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OBJECTIVE: To assess the implementation of a mobile dispensing service to improve opioid users' access to methadone maintenance therapy. METHODS: In March 2019, we started mobile methadone dispensing in an urban underprivileged locality in Delhi, India. The doctor was available only at the main community drug treatment clinic for clinical services, while the nurse dispensed methadone from a converted ambulance. We involved patients in identifying community leaders for sensitization and in deciding the location and timings for dispensing. We conducted a retrospective chart review of the programme data collected during delivery of clinical services. We compared the numbers of patients registered for methadone therapy and their retention and adherence to therapy in the 12-month periods before and after implementation of the mobile service. FINDINGS: The number of patients registered for therapy at the clinic increased from 167 in the year before implementation to 671 in the year after. A significantly higher proportion of patients were retained in therapy at 3, 6 and 9 months after enrolment; 9-month retention rates were 19% (32/167 patients) and 45% (44/97 patients) in the year before and after implementation, respectively. There was no significant difference in patients' adherence to therapy between the two periods. Challenges included providing suitable dispensing hours for patients in employment and concerns of local community near to the dispensing sites. CONCLUSION: It is feasible to dispense methadone by a mobile team in an urban setting, with better retention rates in therapy compared with dispensing through a stationary clinic.
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Analgésicos Opioides/uso terapéutico , Implementación de Plan de Salud , Metadona/uso terapéutico , Unidades Móviles de Salud/organización & administración , Trastornos Relacionados con Opioides/rehabilitación , Adulto , Femenino , Humanos , India , Masculino , Persona de Mediana Edad , Tratamiento de Sustitución de Opiáceos , Trastornos Relacionados con Opioides/tratamiento farmacológico , Evaluación de Programas y Proyectos de Salud , Estudios Retrospectivos , Resultado del TratamientoRESUMEN
BACKGROUND: Given the scarcity of alcohol prevention and use disorder treatments in many low- and middle-income countries (LMICs), the World Health Organization has launched an eHealth portal that includes the web-based self-help program "Alcohol e-Health." OBJECTIVE: We aimed to test the effectiveness of the Alcohol e-Health program in a randomized controlled trial. METHODS: This was a two-arm, individually randomized, and controlled trial across four LMICs comparing the self-help program and a psychoeducation and internet access as usual waiting list. Participants were broadly recruited from community samples in Belarus, Brazil, India, and Mexico from January 2016 through January 2019. The primary outcome measure was change in the Alcohol Use Disorders Identification Test (AUDIT) score with a time frame of 6 months between baseline and follow-up. Secondary outcomes included self-reported numbers of standard drinks over the previous week and cessation of harmful or hazardous drinking (AUDIT score <8). RESULTS: For this study, we recruited 1400 predominantly male (n=982, 70.1%) at least harmful or hazardous alcohol drinkers. The mean age was 37.6 years (SD 10.5). The participants were recruited from Brazil (n=587), Mexico (n=509), India (n=212), and Belarus (n=92). Overall, complete case analysis identified higher AUDIT changes in the intervention group (B=-4.18, 95% CI -5.42 to -2.93, P<.001, d=0.56) that were mirrored by changes in weekly standard drinks (B=-9.34, 95% CI -15.90 to -2.77, P=.005, d=0.28) and cessation rates for harmful or hazardous drinking (χ21=14.56, N=561, P<.001). The supplementary intention-to-treat analyses largely confirmed these initial results. CONCLUSIONS: The expansion of the Alcohol e-Health program to other LMICs with underdeveloped alcohol prevention and treatment systems for alcohol use disorders should be considered after successful replication of the present results. TRIAL REGISTRATION: ISRCTN ISRCTN14037475; https://www.isrctn.com/ISRCTN14037475. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.1111/add.14034.
