Challenges in the scale-up of opioid substitution treatment in India

HIV, hepatitis B & C in people who inject drugs in India: A systematic review of regional heterogeneity & overview of opioid substitution treatment

BACKGROUND OBJECTIVES

This systematic review evaluates the human immunodeficiency virus (HIV), hepatitis C virus (HCV) and hepatitis B virus (HBV) burden among people who inject drugs (PWIDs) in India. In addition, we selectively examined research on opioid substitution treatment (OST)-related services due to their role in antiviral treatment uptake and adherence.

METHODS

Data were sourced from peer-reviewed and government publications between 1991 and September 20, 2023, searched in MEDLINE, Scopus and EBSCOhost. English language studies reporting weighted prevalence or raw numbers and recruitment sites were included for review. Quality was assessed using the Joanna Briggs Institute tool. Data synthesis was done in graphs and tables.

RESULTS

We included 50 reports, yielding 150 HIV, 68 HCV and 24 HBV prevalence estimates across India, revealing significant regional heterogeneity. Notably, 16 States had a single community-based HIV estimate, and 19 States had limited or no HCV data. The highest HIV and HCV prevalence was in Manipur (74.7% and 97.5%, respectively) in 1996. Recent spikes included 50.2 per cent HIV prevalence in Punjab (2010) and 73 per cent HCV in Uttar Pradesh (2021). Nationally, OST coverage in 2020 was under five per cent, with some northeast, north and central States exceeding this, but most others were falling below two per cent. No studies on the cost-effectiveness of directly observed treatment models for OST were identified.

INTERPRETATION CONCLUSIONS

There is a lack of sufficiently granular and generalizable estimates for HIV prevalence and any estimates for HCV and HBV among PWIDs in large parts of the country. Community-based representative studies are required to quantify the prevalence and severity of these diseases and allocate resources.

Buprenorphine treatment receipt characteristics and retention among people who inject drugs at Integrated Care Centers in India

BACKGROUND

India is facing overlapping opioid injection and HIV epidemics among people who inject drugs (PWID) in several cities. Integrated Care Centers (ICCs) provide single-venue HIV and substance use services to PWID. We evaluated PWID engagement in daily observed buprenorphine treatment at 7 ICCs to inform interventions.

METHODS

We analyzed 1-year follow-up data for PWID initiating buprenorphine between 1 January - 31 December 2018, evaluating receipt frequency, treatment interruptions (no buprenorphine receipt for 60 consecutive days with subsequent re-engagement), and drop-out (no buprenorphine receipt for 60 consecutive days without re-engagement). Using descriptive statistics, we explored differences between ICCs in the opioid-endemic Northeast region and ICCs in the emerging opioid epidemic North/Central region. We used a multivariable logistic regression model to determine predictors of treatment drop-out by 6 months.

RESULTS

1312 PWID initiated buprenorphine (76% North/Central ICCs vs. 24% Northeast ICCs). 31% of PWID in North/Central, and 25% in Northeast ICCs experienced ≥ 1 treatment interruption in 1 year. Over 6 months, 48% of PWID in North/Central vs. 60% in Northeast ICCs received buprenorphine ≤ 2 times/week (p < 0.0001). A third of PWID in North/Central vs. half in Northeast ICCs experienced treatment drop-out by 6 months (p < 0.001). In the multivariable model, living in Northeast cities was associated with increased odds of drop-out while counseling receipt was associated with decreased odds.

CONCLUSIONS

Retention among PWID initiating buprenorphine at ICCs was comparable to global reports. However, regional heterogeneity in retention, and low daily buprenorphine receipt suggest patient-centered interventions adapted to regional contexts are urgently needed.

