A Prospective Three-Months Naturalistic Follow-Up Study of Outcomes of Patients with Opioid Dependence Discharged on Buprenorphine or Oral Naltrexone.

Background: Comparative studies of the naturalistic course of patients of opioid dependence on naltrexone and buprenorphine are likely to be helpful for clinical decision-making. The article aimed to report on the three-months naturalistic outcomes of patients discharged on naltrexone or buprenorphine from the same center. Methods: Patients with opioid dependence who were discharged on either naltrexone (n = 86) or buprenorphine (n = 30) were followed up for three months for retention in treatment. The patients were also followed up telephonically, and the Maudsley Addiction Profile was applied. Results: The days of retention in treatment were significantly higher in the buprenorphine group (69.5 versus 48.7 days, P = 0.009). Heroin use, pharmaceutical opioid use, injection drug use, involvement in illegal activity, and percentage of contact days in conflict with friends in the last 30 days reduced over three months in both the groups, while the physical and psychological quality of life improved in both the groups. Additionally, in the naltrexone group, smoked tobacco use, cannabis use, and percentage of contact days in conflict with family within the last 30 days reduced at three months compared to baseline. Conclusion: With the possible limitations of choice of medication-assisted treatment for opioid dependence being determined by the patient, and prescribing related factors and sample size constraints, the study suggests that retention outcomes may vary between naltrexone and buprenorphine, though both medications may improve several patient-related parameters. However, a true head-to-head comparison of the outcomes of buprenorphine and naltrexone in a naturalistic setting may be difficult.

Substance use and its associated factors among school students.

Background: . There is lack of comprehensive data on substance use and associated factors among school students in Delhi, India. Methods: . We used a cluster sampling method based on sections of classes in schools to conduct this study in two government-run schools in Delhi. All enrolled students from 8th, 9th and 11th grades participated (n = 405). The WHO Student Drug Use questionnaire was administered in a single session for a class section for assessing substance use. Results: . The participation rate was 90.6%. The rates of past 12 months' use of tobacco, alcohol, cannabis and inhalants were 22%, 12.1%, 12.1% and 8.6%, respectively, while rates for 'sedatives and tranquillizers' were 4.9%, opium 2.7% and other opioids 1.2%. Lifetime use of heroin was reported by two students and use in the past 12 months by one student. Multiple substance use was high. Higher age was associated with the use of alcohol and cannabis. According to logistic regression model results, use by a family member significantly increased the probability of using tobacco (adjusted odds ratio [AOR] 11.3; 95% confidence interval (CI) 3.4-37.8) and alcohol (AOR 3.75; 95% CI 5.1-1059.3). Similarly, use by peers significantly increased the probability of tobacco (AOR 7.7; 95% CI 2.0-29.8) and cannabis use (AOR 5.7; 95% CI 1.5-21.5). Having poor harm perception significantly increased the chances of inhalant use by students (AOR 5.5; 95% CI 1.5-20.1). Conclusion: . The study results bring to attention the prevalent and important problem of substance use among schoolchildren. We recommend that (i) intervention strategies for school settings are important and need to factor in the use of illicit substances (cannabis); (ii) psychosocial intervention by trained school counsellors in school settings is the mainstay for intervention for cannabis and inhalants; and (iii) heroin users should be referred to healthcare facilities for detoxification.

Effectiveness of Interventions Based on Yogic Breathing Practices (IB-YBP) on Substance Use Disorders-A Systematic Review of the Randomized Control Trials and Quasi-Experimental Trials.