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Alcoholismo , Países en Desarrollo , Adulto , Consumo de Bebidas Alcohólicas/prevención & control , Alcoholismo/prevención & control , Conductas Relacionadas con la Salud , Humanos , Internet , MasculinoRESUMEN
Drug use, including opioid use disorder, is one of the rapidly rising and serious problems affecting populations globally. There is a treatment gap and delay in presentation of drug users to treatment centers. The present study aimed at assessing the pathways to care among opioid-dependent individuals seeking treatment from a community-based treatment center in India. In a cross-sectional observational study conducted at a community clinic of the National Drug Dependence Treatment Centre (NDDTC), New Delhi, India, a total of 100 treatment-seeking drug users (age 18-60 years) fulfilling DSM IV TR criteria for opioid dependence were recruited. The data were collected using a semistructured pro forma based on patient self-report and the encounter form used in the World Health Organization (WHO) Pathway Study. All participants were male, were mostly married, were employed, and belonged to nuclear families. Ninety-eight percent of participants has ever used heroin in a dependent fashion and 20% were using it currently. Mean age of the participants was 40.83 years (SD 12.7). Median age of onset of heroin use was 22 years (IQR 12). Median duration of heroin use was 138 months (IQR 132). Only 21% of participants visited the community deaddiction clinic at the first contact with care. The median time for first treatment-seeking attempt was 9.5 years (IQR 7). The study findings suggest significant delay between onset of drug-related problems and first treatment contact. There is a need to increase the availability and accessibility of treatment services to reduce the delay in treatment seeking.
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Servicios de Salud Comunitaria/estadística & datos numéricos , Trastornos Relacionados con Opioides/epidemiología , Trastornos Relacionados con Opioides/terapia , Aceptación de la Atención de Salud/estadística & datos numéricos , Centros de Tratamiento de Abuso de Sustancias/estadística & datos numéricos , Tiempo de Tratamiento/estadística & datos numéricos , Adolescente , Adulto , Edad de Inicio , Vías Clínicas , Estudios Transversales , Dependencia de Heroína/epidemiología , Dependencia de Heroína/terapia , Humanos , India/epidemiología , Masculino , Persona de Mediana Edad , Adulto JovenRESUMEN
Chronic pain is associated with higher rates of psychiatric comorbidity, including substance use disorders. Patients with chronic pain often require opioids for their pain relief. Often, clinicians are reluctant to prescribe opioids to patients with chronic pain due to fear of patients becoming dependent on opioids. Diagnosing opioid addiction in chronic pain with comorbid prescription opioid use is challenging, as some of the symptoms of addiction overlap with those of physical dependence. A 28-year-old female presented with a history of recurrent abdominal pain beginning at the age of 16 years. The patient was diagnosed with chronic pancreatitis and was prescribed tramadol orally or injections for pain. The patient started experiencing craving with repeated administration of tramadol. She started using it daily and increased her dose to about 6-7 ampoules per day. She also developed complications due to injections. She was not able to work due to her pain, as well as injection use. She would go to multiple chemist shops for getting herself injected with tramadol injections. She also developed depressive symptoms in this period. Due to abdominal pain, the patient was admitted in the gastroenterology ward, from where she was shifted to the psychiatry ward for the management of opioid misuse and depressive symptoms. The patient was diagnosed to be suffering from opioid dependence syndrome with depressive episodes, for which she was provided tablet buprenorphine 14 mg/day dose along with tablet sertraline 150 mg/day. The case demonstrates several challenges in the diagnosis and management of opioid dependence and chronic pain when they occur simultaneously.
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Irritable bowel syndrome is a common gastrointestinal condition with underlying psychological factors. Its management can be challenging, sometimes necessitating a multidisciplinary team of gastroenterologists, psychiatrists and clinical psychologists. Non-pharmacological interventions are gaining attention for the management of chronic irritable bowel syndrome. We present a difficult-to-treat case of chronic irritable bowel syndrome, which was managed successfully with psychological interventions.
