Type of opioids injected: does it matter? A multicentric cross-sectional study of people who inject drugs

Patterns of use and adverse events reported among persons who regularly inject buprenorphine: a systematic review

BACKGROUND AND AIMS

Given the ongoing opioid crisis, novel interventions to treat severe opioid use disorder (OUD) are urgently needed. Injectable opioid agonist therapy (iOAT) with diacetylmorphine or hydromorphone is effective for the treatment of severe, treatment-refractory OUD, however barriers to implementation persist. Intravenous buprenorphine for the treatment of OUD (BUP iOAT) has several possible advantages over traditional iOAT, including a safety profile that might enable take-home dosing. We aimed to characterize injecting practices among real-world populations of persons who regularly inject buprenorphine, as well as associated adverse events reported in order to inform a possible future BUP iOAT intervention.

METHODS

We conducted a systematic review. We searched MEDLINE, EMBASE, and PsycINFO from inception through July 2020 and used backwards citation screening to search for publications reporting on dose, frequency among persons who regularly inject the drug, or adverse events associated with intravenous use of buprenorphine. The review was limited to English language publications and there was no limitation on study type. Study quality and risk of bias was assessed using the Mixed Methods Appraisal Tool. Narrative synthesis was used in reporting the results.

RESULTS

Eighty-eight studies were included in our review. Regular injection of buprenorphine was identified across diverse settings world-wide. Daily dose of oral buprenorphine injected was < 1-12 mg. Frequency of injection was 0-10 times daily. Adverse events could be characterized as known side effects of opioids/buprenorphine or injection-related complications. Most studies were deemed to be of low quality.

CONCLUSIONS

Extramedical, intravenous use of buprenorphine, continues to be documented. BUP iOAT may be feasible and results may inform the development of a study to test the efficacy and safety of such an intervention. Future work should also examine acceptability among people with severe OUD in North America. Our review was limited by the quality of included studies.

Exploring the clinical variables among drug-dependent HIV-Positive patients: Implications for treatment strategies

This study explored the profile of HIV positive patients seeking treatment at a tertiary care addiction treatment facility. A retrospective study was done to collet detailed information on clinical characteristics: drug use (type, age of initiation, duration), general medical condition and past treatment history. The study included 138 patients with mean (SD) age 30.2 (8.3) years. Opioid dependence with injecting drug use (IDU) was diagnosed in 97% of the patients. The median age of injecting onset was 24.5 years (IQR 20-31 years). The most frequently injected substances were pheniramine (60.1%) and buprenorphine (59.4%). Past treatment seeking was reported by 57% patients and interestingly they were less likely to present any medical condition (2 =69.611, p < 0.001). Variability in the age of onset of drug use indicates the need for broad based approach to prevent IDU and motivation to seek treatment may lead to better health conditions.

Health harms of non-medical prescription opioid use: A systematic review

ISSUES

Non-medical prescription opioid use (NMPOU) contributes substantially to the global burden of morbidity. However, no systematic assessment of the scientific literature on the associations between NMPOU and health outcomes has yet been undertaken.

APPROACH

We undertook a systematic review evaluating health outcomes related to NMPOU based on ICD-10 clinical domains. We searched 13 electronic databases for original research articles until 1 July 2021. We employed an adaptation of the Oxford Centre for Evidence-Based Medicine 'Levels of Evidence' scale to assess study quality.

KEY FINDINGS

Overall, 182 studies were included. The evidence base was largest on the association between NMPOU and mental and behavioural disorders; 71% (129) studies reported on these outcomes. Less evidence exists on the association of NMPOU with infectious disease outcomes (26; 14%), and on external causes of morbidity and mortality, with 13 (7%) studies assessing its association with intentional self-harm and 1 study assessing its association with assault (<1%).

IMPLICATIONS

A large body of evidence has identified associations between NMPOU and opioid use disorder as well as on fatal and non-fatal overdose. We found equivocal evidence on the association between NMPOU and the acquisition of HIV, hepatitis C and other infectious diseases. We identified weak evidence regarding the potential association between NMPOU and intentional self-harm, suicidal ideation and assault.