INTRODUCTION: Interventions based on Yogic Breathing Practices (IB-YBP) have shown promising results for substance use disorders (SUD). Research in this area is methodologically heterogeneous and only a few, but restricted, systematic reviews are available. The current systematic review aims to assess the effectiveness of IB-YBP for SUD. Materials and Methods: PubMed, Cochrane's Library, EBSCO-Medline, and Google Scholar databases were searched for the randomized- (RCTs) and quasi-randomized trials. Research involving participants with SUD, of either gender or any age, assessing the effectiveness of the IB-YBP either as a standalone intervention or as an adjuvant to standard treatment versus standard pharmacological/non-pharmacological treatment or no-intervention control were included. Studies having participants with co-morbid psychiatric illness and interventions not having IB-YBP as the predominant component were excluded. Results: The initial literature search yielded 396 articles and upon screening, only 14 studies were found eligible for this review. Most studies have researched IB-YBP as an adjunct to the standard treatment for SUD. Evidence for the effectiveness of IB-YBP is mostly available for tobacco and opioid use disorders, though only for short-term outcomes; however, literature is scarce for alcohol- and cocaine-use disorders. This review documented the effectiveness of the IB-YBP for substance use-related outcome parameters such as abstinence, quality of life (QoL), mood, craving, and withdrawal symptoms. Conclusion: IB-YBP may be an effective adjuvant to standard treatment for various SUD. However, more research is required to compare its effectiveness with standard treatment, and assessing its long-term efficacy, for it to be strongly recommended as a treatment strategy.

Co-administration of nalbuphine attenuates the morphine-induced anxiety and dopaminergic alterations in morphine-withdrawn rats.

INTRODUCTION: The classical effects of exogenous opioids, such as morphine, are predominantly mediated through µ-opioid receptors. The chronic use of morphine induces anxiety-like behavior causing functional changes in the mesolimbic dopaminergic system. The mixed µ/κ-agonist, nalbuphine, used either as an analgesic or as an adjuvant with morphine, produces different and opposite effects. However, whether nalbuphine can be used to antagonize morphine-induced anxiety and dopaminergic alterations is not fully known. OBJECTIVE: This study aimed to compare acute and chronic effects of nalbuphine on morphine-induced anxiety and dopaminergic alterations in rats. METHODS: Male adult Wistar albino rats were made opioid-dependent by administering increasing doses of morphine (5-25 mg/kg; i.p.; b.i.d.). Withdrawal was induced by naloxone (1 mg/kg, i.p.), 4 h after the last morphine injection. Anxiety-like behavior was measured using Activity Monitor (Coulbourn Instruments, Inc. USA). Thereafter, the animals were sacrificed and the brain dissected out and the level of cAMP and the transcriptional and translational expression of TH was measured. Nalbuphine was co-administered with morphine, acutely and chronically, at various doses (0.1, 0.3, 1.0, 3.0 mg/kg, i.p.). RESULTS: Morphine-dependent rats showed a significant higher anxiety and cAMP levels and a significant decrease in the expression of TH. Co-administration of chronic doses of nalbuphine attenuates the higher anxiety, cAMP levels, and upregulates the TH expressions; however, the acute nalbuphine treatment does not attenuate the morphine-induced side effects. CONCLUSION: Therefore, nalbuphine might have an important role in attenuating the anxiety and the effects of the dopaminergic pathway and may have potential in the treatment of opioid addiction.

Assessment of Subjective Sleep Problems in Men With Opioid Dependence Maintained on Buprenorphine.