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Trastornos de Ansiedad , Terapia Cognitivo-Conductual/métodos , Síndrome del Colon Irritable , Sertralina/administración & dosificación , Trastornos de Ansiedad/diagnóstico , Trastornos de Ansiedad/etiología , Trastornos de Ansiedad/fisiopatología , Trastornos de Ansiedad/terapia , Conducta Compulsiva/terapia , Humanos , Síndrome del Colon Irritable/complicaciones , Síndrome del Colon Irritable/psicología , Síndrome del Colon Irritable/terapia , Masculino , Escala del Estado Mental , Persona de Mediana Edad , Inhibidores Selectivos de la Recaptación de Serotonina/administración & dosificación , Resultado del TratamientoRESUMEN
Somatization disorder is a common cause of chronic non-cancer pain. The use of opioids in such conditions carries a risk of their potential abuse. Lax regulations coupled with sub-optimal medical training in India lead to the rampant use of prescription opioids. We present a case of somatization disorder along with injection pentazocine dependence in a woman, in whom use of pentazocine was initiated by a registered medical practitioner for somatoform pain management, followed by self-injection because of its easy availability in local pharmacy shops. We highlight the need for education of medical practitioners on appropriate use of pharmaceutical opioids, need for regulation of local pharmacy shops, and development of guidelines for use of opioids in chronic non-cancer pain.
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Analgésicos Opioides/uso terapéutico , Dolor Crónico/tratamiento farmacológico , Prescripción Inadecuada , Trastornos Relacionados con Opioides , Pentazocina/uso terapéutico , Trastornos Somatomorfos/tratamiento farmacológico , Adulto , Femenino , HumanosRESUMEN
INTRODUCTION: Opioid agonist treatment (OAT) is an effective treatment for opioid dependence syndrome in adults. However, studies on effectiveness of OAT in adolescents are limited; existing studies show varying retention rates. The present study aimed to assess OAT retention rates in adolescent patients with opioid dependence syndrome registered in a community drug treatment clinic in Delhi, India, and to analyse factors associated with retention at 1 year. METHODS: Retrospective cohort study. All adolescents (n = 130) aged 10-19 years, started on OAT from January 2020 to July 2022 were included. Baseline and follow-up data was extracted from online record system maintained at the clinic. OAT retention rates at different timepoints were assessed. Multivariable logistic regression was used to discern factors associated with one-year retention. RESULTS: The participants' mean age was 16.9 (SD 1.4) years. Mean age of starting opioids was 14.9 (SD 2.2) years; 29.5% (n = 38) injected opioids. The 6-, 12-, 18- and 24-month retention rate on OAT was 64.4%, 45.6%, 38.7% and 29% respectively. The retention rates with buprenorphine and methadone were comparable. Multivariate logistic regression showed retention for less than 12 months to be significantly associated with younger age of starting heroin, involvement in illegal activities, absenteeism from school and substance use in family. DISCUSSION AND CONCLUSIONS: The 12-month retention rates on OAT in adolescents is comparable to retention rates in adults. Various factors associated with early age of onset of opioid use are also associated with lower retention rates on OAT.
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BACKGROUND: Methadone take-home doses for opioid dependence treatment are strictly regulated due to diversion and overdose concerns, so patients must visit the clinic daily for dispensing. This was also done in India until the COVID-19 pandemic, when lockdown restriction compelled take- home dispensing of methadone. This study examined experience of patients who received take- home methadone during COVID-19 pandemic in India. METHODS: Observational, cross-sectional design. We contacted all consenting methadone centres in India during the lockdown and selected those that provided take-home doses for the study. Patients who received daily methadone before the lockdown and take-home doses after were interviewed using a study-specific questionnaire. RESULTS: The study had 210 participants. Take-home methadone was dispensed for 2.5 days on average in each dispensing. When taking methadone at home, 3.3% split their dose 25% took less than the prescribed dose to save it for a rainy days, and 3.3% reported an overdose episode. Adherence improved in 58.6% participants after take-home methadone. Participants perceived many benefits from take-home methadone such as reduced hospital visits and travel time to collect methadone, improvement in work, and financial savings. About 54.3% participants reported storing their take-home doses safely, and 1.9% reported that their family consumed methadone by mistake. CONCLUSIONS: Take-home methadone was found to be beneficial to most participants in terms of time saved and improved productivity. Preconceived concerns of providing take-home methadone in terms of its overdose, diversion, or accidental ingestion by others are not commonly seen when individuals are provided take-home doses of methadone.