DISCUSSION AND CONCLUSIONS

Findings may inform the prevention of harms associated with NMPOU, although higher-quality research is needed to characterise the association between NMPOU and the full spectrum of physical and mental health disorders.

Predictors of Five-year Readmission to an Inpatient Service among Patients with Opioid Use Disorders

Background Opioid use disorder (OUD), a relapsing-remitting chronic medical disease, accounts for a sizable proportion of all-cause adult inpatient stays. We evaluated the incidence and predictors of any and multiple readmissions to inpatient care for OUD. Methods This retrospective, register-based cohort study assessed consecutive patients with OUD admitted to a federally-funded inpatient service of an addiction treatment center in North India between January 2007 and December 2014. Binary logistic regression was used to determine independent readmission predictors based on demographic, clinical, and treatment variables that significantly differed in bivariate analysis. Results Among 908 patients, 306 (33.7%) and 106 (11.7%) had any and multiple readmissions, respectively. Injection drug use (Odds ratio [OR] 2.92, 95% confidence interval [CI] 1.90-4.49), comorbid severe mental illness (OR 2.80, 95% CI 1.42-5.55) and common mental disorder (OR 3.4 95% CI 1.65-6.95), antagonist treatment (OR 1.6 95% CI 1.14-2.27), and urban residence (OR 1.38 95% CI 1.01-1.90) increased odds of readmission. 'Improved' discharge status (OR 0.48 95% CI 0.34-0.70) in first admissions reduced odds of any readmission. Similar risk factors also influenced multiple readmissions with higher odds ratios. Conclusions Identification and adequate treatment of risk factors may reduce the chances of readmission.

Pattern and prevalence of substance use and dependence in two districts of Union Territory of Jammu & Kashmir: Special focus on opioids

Background:

Kashmir has been at the centre of conflict between India and Pakistan after partition of erstwhile British India in 1947. While research suggests that conflict exposure may result in increased substance use, the prevalence of substance use disorders has remained an under-searched area in Kashmir.

Method:

We employed respondent-driven sampling (RDS) for recruiting substance users from two districts of Kashmir. Estimation of substance dependence was done using benchmarkmultiplier method.

Results:

Prevalence of any substance dependence was estimated to be 1.95% while as for any opioids, it was 1.80%. Heroin was the most common opioid with last year use by 84.33% respondents. Current prevalence of injection drug use was 0.95% and heroin was the most common opioid among Injection Drug User (IDU), being used by 91.12% IDUs followed by Pentazocine (5.92%).

Conclusion:

Our results indicate that RDS was a feasible and acceptable sampling method for recruiting 'difficult to reach 'participants like illicit substance users including IDUs. Our results further demonstrate that opioids are highly prevalent in Kashmir and heroin injection is not uncommon. All these findings call for attention from policy makers as opioids are one of the important contributors to mortality and morbidity related to substances.

Rates, knowledge and risk factors of non-fatal opioid overdose among people who inject drugs in India: A community-based study

INTRODUCTION AND AIMS

Non-fatal opioid overdose (NFOO) predicts future fatal opioid overdose and is associated with significant morbidity. There is limited literature on the rates and risk factors for NFOO in people who inject drugs (PWID) from India. We aimed to study the rates of NFOO and documented risk factors for NFOO, as well as knowledge-level of NFOO among PWID from India.

DESIGN AND METHODS

Community-based, cross-sectional and observational study. We interviewed 104 adult male participants receiving HIV prevention services. Drug use patterns, rates of NFOO and opioid overdose risk factors, knowledge about opioid overdose and its management were assessed.

RESULTS

The mean age of the participants was 27.9 years. The most common opioid used for injecting was heroin followed by buprenorphine. About 45% (n = 47) participants had experienced an opioid overdose at least once in their lifetime. Around 25% (n = 26) participants had overdosed in the past year, while 21% (n = 22) participants had overdosed within the past 3 months. The majority had risk factors that could predispose them to NFOO. No participant was aware of the use of naloxone for opioid overdose.

