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研究生:黃彥芳
研究生(外文):Yen-Fang Huang
論文名稱:臺灣美沙冬替代治療計畫評價
論文名稱(外文):The Evaluation of Methadone Maintainence Treatment Program in Taiwan
指導教授:丁志音丁志音引用關係江東亮江東亮引用關係
指導教授(外文):Chin-Yin Lew-TingTung-liang Chiang
口試委員:鄭若瑟林健陽謝雨生楊銘欽
口試日期:2015-07-09
學位類別:博士
校院名稱:國立臺灣大學
系所名稱:健康政策與管理研究所
學門:醫藥衛生學門
學類:公共衛生學類
論文種類:學術論文
論文出版年:2015
畢業學年度:103
語文別:中文
論文頁數:213
中文關鍵詞:注射藥癮者海洛因減害計畫美沙冬替代治療愛滋病毒愛滋發生率增加工作入獄評價
外文關鍵詞:People who inject drugsInjection drug usersheroinharm reductionmethadone maintainence treatmentHIVHIV incidenceemploymentincarcerationevaluation
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研究背景與目的:
政府因應國內2003年起開始爆發的藥癮愛滋疫情,於2006年開始推動美沙冬替代治療計畫,計畫目標包括降低愛滋、改善治安、和增加工作,該計畫是一新策略,實應進行計畫評價,以為未來計畫改進之參考。故本研究的目的:一、過程評價,探討影響注射藥癮者參加和持續美沙冬替代治療的決定因素。二、成效評價,包括美沙冬替代治療對降低感染愛滋風險、增加穩定工作、和減少再入獄的影響。
研究方法:
本研究是一追蹤研究,以「96年罪犯減刑條例」減刑日(2007年7月16日)出獄之4,357名藥癮減刑個案為對象,透過4次面訪抽血檢驗和資料庫勾稽進行追蹤,追蹤期間至2010年12月31日止。完成3,153名個案(72%)的面訪,其中2,796名個案(89%)表示曾使用過海洛因,問卷資料完整者計2,737名,以此分析參加美沙冬替代治療的決定因素,扣除未參加者,進行1,708名美沙冬替代治療個案持續治療的影響因素分析。在效益評價方面,以2,737名個案分析美沙冬替代治療和再入獄之關係;以曾在社區1,510名受訪個案
進行美沙冬替代治療對增加穩定工作的效益評估;扣除2006年前已感染愛滋數,以2,473名個案進行美沙冬替代治療降低愛滋感染風險評估。
研究結果:
一、 影響注射藥癮者參加和持續美沙冬替代治療的決定因素:
(一)、邏輯斯複迴歸分析顯示越年長 (校正勝算比1.01;95%信賴區間:1.00 - 1.02)、沒有嚼檳榔習慣(校正勝算比1.31;95%信賴區間:1.07-1.60)、愛滋病毒感染(免費治療和個案管理)(校正勝算比2.72;95%信賴區間:2.05-3.61)、家庭支持(校正勝算比1.45;95%信賴區間:1.23-1.72)與參加美沙冬替代治療為正相關;再入獄(校正勝算比0.62;95%信賴區間:0.51-0.76)和交通花費時間(每增1分鐘,校正勝算比0.98;95%信賴區間:0.97-0.98)與參加治療為負相關。
(二)、群體軌跡分析顯示曾接受治療的個案有4種治療類型:早衰型、慢熱型、慢衰型、持續型。曾接受治療個案的持續治療率為34%,未再入獄者的持續治療率為73%。多分類反應變數邏輯斯迴歸模式顯示:其他型與持續型相較下,再入獄相對於未再入獄,未持續治療的機率較高(校正勝算比35、5、9;95%信賴區間:21-57、4-7、6-13);美沙冬藥物劑量越高,早衰和慢熱型機率越低(每增1毫克,校正勝算比0.98、0.98;95%信賴區間:0.97-0.99、0.98-0.99);愛滋病毒感染(免費治療和個案管理),早衰和慢衰型機率越低(校正勝算比0.66、0.61;95%信賴區間:0.45-0.95、0.41-0.93);有家庭支持,其早衰型的機率較低(校正勝算比0.71;95%信賴區間:0.52-0.97);交通花費時間越長,慢熱型的機率較高(每增1分鐘,校正勝算比1.01;95%信賴區間:1.01-1.02);男性,其慢衰型的機率較低(校正勝算比0.50;95%信賴區間:0.30-0.80)。
二、 美沙冬替代治療對降低愛滋、增加工作、和減少入獄的成效評價:
(一)、在2006年到2010年間,51人新感染愛滋病毒。存活分析顯示有參加美沙冬替代治療組之於未參加美沙冬替代治療組其感染愛滋風險的校正相對風險比為0.13(95% 信賴區間:0.04-0.46),逆選擇機率加權估計值的存活分析顯示有參加美沙冬替代治療組之於未參加美沙冬替代治療組其感染愛滋風險的加權相對風險比為0.12(95% 信賴區間:0.03-0.41)。
(二)、在2008年到2010年間的社區受訪個案,43%曾有全職工作、25%曾有臨時工作。廣義估計方程式顯示美沙冬替代治療個案比無治療個案其有全職工作之校正勝算比為1.30。同時,男性(校正勝算比1.93)和全職工作為正相關;年長(每增1歲,校正勝算比0.95)和感染愛滋病毒(校正勝算比0.49)和全職工作為負相關。另,美沙冬藥物劑量在中等高者有較佳全職工作機率。