Yoga as an Adjunct for Management of Opioid Dependence Syndrome: A Nine-Month Follow-Up Case Report

Opioid dependence syndrome (ODS) is a chronic relapsing remitting condition associated with significant impairment and mortality risk. Opioid substitution therapy is used worldwide, but long-term retention rates are low and there is risk of misuse and diversion. Yoga practice can improve quality of life, reduce chronic pain, and enhance endogenous opioids (beta-endorphins). We describe a case of ODS where yoga was added to the conventional management and who was followed up for 9 months. Assessments were done for clinical symptoms, urine drug screening, plasma beta-endorphins, and Buprenorphine dosage. We observed an improvement in his clinical symptoms and reduction in the requirements for Buprenorphine. A slight increase in basal plasma beta-endorphin levels was also observed at the 9-month follow-up (from 2.02 pmol/L at baseline to 6.51 pmol/L).

Relapse in opioid dependence: Role of psychosocial factors

BACKGROUND

Although our understanding about neurobiology of opioid dependence and availability of pharmacological treatment has gone a long way in the last few decades, psychosocial interventions play a pivotal role in the prevention of relapse owing to reasons such as less treatment-seeking behavior and poor penetrance of opioid substitution treatment. There are many studies assessing psychosocial factors in alcohol and nicotine dependence, yet the availability of such studies for opioid dependence is sparse. This study aimed at evaluating the association of relapse in opioid dependence with various psychosocial factors.

MATERIALS AND METHODS

This was a cross-sectional study with two groups of opioid dependence patients: In abstinence (N = 28) and relapse (N = 33). Psychosocial variables such as high-risk situations, coping behavior, stressful life events, self-efficacy, and social support were assessed in the two groups and analyzed for the association with opioid relapse.

RESULTS

This study reports that more high risk situations (odds ratio [OR] =1.58; 95% confidence interval [CI] =1.22-2.03; P = 0.017), especially negative mood state and undesirable stressful life events (OR = 2.08; 95% CI = 1.28-3.37; P = 0.05) were significantly associated with higher odds of relapse in patients of opioid dependence. Further, higher self-efficacy (OR = 0.92; 95% CI = 0.87-0.96; P = 0.017) was significantly associated with lower odds of relapse.

CONCLUSION

Psychosocial factors such as high risk situations, undesirable stressful life events, and self-efficacy were significantly associated with relapse in opioid dependence. Hence, practice of a holistic, multimodal, and individualized treatment plan addressing these factors might help in reducing the relapse rates in them.

Retention and outcomes for clients attending a methadone clinic in a resource-constrained setting: a mixed methods prospective cohort study in Imphal, Northeast India

Background

Opioid substitution therapy (OST) with buprenorphine has been widely available in India since 2007, but the introduction of methadone occurred much later in 2012, and availability remains limited. Illicit injecting drug use is a long-standing public health problem in Manipur, a state in Northeast India characterised by major resource constraints and political unrest. We investigated retention and outcomes for clients attending a methadone-based OST program in Manipur with the aim of strengthening the evidence base for development of relevant policies and programs.

Methods

All clients enrolling in the methadone clinic over a 1 year period were invited to be part of a prospective cohort study, which followed up and surveyed both retained and defaulting clients for 12 months post-enrollment to assess retention as well as social, behavioural and mental health outcomes. Additionally, we conducted semi-structured qualitative interviews to supplement quantitative information and identify factors contributing to retention and drop-out.

Results

Of the 74 clients enrolled, 21 had dropped out and three had died (all defaulters) by 12 months post-enrollment, leaving 67.6% still in the program. Using an intention-to-treat analysis, meaningful and statistically significant gains were observed for all social, behavioural and mental health variables. Between baseline and 12 months there were reductions in needle sharing, drug use, property crime, anxiety, depression and suicidal thoughts; and improvements in physical health, mental health, quality of family relationships, employment and hopefulness. Factors contributing to retention and drop-out were identified, including the centrality of family, and general lack of awareness of and misunderstanding about methadone.

Conclusion

Even in parts of India where resources are constrained, methadone is an effective treatment for opioid dependence. Scaling up the availability of methadone elsewhere in Manipur and in other areas of India experiencing problematic opioid dependence is indicated.