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COVID-19 , Metadona , Tratamiento de Sustitución de Opiáceos , Trastornos Relacionados con Opioides , Humanos , Metadona/administración & dosificación , Metadona/uso terapéutico , India , Tratamiento de Sustitución de Opiáceos/métodos , Masculino , Adulto , Femenino , Estudios Transversales , Trastornos Relacionados con Opioides/tratamiento farmacológico , Persona de Mediana Edad , Cumplimiento de la Medicación , Analgésicos Opioides/administración & dosificaciónRESUMEN
Addiction medicine is a dynamic field that encompasses clinical practice and research in the context of societal, economic, and cultural factors at the local, national, regional, and global levels. This field has evolved profoundly during the past decades in terms of scopes and activities with the contribution of addiction medicine scientists and professionals globally. The dynamic nature of drug addiction at the global level has resulted in a crucial need for developing an international collaborative network of addiction societies, treatment programs and experts to monitor emerging national, regional, and global concerns. This protocol paper presents methodological details of running longitudinal surveys at national, regional, and global levels through the Global Expert Network of the International Society of Addiction Medicine (ISAM-GEN). The initial formation of the network with a recruitment phase and a round of snowball sampling provided 354 experts from 78 countries across the globe. In addition, 43 national/regional addiction societies/associations are also included in the database. The surveys will be developed by global experts in addiction medicine on treatment services, service coverage, co-occurring disorders, treatment standards and barriers, emerging addictions and/or dynamic changes in treatment needs worldwide. Survey participants in categories of (1) addiction societies/associations, (2) addiction treatment programs, (3) addiction experts/clinicians and (4) related stakeholders will respond to these global longitudinal surveys. The results will be analyzed and cross-examined with available data and peer-reviewed for publication.
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BACKGROUND: Sleep disturbances are seen even in individuals on opioid agonist treatment (OAT). Established pharmacotherapy for sleep disturbances such as benzodiazepines have misuse potential and increased mortality risk in patients with OAT. No study has explored the role of trazodone on sleep disturbance in individuals maintained on buprenorphine. We aimed to assess the efficacy of trazodone in improving sleep disturbance among individuals maintained on buprenorphine. METHODS: The study was a double-blind, placebo-controlled, parallel, randomised trial. Adult males (18-60 years) stabilised on buprenorphine with Pittsburgh Sleep Quality Index (PSQI) score of above five, without other psychiatric comorbidity were randomised to receive either trazodone (50-150mg per day) or placebo. Sleep-50 questionnaire, Epworth Sleepiness Scale (ESS), Brief Pain Inventory (BPI), Clinical Opiate Withdrawal Scale (COWS), Depression, Anxiety and Stress Scale (DASS)-21, Visual Analogue Scale (VAS) for opioid craving, and PSQI were assessed at baseline and at the end of six weeks. RESULTS: Fifty-one patients were allocated to trazodone arm and 49 to placebo arm. Side-effects of trazodone were minimal and well-tolerated with comparable discontiuation rates between both groups. Significantly greater proportion of patients on trazodone (82%, mean dose 101.9 mg) had PSQI scores five or less than those on placebo (16%) at the end of six weeks. Sleep improvement was in various components like sleep quality, latency, efficiency, and duration of sleep. CONCLUSION: Trazodone is well-tolerated and effective in improving sleep disturbances in individuals with opioid dependence maintained on buprenorphine over a six-week period.