OBJECTIVES: To assess the rates of sleep disturbances in male patients with opioid dependence maintained on buprenorphine and to assess the factors associated with sleep disturbances in this population. METHODS: Observational, cross-sectional study. Male patients with opioid dependence aged 18 years and older, and started on buprenorphine at least 6 months before were screened. Those with history of comorbid psychiatric illnesses (except sleep disorders), on any other substance in high-risk category (based on WHO-Alcohol Smoking Substance Involvement Screening Test (ASSIST)), or on any other psychotropic medications (in addition to OAT with buprenorphine) were excluded. Sleep was assessed using the Pittsburgh Sleep Quality Index (PSQI), Sleep-50, and Epworth Sleepiness Scale (ESS). Each participant was interviewed in a single session lasting 60 minutes. RESULTS: One hundred six participants were included. Their mean age was 41.1 (SD 14.3) years. The participants had been on OAT with buprenorphine for a median duration of 60 months (IQR 17-120), with excellent adherence rate in past 1 month. The mean current dose of buprenorphine was 10.2 (SD 3.8) mg per day. The mean subjective total sleep time was 403.5 minutes (SD 94.8) and the median sleep latency was 35 minutes (IQR 18.8-62.5). The mean PSQI score was 6.6 (SD 3.4). Nearly 63% (n = 67) participants had PSQI scores more than 5 (PSQI > 5) suggesting sleep problems. Sociodemographic, substance use, and treatment variables were compared between participants who scored more than 5 and those who scored less than 5 on PSQI. No significant difference was found between the 2 groups. CONCLUSIONS: Substantial proportion of male patients with opioid dependence maintained on buprenorphine have sleep problems. The sleep problems in buprenorphine-maintained patients seem to be independent of substance use and treatment-related attributes.

Estimating the size of substance using street children in Delhi using Respondent-Driven Sampling (RDS).

Street children as a population sub-group exist in significant numbers in the developing world and have been reported to be vulnerable to adverse health and risk behaviours that include physical and sexual risk behaviour. However, the estimation of prevalence for various psychoactive substances among the street children in a representative sample has not been attempted in the developing country like India. This is challenging due to the absence of an appropriate sampling frame, the population living in isolation, hiding their identity and concealing their behaviour. Use of psychoactive substances in street children is riddled with these challenges. The present investigation describes the findings from size estimation study on a representative sample of street child (n = 766) in Delhi, by implementing the Respondent Driven Sampling Methodology (RDS). The weighted prevalence for three commonest substances was found as Tobacco (31.1 %), alcohol (13.5 %) and inhalants (11.3 %) used during the last one year with the estimated number as -Tobacco (21,770), Alcohol (9450) and Inhalants (5600). Almost one third of street children were using some substance. Also, a large majority of ever users were also using substances currently. The study demonstrates successfully the implementation of RDS for the estimation of the prevalence of psychoactive substances in a representative manner. A large majority of street children use psychoactive substances, and there is a need for more of such studies in other metropolitan cities so that local level interventions and planning can be done for treatment and prevention of psychoactive substances among the street children. The important public health implications had been discussed.

Preferences for Treatment Setting by Substance Users in India.

BACKGROUND: Drug and alcohol use is a growing public health concern for India. Treatment services delivery for substance use disorders is available through three sectors viz. Government (GO) centres under Ministry of Health and FW, Non-Government (NGO) under Ministry of Social Justice and Empowerment and the private sector. Information on ttreatment utilisation and preferences of treatment settings by substance users are not available for India. METHODS: A performa was filled up prospectively for each consecutive new patient seeking treatment for drug/alcohol use (excluding tobacco) at De-addiction centres funded by MOH&FW; NGOs under MoSJE and private psychiatrists between 15(th) July to 15(th) October, 2011. All data available for 182 drug using persons from private, 1228 persons from 35 NGOs and 1700 persons from GO organizations were entered into SPSS-21.0, data quality checks performed and analysed. RESULTS: There was a variance in the population profile in the three sectors providing treatment delivery for substance users in India. Treatment seeking for illicit drugs (heroin, opiates and cannabis) was higher in GO sector; injection drug use was higher in NGO sector while alcohol was higher in private sector. CONCLUSIONS: Strengthening linkages between GO and NGO sector is important for an improved coverage and quality of treatment services in the country. The Andersen's Behavioural Model as theoretical background to clarify some issues in analyzing with larger datasets is warranted.

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.

A double-blind, double-dummy, randomized controlled study of memantine versus buprenorphine in naloxone-precipitated acute withdrawal in heroin addicts.