DISCUSSION AND CONCLUSION

The rates of NFOO as well as risk factors for overdose among PWID from India are high, with poor knowledge on overdose management. There is urgent need for a program to prevent and manage opioid overdose among PWID in India.

Development and clinical evaluation of a dried urine spot method for detection of morphine among opioid users

BACKGROUND:

In recent years, drug testing in body fluids has gained popularity for validating self-reported drug use. The storage and transportation of urine specimens is a major concern for remote areas where the facilities for performing drug abuse testing are lacking.

AIMS AND OBJECTIVES:

The aim of the present study was to develop an efficient method for testing opiate in dried urine spots (DUS) and to evaluate its clinical applicability.

MATERIALS AND METHODS:

The methodology involved optimization of conditions for extraction, recovery, short-, and long-term stability (room temperature, 4°C,−20°C) for detection of opiate from dried urine spots. Further, the extraction efficiency from dried urine spots was compared with the conventional drug testing methodology. The screening was done by using enzyme-linked immunosorbent assay technique, and confirmation was achieved by gas chromatography equipped with nitrogen phosphorus detector.

RESULTS:

Deionized water was found to be a suitable extracting solvent compare to bi-carbonate buffer (pH 9.2) and saline. Primary screening was achieved by 2 punches taken from a 20-μl (diameter 1.3 cm) spotted urine samples, whereas confirmation was achieved by 2 complete circles each of 20 μl sample volume. The recovery was found to be 99.41% in water. No sign of significant degradation was seen among all storage conditions.

CONCLUSIONS:

In the current study, DUS has achieved the same level of precision and reproducibility as that of standard methods used for drug testing in urine. Hence, the DUS sampling appears to have potential to detect opiate among drug users in a clinical setting.

A Cross-Sectional Web-Based Survey of Medical Practitioners in India to Assess their Knowledge, Attitude, Prescription Practices, and Barriers toward Opioid Analgesic Prescriptions

CONTEXT

Inadequate training of medical practitioners is a key factor responsible for inappropriate use of opioid analgesics.

AIMS

We assessed the current knowledge, attitude, prescribing practices, and barriers perceived by the Indian medical practitioners in three tertiary care hospitals toward the use of opioid analgesics.

SUBJECTS AND METHODS

Web-based survey of registered medical practitioner employed at three chosen tertiary health care institutions in New Delhi.

STATISTICAL ANALYSIS USED

Descriptive analysis of survey responses was carried out. Comparative analysis was done using Chi-square test, independent samples t-test, and Pearson correlation coefficient.

RESULTS

The response rate was 10.4% (n = 308). Two-thirds of the participants (61.7%) had never received formal pain management training, and 86.7% participants would like further training. Most participants (71.1%) agreed that opioids should be prescribed in cancer pain, while 26.3% agreed that opioids should be prescribed in noncancer pain. Half of the participants agreed that SOS (if necessary) dosing schedule (48.4%), low dosage (61.7%), and short duration of use (51.4%) could decrease the harmful effect of opioids. Lack of information about opioid-related policies and addiction potential were identified as the most common barriers to prescribing opioids. Those seeing more patients with chronic noncancer pain come across opioid misuse and diversion more often (P = 0.02). Those who understood addiction were more likely to agree that patients of chronic cancer pain with substance use disorders should be prescribed opioid analgesics (P < 0.01).

CONCLUSIONS

Indian medical practitioners felt the need for formal pain management training. There is a lack of consensus on how to manage the pain using opioid analgesics. Tough regulations on medical and scientific use of opioids are the most commonly reported barrier to prescribing them.