Clinical profile and outcomes of opioid abuse gastroenteropathy: an underdiagnosed disease entity

Background/Aims

Opioid-induced bowel dysfunction includes nausea, vomiting, constipation and abdominal distension. We describe patients presenting with gastrointestinal (GI) ulcers and ulcerated strictures secondary to opioid abuse, an entity not well described in literature.

Methods

This retrospective observational study included patients with opioid abuse gastroenteropathy presenting to Dayanand Medical College and Hospital, Ludhiana, India between January 2013 and December 2018. Opioid abuse gastroenteropathy was defined as gastric or small bowel ulcers and ulcerated strictures in patients abusing opioids, where all other possible etiologies of GI ulcers/strictures were excluded. Clinical, biochemical, endoscopic, radiological and histological parameters as well as response to treatment were assessed.

Results

During the study period, 20 patients (mean age, 38.5±14.2 years; 100% males) were diagnosed to have opioid induced GI ulcers and/or ulcerated strictures. The mean duration of opioid consumption was 6.2±3.4 years. The mean duration of symptoms at presentation was 222.1±392.3 days. Thirteen patients (65%) had gastroduodenal involvement, 6 (30%) had a jejunoileal disease and 1 (5%) had an ileocecal stricture. Two patients (10%) presented with upper GI bleeding, 11 (55%) had features of gastric outlet obstruction and 7 (35%) presented with small bowel obstruction. Abdominal pain and iron deficiency anemia were the most common presentations. Only 1 patient (5%) responded to proton pump inhibitors, 3 (15%) had a lasting response to endoscopic balloon dilatation, while all other (80%) required surgical intervention.

Conclusions

Opioid abuse gastroenteropathy presents as ulcers and ulcerated strictures which respond poorly to medical management and endoscopic balloon dilatation. A majority of these cases need surgical intervention.

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.

Buprenorphine-based opioid substitution therapy in India: A few observations, thoughts, and opinions

The most evidence-based treatment for opioid dependence is opioid agonist maintenance treatment also known as opioid substitution therapy (OST). However, there are some critical, yet unaddressed issues of buprenorphine-based substitution therapy, especially in the Indian context. These comprise of generalizability of the evidence for OST, especially for natural and pharmaceutical opioids and for all age groups, optimum dose and duration of OST, and mode of treatment delivery including the frequency of dispensing. Notwithstanding the use of buprenorphine-naloxone combination, abuse and diversion are serious but often underreported problems. There is an urgent need for health services research in India on OST, focusing on these aspects. Rather than directly copying from Western models, it is important to try to understand the useful and safe program and policy options likely to be applicable in the Indian setting, with our own assets as well as vulnerabilities.

National Institute on Drug Abuse International Program: improving opioid use disorder treatment through international research training

PURPOSE OF REVIEW

For more than 25 years, the National Institute on Drug Abuse (NIDA) has supported research-training programs, establishing a global research network and expanding the knowledge base on substance use disorders. International research to inform approaches to opioid addiction is particularly important and relevant to the United States, where opioid misuse, addiction, and overdose constitute an emerging public health crisis. This article summarizes the NIDA International Program and illustrates its impact by reviewing recent articles about treatment approaches for opioid use disorders (OUD).

RECENT FINDINGS

Studies in several countries have demonstrated the effectiveness of physician office-based opioid substitution therapies. Other research has demonstrated the effectiveness of different formulations and doses of the opioid antagonist naltrexone, as well as different approaches to providing naloxone to treat opioid overdose. Continuing research into implementation of evidence-based treatment in international settings with limited resources is applicable to US regions that face similar structural, legal, and fiscal constraints.

SUMMARY

The current review describes international research on OUD treatment and opioid overdose, most coauthored by former NIDA fellows. The findings from outside the United States have important implications for best practices domestically and in other countries that are experiencing increases in OUD prevalence and related overdose deaths.