(三)、廣義估計方程式顯示在社區期間美沙冬替代治療個案比無接受美沙冬替代治療的個案其再入獄之校正勝算比為0.74(95% 信賴區間:0.66-0.83)。同時,男性(校正勝算比2.24)和感染愛滋病毒(校正勝算比1.22)和再入獄為正相關;年長(每增1歲,校正勝算比0.98)和再入獄為負相關。
結論與建議:
本研究發現美沙冬替代治療有助於降低感染愛滋風險、增加個案穩定工作、和降低再入獄的機率,建議減害政策中的藥癮戒治醫療服務應持續提供。另外,建議美沙冬替代治療政策可從提高可近性、免費治療和個案管理、較高足夠藥物劑量著手,增加個案參與或持續治療。


Background: The related social and health issues of illegal drug use continue to attract great international concern. An epidemic of HIV among people who inject drugs (PWID) bagan to spread rapidly since 2003 in Taiwan. In response to this problem, the government developed harm reduction programs in 2005. The first person was not enrolled in Methadone maintentence treatment (MMT) until February 2006. However, large-scale studies that incorporated sensitive measurements of HIV incidence and intervention exposures in defined cohorts such as these was much needed but rare worldwide. Therefore, the aims of this dissertation were: first, to determine the dominate predictors of enrollment for MMT and MMT retention; and then, to evaluate the outcome impacts of MMT programs on HIV incidence, employment, and re-incarceration.
Methods: We enrolled in a prospective study a cohort of 4,357 individuals who were released from prison via an amnesty on July 16, 2007. Within, a total of 2,737, among the 3,153 participants who had completed the interview were used for the analysis of the predictors of MMT enrollment and retention, and the association between MMT and re-incarceration. In the analysis of the association of harm reduction strategies with HIV seroconversion, 2,473 individuals who were HIV negative before 2006 were used. In addition, 1,510 individuals who held current employment status were included in the analysis of the association of MMT with employment.
Results:
1. Mutivariate logistic regression models revealed that positive factors associated with enrolling in MMT included older age (adjusted Odds Ratio per 1 year [aOR]=1.01; 95% CI: 1.00-1.02), without chewing betal nuts (aOR 1.31;95% CI: 1.07-1.60), free MMT treatment (aOR 2.72;95% CI: 2.05-3.61), and family support (aOR 1.45;95% CI: 1.23-1.72). People who were re-incarceration (aOR 0.62;95% CI: 0.51-0.76) or spent more transportation time (aOR per 1 minute 0.98; 95% CI: 0.97-0.98) were less likely to be enrolled.