Research on opioid substitution therapy in India: A brief, narrative review

Opioid dependence is a significant clinical and public health issue in India. Opioid substitution therapy (OST) is the most evidence-based treatment for opioid dependence. Although available in India for about three decades now, Indian research on this treatment modality has not been adequately reviewed so far. We conducted a narrative review of Indian research on OST. We conducted an online search for relevant literature in the peer-reviewed journals as well as the general online search for books and monographs. We present the findings of the review in the form of description of literature according to certain identified themes. Considering that methadone has became available in India, only recently, the Indian research on OST predominantly features buprenorphine as the agent. Effectiveness of OST among Indian opioid-dependent patients has been well established through prospective, experimental designs as well as through naturalistic studies using retrospective, chart-review approach. Naturalistic and observational postmarketing surveillance studies have demonstrated the safety of buprenorphine and methadone when used as OST. There are certain areas in which more research on OST will be beneficial for Indian clinicians as well as policy-makers. However, the quantum of evidence base that exists in India is more than adequate to justify the scale-up of this modality of treatment. A conducive policy environment for scaling-up OST is need of the hour.

Unsafe injecting practices, sexual risk behaviours and determinants of HIV among men who inject drugs: Results from Integrated Biological and Behavioural Surveillance in India

In India, while an overall reduction in HIV is achieved among most key populations, the continued higher prevalence among people who inject drugs (PWIDs) is an area of concern. This paper analyses unsafe injecting and sexual risk behaviours in male PWIDs according to HIV status and also examines the determinants of HIV infection in this high-risk group. Data from India's Integrated Biological and Behavioural Surveillance, conducted across 29 Indian states and Union Territories among 19,902 male PWIDs, were used. Informed consent was obtained and men aged 15 years or more, who used psychotropic substances or drugs in the past three months for non-medical reasons were recruited for the survey. Results from the multivariable analysis suggest that drug use debut at age 25 years or above (adjusted odds ratio [AOR]: 1.41, confidence interval [CI]: 1.05-1.88), engagement in drug use for a longer duration (AOR: 1.81, CI: 1.32-2.48), injecting three times or more per day (AOR: 1.53, CI: 1.1-2.12), sharing of needle/syringes (AOR: 1.34, CI: 1.02-1.76), self-reported sexually transmitted infections (AOR: 1.55, CI: 1.12-2.14) and higher self-risk perception for exposure to HIV (AOR: 2.08, CI: 1.58-2.75) increase the likelihood of HIV infection. Sustained higher prevalence, unsafe injecting and risky sexual practices are major challenges which may prevent India from reaching the 'end of AIDS' by 2030. This underscores the need for adoption of a tailored, evidence-driven HIV prevention approach that adequately addresses local needs to limit the spread of HIV within this population, and thereby prevents the onward transmission of HIV to the general population.

The journey of opioid substitution therapy in India: Achievements and challenges

Opioids are one of the most problematic illegal substances globally. Opioid abuse is associated with complications in various spheres of the user's life, his/her family, and the society. Injecting drug use (IDU) is also linked to public health problems such as HIV infection and viral hepatitis. Medications form an important cornerstone in the treatment of opioid dependence. Treatment strategies such as "detoxification" alone or long-term treatment with opioid antagonist have limited acceptability and retention rates. Opioid substitution therapy (OST) has demonstrated better retention rates than other existing treatment strategies and helps improve the individual's functioning as well as his/her quality of life. The use of OST in India spans three decades, with initial use of low-dose buprenorphine followed by higher strength buprenorphine and buprenorphine-naloxone. Other medications such as slow-release oral morphine, and recently, methadone have also been introduced. Indian research also confirms the findings from Western literature on the effectiveness as well as acceptability of this treatment modality. OST received its biggest thrust when it became a part of the National AIDS Control Programme. In recent years, the number of OST centers in India has increased manifold. Practice guidelines, standard operating procedures, and capacity-building mechanisms have been put in place for effective OST implementation. Despite such widespread use, many challenges exist for OST implementation. The targets for ensuring adequate coverage of the population with this treatment are still far away. There is concern of OST being branded as a "harm reduction" intervention reserved only for injecting drug users. Despite three decades of advancements, certain sections of policymakers and practitioners still have reservations with this treatment modality. There is a need to overcome these barriers for OST to become easily accessible to those who need it.

