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Évaluation de la douleur et du mésusage de la buprénorphine et de la méthadone chez les patients dépendants aux opioïdes substitués

Abstract : Opioid dependence is a major public health problem with increasing prevalence and incidence. Its pharmacological management is based on opioid substitution treatment (OST) (buprenorphine (HDB) and methadone (MTD)), marketed since 1995-1996 in France. Their clinical efficacy has been widely demonstrated by reducing heroin use, overdose mortality and improving patients' quality of life. Nevertheless, at the same time, problems related to the misuse of OST have emerged, which may lead to negative consequences for patients. The first part of this work consisted in studying the misuse of OST in opioid-dependent patients in France through the identification of doctor shopping, using the national EGB database according to two approaches: 1/ a repeated cross-sectional study estimating the annual prevalence of OST misuse between 2004 and 2014: the prevalence of HDB doctor shopping decreased significantly between 2004 and 2014 (12.6 % vs 3.9 %, p<0.001), while that of MTD remained low with no significant change over the study period (0.2 % in 2004 to 0.5 % in 2014); 2/a cohort study to estimate the incidence of OST misuse in opioid-dependent patients and identify the risk factors associated with this misuse: the one-year incidence was 8.4 % [95 % CI: 7.0-10.1] in the HDB group and 0 % in the MTD group, compared to 0.2 % [95 % CI: 0.1-0.2] for the diuretic group (negative control). Factors associated with doctor shopping were female gender (HR: 1.74 [1.20-2.54]), low socio-economic status (HR: 2.95 [2.07-4.44]), psychiatric comorbidities (HR : 1.43 [1.06-1.94]), coprescriptions of hypnotics (HR : 1.90 [1.39-2.61]), weak opioid analgesics (HR : 1.48 [1.09-1.99]) and morphine (HR : 1.69 [1.02-2.80]). Among the many reasons underlying this OST misuse, the existence of poorly relieved pain is frequently found. Indeed, pain is a major problem among opioid-dependent patients because it is still too often underdiagnosed and underestimated, while its prevalence is much higher than in the general population. Its adequate management is all the more important as it will contribute to an improvement and a better balance of the addictive pathology. No french data are available concerning the estimation of the prevalence of pain in OST patients and the description of associated pharmaco-therapeutic analgesic profiles in a real life setting.These issues around pain were the subject of the second and third chapters of this work. The second part of this manuscript focused on estimating the prevalence of pain among opioid-dependent patients in France using a dual approach: 1/ a traditional field prevalence study, including a representative sample of 509 opioid-dependent patients recruited from 12 addiction care centers: the prevalence of acute pain was estimated at 42.0 % [95 % CI: 37.7 - 46.3] and that of chronic pain at 33.2 % [29.1 - 37.3] with no significant difference between BHD and MTD; 2/ an original alternative approach, based on the capture-recapture method to the exhaustive SNIIRAM database: in 2015-2016, the prevalence of chronic pain was estimated at 31.1 % [28.0 - 34.9] in OST patients vs 8.6 % [7.08 - 10.7] in the control population of non-dependent patients. This method has demonstrated its major interest, given not only the speed and reliability of the estimates obtained, but also the ease of implementation and lower cost compared to studies or field surveys, while overcoming the traditional limitations of the latter in terms of representativeness and generalization of results. (...)
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Jessica Delorme. Évaluation de la douleur et du mésusage de la buprénorphine et de la méthadone chez les patients dépendants aux opioïdes substitués. Neurosciences [q-bio.NC]. Université Clermont Auvergne, 2019. Français. ⟨NNT : 2019CLFAS023⟩. ⟨tel-02874758⟩

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