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Buprenorfina , Trastornos Relacionados con Opioides , Trazodona , Masculino , Humanos , Trazodona/uso terapéutico , Trazodona/farmacología , Analgésicos Opioides/uso terapéutico , Sueño , Trastornos Relacionados con Opioides/complicaciones , Trastornos Relacionados con Opioides/tratamiento farmacológico , Método Doble Ciego , Resultado del TratamientoRESUMEN
Addiction medicine is a rapidly growing field with many young professionals seeking careers in this field. However, early-career professionals (ECPs) face challenges such as a lack of competency-based training due to a shortage of trainers, limited resources, limited mentorship opportunities, and establishment of suitable research areas. The International Society of Addiction Medicine (ISAM) New Professionals Exploration, Training & Education (NExT) committee, a global platform for early-career addiction medicine professionals (ECAMPs), conducted a two-phase online survey using a modified Delphi-based approach among ECAMPs across 56 countries to assess the need for standardized training, research opportunities, and mentorship. A total of 110 respondents participated in Phase I (online key informant survey), and 28 respondents participated in Phase II (online expert group discussions on three themes identified in Phase I). The survey found that there is a lack of standardized training, structured mentorship programs, research funding, and research opportunities in addiction medicine for ECAMPs. There is a need for standardized training programs, improving research opportunities, and effective mentorship programs to promote the next generation of addiction medicine professionals and further development in the entire field. The efforts of ISAM NExT are well-received and give a template of how this gap can be addressed.
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Background: Integrating mobile technologies in healthcare (mHealth) is helpful to manage various medical conditions. mHealth applications can bridge the gap in the management of patients with opioid use disorder (OUD). Research evaluating the feasibility of mHealth to address OUD is limited in developing countries. We aimed to assess the digital capacity and interest in mHealth interventions in patients maintained on opioid agonist treatment (OAT). Methods: 150 patients on OAT from a community drug treatment clinic in New Delhi, India, were included. We assessed the participants on their pattern of mobile and Internet use and their willingness to use mHealth technology to access health information and services related to OUD. Results: 88% of participants (n = 132) owned a mobile phone at assessment; 2.7% (n = 4) had never used a mobile phone in their lifetime. 70% (n = 105) participants had Internet access. 80% (n = 120) of participants showed interest in receiving text messages related to the management of OUD. 60% of participants showed a willingness to download and use applications for monitoring their substance use. Conclusions: In India, there is an interest among people on OAT to use mHealth interventions to manage their substance use. This population also has access to mobile phones and the necessary knowledge to install and run applications needed for various mHealth interventions.
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The World Health Organization (WHO) has added gaming disorder to ICD-11 as a clinical condition associated with distress or interference with personal functioning. This inclusion leads to clinical and public health benefits, such as harmonising terminology, offering clinical landmarks and improving monitoring capabilities and data comparability. Training health professionals to identify and manage gaming disorder is a key challenge for countries. In the present paper we compiled opinions from different countries around the globe on their state of preparedness and needs to tackle this issue. The global views on the topic feed arguments for developing an evidence-based and cross-cultural training tool for gaming disorder management by health professionals.
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The COVID-19 pandemic has significantly affected treatment services for people with substance use disorders (SUDs). Based on the perspectives of service providers from eight countries, we discuss the impact of the pandemic on SUD treatment services. Although many countries quickly adapted in provision of harm reduction services by changes in policy and service delivery, some went into a forced abstinence-based strategy. Similarly, disruption of abstinence-based approaches such as therapeutic communities has been reported. Global awareness is crucial for responsible management of SUDs during the pandemic, and the development of international health policy guidelines is an urgent need in this area.
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India has a huge burden of substance use disorder (SUD). The national response to the problem of SUD has been to support addiction treatment centers either in government hospitals or in nongovernmental settings. The existing number of addiction treatment facilities is less compared to the burden of substance use in India. The existing models of treatment in India place undue emphasis on inpatient treatment of SUD. Community-based treatment aims to bring the treatment of SUD closer to the patients in their community. Community-based treatment of SUD utilizes existing services available in the community by establishing an integrated network of community-based services. There have been different models of community-based care for the management of SUD in India. Most of them, however, address short-term withdrawals and do not provide long-term treatment in community. National Drug Dependence Treatment Centre, AIIMS, New Delhi, has been providing community-based treatment for SUD since the 1990s. Two of the three community drug treatment clinics (CDTCs) are in operation for more than 5 years now and cater to the population residing within a defined catchment area. The CDTCs use infrastructure available in the community to operate the clinics. The clinics are run daily by a team of nursing staff, while the doctor is available only twice a week. A menu of options, ranging from short-term treatment to long-term agonist maintenance treatment is provided in the clinic. Both pharmacotherapy and psychosocial interventions are provided. Each clinic caters to hundreds of patients through these facilities. There is a need to expand CDTCs in India considering their cost-effectiveness, acceptability, and overall effectiveness, especially in urban colonies with higher substance-related problems.