Injection drug use among children and adolescents in India: Ringing the alarm bells

INTRODUCTION

Injection drug use (IDU) is intricately linked to preventive aspects for human immunodeficiency virus from a public health perspective. No large-scale data are yet available for injectable drug use among children and adolescents in India, apart from few anecdotal reports.

AIMS AND METHODS

The present paper reports on the profile and substance use pattern of 509 child IDU users, among a total sample of over 4000 children using substances across 100 sites from 27 states and 2 UTs in India. It was undertaken in 2012-2013 by the National Commission of Protection for Child Rights in collaboration with the National Drug Dependence Treatment Centre, All India Institute of Medical Sciences, New Delhi. For inclusion, participants had to be 18 years or less, should have used at least one other substance besides tobacco in the last 1 year, and should be living at home/street, in or out of school. Data were gathered using a 95-item semi-structured questionnaire.

RESULTS

A large proportion of ever users of IDU also reported use in the past year (96.5%) and past month (92.7%). Apart from IDU, tobacco, alcohol, cannabis, and pharmaceutical opioids were the most common substances of abuse in order of frequency. There was an interval of about 3 years from the initiation of tobacco to the initiation of IDU. Average age of onset for IDU was a year lesser in males than female users. The street children initiated IDU earlier than out-of-school and schoolgoing children. No quit attempt was made by more than half of the children. More than 40% had frequent familial conflicts, more than half had a familial history of substance use, and three-fourths had drug-using peers.

CONCLUSION

The paper highlights the profile and pattern of children and adolescents using IDU across many parts of India, dispelling the myth that IDU is largely an adult phenomenon in India. There is a clear need to promote different harm reduction and preventive strategies across the "hard-to-reach" younger age groups using injecting drugs.

Health outcomes associated with illicit prescription opioid injection: A systematic review

Prescription opioid injection is a growing concern among people who use illicit drugs. Little is known about the potential health-related harms of injecting prescription opioids. Therefore, the authors undertook a systematic review to identify health outcomes associated with injecting prescription opioids. PubMed, Ovid MEDLINE®, EMBASE, Journals@Ovid, CINAHL, PsycInfo, Web of Science® Core Collection, CAB Direct, and ERIC databases were searched to identify English articles published between January 1990 and February 2015 that matched the inclusion criteria. Potentially relevant articles were those examining a clinical health outcome among people who use illicit drugs, in which a sub-group injects prescription opioids. The International Classification of Diseases (ICD-10) was used to clinically classify health outcomes. In total, 31 studies that met the inclusion criteria were identified and summarized. A modified version of the Downs and Black checklist was used to assess individual study quality and identify sources of bias. Findings supported associations between prescription opioid injection and hepatitis C infection, substance dependence and other mental health indicators, and lower general health. Associations with human immunodeficiency virus, overdose, and cutaneous infection were less consistent and varied according to prescription opioid type(s). Several potential sources of bias were identified as well as a need for more longitudinal research and more rigorous confounding adjustment. The current findings highlight a need to consider the growing popularity of prescription opioid injection in efforts to reduce drug-related harm among people who inject drugs.

Pentazocine use among people who inject drugs in India

Data regarding prevalence of Pentazocine use is sparse and intervention strategies aimed at it are meager. In view of the fact that Pentazocine has significant abuse potential contrary to what was earlier thought, along with the actuality that people who use injectable Pentazocine are at risk of various complications as HIV, this domain needs more attention. This review examines the extent of the problem of Pentazocine use with consequent effects on the overall health of the people. It is based on nationally representative large scale survey(s) and other reliable documented data on Pentazocine abuse. Possible strategies and future lines of actions have been delineated. Data suggests Pentazocine use from 0.1% to 21.8% in different parts of the country. Various reports have also linked it with unique health complications. Its use has been reported mostly among subjects seeking treatment, with recent reports suggesting increasing use at street level. The strategies to document the extent of injection drug use applied in most cases might not be adequate. There is a need for further research and monitoring to document the burden of the problem. Indirect methods to estimate the extent of problem may need to be implemented and regulatory mechanisms for prescription drug use may need to be strengthened.