Knight, D., Wallace, G., Joe, G., & Logan, S. (2001). Change in psychosocial functioning and social relations among women in residential substance abuse treatment.

Journal of substance abuse, 13

(4), 533-547.

Krambeer, L., Von Mcknelly, W., Gabrielli, W., & Penick, E.

(2001). Methadone therapy for opioid dependence.

American Family Physician

,

63

(12), 2404-2412.

Lee TSH, Fu LA, & Fleming P. (2006). Using Focus Groups to Investigate the Educational Needs of Female Heroin Injection Users in Taiwan in Relation to HIV/AIDS Prevention.

Health Education Research, 21

(1), 55-65.

Longshore, D., & Teruya, C. (2006). Treatment motivation in drug users: A theory-based analysis.

Drug and alcohol dependence, 81

(2), 179-188.

Mark, T., Woody, G., Juday, T., & Kleber, H. (2001). The economic costs of heroin addiction in the United States.

Drug and alcohol dependence, 61

(2), 195-206.

Michels, I., Stover, H., & Gerlach, R. (2007). Substitution treatment for opioid addicts in Germany.

Harm Reduction Journal

, 4(1), 5-17.

National Institute on Drug Abuse (NIDA). (2009).

Principles of drug addiction treatment: a research-based guide.

(2nd ed.).

Bethesda: Author

Padaiga, Z., Subata, E., & Vanagas, G. (2007). Outpatient

and health of opioid-dependent persons in Lithuania.

Medicina (Kaunas)

, 43(3), 235-241.

Peles, E., Schreiber, S., & Adelson, M. (2006). Factors

predicting retention in treatment: 10-year experience of a methadone maintenance treatment (MMT) clinic in Israel.

Drug and alcohol dependence

, 82(3), 211-217.

Preston, K., Umbricht, A., & Epstein, D. (2000). Methadone dose increase and abstinence reinforcement for treatment of continued heroin use during methadone maintenance.

Archives of General Psychiatry, 57

(4), 395-404.

Simpson, D.D., G.W. Joe, and G.A. Rowan-Szal. (1997). Drug abuse treatment retention and process effects on follow-up outcomes.

Drug Alcohol Depend, 47

(3)

,

227-35.

Strike, C., Gnam, W., Urbanoski, K., Fischer, B., Marsh, D., &

Millson, M. (2005). Factors predicting 2-year retention in methadone maintenance treatment for opioid dependence.

Addictive behaviors

, 30(5), 1025-1028.

United Nations Office on Drugs and Crime (UNODC). (2009).

World Drug Report 2009.

Vienna: Author

Van den Brink, W., & Haasen, C. (2006). Evidenced-based treatment of opioid-dependent patients. Canadian journal of

psychiatry.

Revue canadienne de psychiatrie

, 51(10), 635-646.

Villafranca, S., McKellar, J., Trafton, J., & Humphreys, K.

(2006). Predictors of retention in methadone programs: a signal detection analysis.

Drug and alcohol dependence

, 83(3), 218-224.

Wimbush, J., A. Amicarelli, and M.D. Stein. (1996). Does HIV test result influence methadone maintenance treatment retention?

Journal of Substance Abuse, 8(2)

, 263-269.

World Health Organization (2005a). Effectiveness of Drug Dependence Treatment in Preventing HIV among Injecting Drug Users. World Health Organization: Geneva,

Switzerland. Available at

pdf .

Zaric, G., Barnett, P., & Brandeau, M. (2000). HIV transmission and the cost-effectiveness of methadone maintenance.

American Journal of Public Health, 90

(7), 1100-1111.

Zhang, Z., Friedmann, P., & Gerstein, D. (2003). Does retention matter? Treatment duration and improvement in drug use.

Addiction

, 98(5), 673-684.

在文檔中 接受美沙冬療法留置情形與影響因素：海洛因藥癮者之前瞻性追蹤研究 (頁 100-109)