2. In 1,708 MMT cases, four trajectory groups, including drop-out-early, treatment late, drop-out-late and keep on treatment, were identified. A total of 581 (34%) of them continued MMT. At the same time, the percentage of continue on MMT was 73% in no-incarceration group. In multivariate generalized logistic regression models, others three group compared with the Keep-on-Treatment group, re-incarceration were associated with lesser medication adherence (aOR 35; 5, and 9, respectively); higher dosages were associated with lesser drop-out-early and treatment late (aOR 0.98; and 0.98, respectively); family support was associated with lesser early failure (aOR 0.71); more transportation time was associated with more failure late (aOR per 1 minute 1.01); male was associated with lesser late failure (aOR 0.50).
3. A total of 51 HIV seroconverted cases occurred between 2006 and 2010. Time-varying Cox regression model and Weighted time-varying Cox regression model reveals that attendance at methadone clinics was associated with a significantly lower HIV incidence (adjusted hazard ratio [aHR] 0.13, 95%CI: 0.06–0.67; 0.12, 95%CI: 0.03-0.41; respectively), adjusting for other characteristics.
4. GEE models found that attendance at methadone clinics was associated with a significantly higher full-time employment (aOR 1.3), adjusting for other characteristics. Other significant predictor variables included male, younger, and HIV negative. Compared to those receiving a low dose (<45mg), clients receiving a medium (45-75mg) dose had a higher likelihood of attrition,but high (>75mg) dose had no difference
5. MMT coverage peaked at 45% one and half years after amnesty and later re-incarceration rate alsp peak two years after amnesty. GEE models found that attendance at methadone clinics was associated with a significantly lower reincarceration (aOR=0.74, 95%CI: 0.66-0.83), adjusting for other characteristics.
Conclusion and Suggestion: It is concluded that MMT was associated with lower HIV seroconverted, lower re-incarceration, and higher full-time employment among PWID. In addition, that no re-incarceration was associated with high rate of MMT enrollment and retention. Increase accessibility, free treatment and case management, as well as higher methadone dosage are potent strategies that can increase both MMT emrollment and retention rate.


口試委員會審定書…………………………………………………. i
誌謝…………………………………………………………………. ii
中文摘要…………………………………………………………… iii
英文摘要……………………………………………………………. vi
第一章、緒論……………………………………………………… 1
第一節、研究背景………………………………………………… 1
第二節、研究目的………………………………………………… 9
第二章、文獻探討………………………………………………… 10
第一節、減害計畫、美沙冬替代治療計畫和計畫評價 ………… 12
第二節、影響參加和持續美沙冬替代治療的決定因素 ………… 20
第三節、美沙冬替代治療和感染愛滋病毒 ……………………… 24
第四節、美沙冬替代治療和增加就業 ..………………………… 29
第五節、美沙冬替代治療和再入獄 ……………………………… 32
第三章、研究方法 ………………………………………………… 37
第一節、研究架構和研究假設 …………………………………… 37
第二節、資料來源和研究樣本 …………………………………… 39
第三節、研究變項定義 …………………………………………… 43
第四節、資料分析 ………………………………………………… 48
第四章、研究結果 ………………………………………………… 56
第一節、影響參加美沙冬替代治療之決定因素 ………………… 56
第二節、影響持續接受美沙冬替代治療之決定因素 …………… 61
第三節、美沙冬替代治療有助於降低感染愛滋風險之評估結果… 71
第四節、美沙冬替代治療策略有助於增加就業之評估結果……… 76
第五節、美沙冬替代治療策略有助減少再入獄之評估結果……… 80
第五章、討論………………………………………………………… 83
第一節、參加美沙冬替代治療之影響因素其關聯性討論………… 83
第二節、持續接受美沙冬替代治療之影響因素其關聯性討論…… 87
第三節、美沙冬替代治療與降低感染愛滋風險之關聯性討論…… 92
第四節、美沙冬替代治療有助於增加就業之關聯性討論 ……… 95
第五節、美沙冬替代治療有助減少再入獄之關聯性討論………… 98
第六節、研究限制……………………………………………………100
第六章、結論與建議 ……………………………………………… 101
參考文獻 …………………………………………………………… 104
附錄 ……………………………………………………………… 200
逆選擇機率加權估計(IPW)的SAS語法…………………………. 200
Changes in HIV Incidence among People Who Inject Drugs in Taiwan following Introduction of a Harm Reduction Program: A Study of Two Cohorts ………………………………………… 202


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