OBJECTIVES: To compare the efficacy of memantine with buprenorphine in the suppression of naloxone-precipitated acute withdrawal in heroin-dependent male subjects in an inpatient setting. SETTING: Inpatient unit of tertiary level deaddiction facility. PARTICIPANTS: Forty-five treatment-seeking heroin-dependent males. INTERVENTIONS: Subjects stabilized on 650 mg of dextropropoxyphene for 5 days were randomly divided into two groups on the sixth day: group A (n=25) received 20 mg of memantine with buprenorphineplacebo, and group B (n=20) received 2 mg of buprenorphine with memantine placebo. Acute withdrawals were precipitated with naloxone (0.4 mg, intravenously) and were assessed using subjective and objective opioid withdrawal scales (SOWS and OOWS) and two separate visual analogue scales (VASs) for pain and dysphoria at baseline prior to test drug administration and again after the precipitation of acute withdrawal. MAIN OUTCOME MEASURES: Severity ofprecipitated opioid withdrawals. RESULTS: Baseline opioid withdrawal symptoms in both groups did not differ significantly. After the precipitation of acute withdrawal, there were no significant differences between subjects in both groups on OOWS and both VASs but showed significant difference on SOWS. When changes in ratings from baseline (and after naloxone-precipitated acute withdrawal) were compared between the two groups, a significant difference in the change in SOWS scores was observed with greater decrease in withdrawal scores in the buprenorphine group. CONCLUSIONS: Memantine has comparable efficacy to buprenorphine in the suppression of objective signs of naloxone-precipitated acute opioid withdrawal; however, its role in the suppression of subjective symptoms is debatable.

Inhalant abuse: An exploratory study.

BACKGROUND: Inhalants are being abused by large numbers of people throughout the world, particularly children and adolescents. It is also an often overlooked form of ubstance abuse in adolescents. AIMS: The current study explored the inhalant abuse among adolescents seeking treatment from a tertiary care drug de-addiction clinic. SETTINGS AND DESIGN: The study was conducted at a tertiary level multispecialty hospital. MATERIALS AND METHODS: The current study was a chart review of the cases with inhalant abuse/dependence presenting to the clinic over a 1-year period. All the treatment records of the de-addiction clinic were reviewed, and information was gathered regarding patients with inhalant abuse/dependence. STATISTICAL ANALYSIS: Descriptive statistics with frequency distribution was carried out by using SPSS version 10.0. RESULTS: The mean age of the subjects was 16.24 years (SD±1.9 years; range 12-18 years). Twenty-two percent of the subjects were illiterate. Forty percent of the adolescents had a family history of alcohol use problems and 48% that of tobacco use. The mean age of the initiation of inhalant use was 11.6 years (SD±2.17 years). It varied from 9 to 18 years. Forty percent of the adolescents had made a previous abstinence attempt. CONCLUSIONS: The findings provide important information on an underresearched area in psychiatry.

Assessment of differential doses of buprenorphine for long term pharmacotherapy among opiate dependent subjects.

The aim of the present study was to evaluate, two different doses of sublingual buprenorphine (2 mg and 4 mg) among patients on maintenance treatment and to assess the relationship of steady state plasma level with craving. Twenty three male opioid dependent (ICD-10 DCR) subjects, were assigned to double blind randomized controlled trial of 2 and 4 mg/day doses of buprenorphine in an inpatient setting. They were evaluated thrice (2nd, 7th and 14th day) in 2 weeks for withdrawal symptoms (acute and protracted), sedation, euphoria, craving, side effects, global rating of well being and for measurement of plasma levels of buprenorphine. The data showed that there were no significant difference in scores of euphoria and sedation, protracted withdrawal symptoms and side effects, craving and overall well being and plasma level of buprenorphine among the subjects. However, both the groups had significant difference in score on almost all the measurements on final observation in comparison to initial observation. Both 2 mg/day and 4 mg/day dose of buprenorphine were effective in long term pharmacotherapy of opioid dependence without significant difference as compared by different measures used in the study.