摘要：Objectives. We examined the association between the expansion of methadone and buprenorphine treatment and the prevalence of heroin overdose deaths in Baltimore, Maryland from 1995 to 2009. Methods. We conducted a longitudinal time series analysis of archival data using linear regression with the Newey–West method to correct SEs for heteroscedasticity and autocorrelation, adjusting for average heroin purity. Results. Overdose deaths attributed to heroin ranged from a high of 312 in 1999 to a low of 106 in 2008. While mean heroin purity rose sharply (1995–1999), the increasing number of patients treated with methadone was not associated with a change in the number of overdose deaths, but starting in 2000 expansion of opioid agonist treatment was associated with a decline in overdose deaths. Adjusting for heroin purity and the number of methadone patients, there was a statistically significant inverse relationship between heroin overdose deaths and patients treated with buprenorphine ( P = .002). Conclusions. Increased access to opioid agonist treatment was associated with a reduction in heroin overdose deaths. Implementing policies that support evidence-based medication treatment of opiate dependence may decrease heroin overdose deaths. Heroin overdose death is a major public health problem throughout the world. 1–4 Factors thought to be related to the prevalence of heroin overdose death include the availability and purity of heroin on the streets, 5–8 periods of brief incarceration or detoxification that lower opioid tolerance, 9–14 and the availability and penetration of opioid agonist treatment. 1,15–17 Among public health treatment strategies to reduce opioid overdose deaths are increasing opioid agonist maintenance treatments, such as those involving methadone and buprenorphine; using depot naltrexone 18 ; and distributing naloxone. 19,20 In Baltimore, Maryland, throughout the 1990s, heroin use and addiction were associated with an alarming number of overdose deaths, and from 1990 to 1997 drug overdose deaths increased by 426%, an increase that exceeded that of all the other 26 major US cities reporting to the federal Drug Abuse Warning Network during the same period. 21 Starting in 1998, city and state leaders and local foundations renewed efforts to expand access to drug abuse treatment to reduce the impact of heroin and other drug addiction. The city obtained increased state and city funding for drug abuse treatment and reformed zoning laws to ease the opening of new drug abuse treatment programs. Through these efforts, the city’s methadone treatment capacity increased significantly over the next 6 years. With the passage of the Drug Abuse Treatment Act of 2000 and the Food and Drug Administration’s approval of buprenorphine for the treatment of opioid dependence, 22 buprenorphine became available through private physician offices and in some community health centers in Baltimore. Maryland added buprenorphine to its Medicaid formulary in 2003 and organized efforts to enroll patients in Medicaid. In late 2006, the Baltimore City Health Department and the local substance abuse authority, the Baltimore Substance Abuse Systems, Inc., funded an initiative to expand access to buprenorphine treatment through formerly drug-free outpatient clinics and physicians’ offices by providing funding for Baltimore City physicians to obtain training and the necessary federal license to prescribe buprenorphine. This initiative integrated buprenorphine into the Baltimore Substance Abuse Systems, Inc.–funded network of drug-free outpatient clinics and created a system, overseen by the local nonprofit Baltimore Healthcare Access, to transfer stabilized buprenorphine patients to primary care physicians in community health centers and other primary care sites for ongoing care. From 2006 through 2009, the number of patients treated with buprenorphine in Baltimore City increased substantially. Through the efforts to expand methadone treatment in regulated opioid treatment programs and the increase in availability of buprenorphine treatment outside such programs, the number of patients treated with these evidence-based medications nearly quadrupled from 1995 through 2009. Meanwhile, heroin overdose deaths declined from a peak of 312 in 1999 to 118 in 2009. We examined the association between the increase in the number of patients treated with methadone and buprenorphine and the decline in heroin overdose deaths. We used archival data obtained from various public and private sources to examine the association between heroin overdose deaths and the increase in methadone and buprenorphine patients, controlling for the average purity of seized heroin in Baltimore City from 1995 through 2009.