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Sildenafil is a widely used drug for the treatment of erectile dysfunction in a dosage ranging from 50 to 100âmg per day. Recreational use is reported among youth for its sexual function enhancing effects. To date, however, no study has reported the use of sildenafil for its nonsexual, psychoactive effects. We report a case of a 38-year-old male with opioid and sedative use disorder who self-administered sildenafil orally in a dose of up to 2000âmg per day for its psychoactive effects (primarily) for 10 years before seeking treatment and discuss the literature relevant to the case.
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Disfunción Eréctil , Adolescente , Adulto , Disfunción Eréctil/inducido químicamente , Disfunción Eréctil/tratamiento farmacológico , Humanos , Masculino , Citrato de Sildenafil/efectos adversos , Resultado del TratamientoRESUMEN
Addictive disorders have become increasingly common in India. The health consequences of addictive disorders are immense, and the need for specialized addiction treatment and training far exceeds the capacity and human resources that currently exist. At the same time, increasing demand and treatment gap, need for specialized care, and the emerging sector of medical tourism in the country open avenues for superspecialty training in addiction psychiatry as an attractive career option for Indian psychiatrists. Human resource development and capacity building in the addiction psychiatry field in India is the need of the hour. In the present article, we describe the existing scenario and challenges related to addiction psychiatry training among postgraduate psychiatry trainees and psychiatrists in India and scope for the future.
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Opium has been used in India since ancient times for social, recreational, religious and medicinal purposes. Opium users seem to constitute a distinct sub-population among opioid users, who have minimal complications, better functioning and socio-cultural acceptance. Prominent levels of stigma have been reported against people who use opioid drugs, but the same cannot be extrapolated to opium users. There is a vast number of opium users in India, and it is prudent to understand the stigma faced by them to better address their problems. Hence, in the current study we aimed to assess the internalized stigma and its correlates among opium users who seek treatment at a tertiary care drug treatment centre in North India. 117 adult male participants having opioid dependence (opium being the most common opioid in last 3 months) were assessed using Internalized Stigma of Mental Illness (ISMI) scale - Hindi version. The stigma scores were in the mild to moderate range, which was less than that found in previous studies among heroin and alcohol users in similar setting. Moreover, higher stigma scores were associated with lower educational status and higher proportions of income spent on substances. This is the first study to document stigma among opium users. Further research needs to be conducted to understand the determinants of stigma in this population.
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Trastornos Relacionados con Opioides/psicología , Trastornos Relacionados con Opioides/terapia , Opio , Autoimagen , Estigma Social , Encuestas y Cuestionarios , Adulto , Estudios Transversales , Escolaridad , Femenino , Humanos , India , Masculino , Trastornos Relacionados con Opioides/economía , PsicometríaRESUMEN
Predatory journals (PJ) exploit the open-access model promising high acceptance rate and fast track publishing without proper peer review. At minimum, PJ are eroding the credibility of the scientific literature in the health sciences as they actually boost the propagation of errors. In this article, we identify issues with PJ and provide several responses, from international and interdisciplinary perspectives in health sciences. Authors, particularly researchers with limited previous experience with international publications, need to be careful when considering potential journals for submission, due to the current existence of large numbers of PJ. Universities around the world, particularly in developing countries, might develop strategies to discourage their researchers from submitting manuscripts to PJ or serving as members of their editorial committees.