Opioid Dispensing Patterns from a Tertiary Care Cancer Hospital during the Nationwide Lockdown in COVID-19 Pandemic.

INTRODUCTION: During the current COVID-19 crisis, striking a balance between adequate pain relief in advanced malignancy patients and avoiding hospitals due to fear of contracting the infection has been the biggest challenge for patients as well as palliative care physicians. This study explored the trends in opioid dispensing for cancer pain before and during the lockdown. METHODS: The trends were calculated based on an analysis of quantity of all opioids dispensed. March 24, 2020, was considered as a cutoff for analyzing before and during lockdown period dispensing trends. No information regarding individual patients was retrieved in the current study. RESULTS: There was a decrease in total morphine, tramadol, and fentanyl patch dispensing parallel to decrease in total number of patients visiting the outpatient department. However, there was a statistically significant increase in per capita opioid dispensing during the lockdown period. There was also an increase in the proportion of cancer pain patients that were dispensed morphine during the lockdown. CONCLUSION: Despite the lockdown, the palliative care team at Institute Rotary Cancer Hospital has continued to provide adequate pain relief to patients that could manage to reach the center. Policy-makers need to be cognizant of the pain relief needs of cancer patients in times when accessing hospitals is becoming increasingly difficult. Cancer-related pain and mortality could well be the next pandemic once the current COVID-19 begins to reduce.

Can Tramadol be Used for Maintenance Treatment of Opioid Dependence?

BACKGROUND: Certain limitations of the existing opioid substitution therapies necessitate exploration of other options for maintenance of patients with opioid dependence. This study aimed to present the experience of use of tramadol for long-term treatment of patients with opioid dependence. METHODS: This was a cross-sectional interview-based observational study conducted in Uttar Pradesh state in India. Patients with opioid dependence who received oral tramadol treatment for a period of more than 6 months were recruited. Outcome was assessed in terms of self-reported abstinence on tramadol. RESULTS: A total of 102 participants were recruited in the study, with a mean age of 41.3 years. All the participants were males. Abstinence to extraneous opioids was reported by 58.8% of the sample, and the median dose of tramadol at which abstinence was achieved was 350 mg/d. Those who reported to be taking natural opioids (raw opium or poppy husk) at the time of seeking treatment had higher rates of achieving abstinence. CONCLUSIONS: Tramadol may be a possible option for the maintenance treatment among some opioid-dependent individuals. Further studies are required to establish its efficacy vis-à-vis other medications used in opioid substitution treatment.

Awareness, Self-Assessment and Help Seeking Behavior for Behavioral Addictions Related to Use of Mobile Technology Among Attendees of a Health Camp.

Introduction: Behavioral addictions are increasingly being recognized as a major public health problem. While this issue continues to hog the limelight in the media, there is limited scientific research on this theme from India. Objectives: We aimed at presenting the findings on assessment of the awareness, self-assessment and help seeking behavior for behavioral addictions related to use of mobile technology among attendees of a trade promotion event. Methods: We report findings from a health camp organized as part of a large trade promotion event in the northern part of India. The trade promotion event was open to the general public. As part of the screening services offered at the health camp, the visitors were offered to screen themselves on the theme of behavioral addictions related to use of mobile technology using a self-administered questionnaire. We carried out a chart review of the data gathered at the health camp. Results: We assessed records of a total of 817 respondents who completed the screening using the self-administered questionnaire. The mean age of the respondents was 32.35 years (SD ± 13.62). Approximately 56% of the respondents rated themselves to be having at least one of the nine features of behavioral addictions. Around 15% of the respondents endorsed five or more features. Around 41% of the respondents mentioned that they shall agree to the professional help in case they are having behavioral addiction related to use of mobile technology. Fifteen percent of the respondents agreed to have sought some help in the past. The logistic regression analysis revealed that the odds of help seeking increased significantly with every single increase in the number of self-assessed feature of behavioral addiction.

Successful management of difficult-to-treat irritable bowel syndrome incorporating a psychological approach.

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.

Psychosocial Assessment and Management-related Issues Among Liver Transplant Recipients.

Background and aim: Liver transplant cases have been rising and becoming the choice of treatment for many patients with end-stage liver diseases. With an increasing number of qualified treatment centers and facilities, the effectiveness of liver transplants has been observed to increase over the years. But the success of liver transplants and the quality of life post-transplant have been observed to be influenced due to psychiatric comorbidities. Method: We searched for literature using terms for 'Psychosocial factors', 'liver transplant', 'psychiatric disorders', 'treatment outcomes', and related terms, 'AUD/SUD' in three databases: PubMed, Embase, and Scopus. Articles published in English and that provided original data analyses were included while commentaries and review articles were excluded. This review article focuses on an association between various psychiatric disorders/ Substance Use Disorder (SUD)/Alcohol Use Disorder (AUD) and liver transplant outcomes which indicated the need for psychiatric treatment and its role in improved overall transplant outcomes and enhanced quality of life. Results: Majority of the studies indicated a negative association between psychiatric disorder, AUD, and SUD with the treatment outcomes post liver transplant. A few studies were found supporting a multidisciplinary approach to handling liver transplant patients for a more effective and improved treatment outcome. Conclusion: The current evidence suggests a need for developing an integrated approach to assessment and management of psychiatric and psychosocial issues related to liver transplant recipients.

Incidence and predictors of alcohol relapse following living donor liver transplantation for alcohol related liver disease.

BACKGROUND: Alcohol relapse after liver transplantation has a negative impact on outcomes. There is limited data on its burden, the predictors, and impact following live donor liver transplantation (LDLT). METHODS: A single-center observational study was carried out between July 2011 and March 2021 for patients undergoing LDLT for alcohol associated liver disease (ALD). The incidence, predictors of alcohol relapse, and post-transplant outcomes were assessed. RESULTS: Altogether 720 LDLT were performed during the study period, 203 (28.19%) for ALD. The overall relapse rate was 9.85% (n = 20) with a median follow-up of 52 months (range, 12-140 months). Sustained harmful alcohol use was seen in 4 (1.97%). On multivariate analysis, pre-LT relapse (P = .001), duration of abstinence period (P = .007), daily intake of alcohol (P = .001), absence of life partner (P = .021), concurrent tobacco abuse before transplant (P = .001), the donation from second-degree relative (P = .003) and poor compliance with medications (P = .001) were identified as predictors for relapse. Alcohol relapse was associated with the risk of graft rejection (HR 4.54, 95% CI: 1.751-11.80, P = .002). CONCLUSION: Our results show that the overall incidence of relapse and rate of harmful drinking following LDLT is low. Donation from spouse and first degree relative was protective. History of daily intake, prior relapse, shorter pretransplant abstinence duration and lack of family support significantly predicted relapse.

Evaluation of alcohol use pattern among OST patients using alcohol biomarkers: Report from community clinics in India.

Background: Opioid-dependent patients undergoing opioid substitution therapy (OST) consume alcohol in a hazardous pattern which adversely affects their treatment outcome. This study aims to measure alcohol biomarkers to screen for secondary alcohol use in OST patients. Methods: A pilot study was planned to measure alcohol biomarkers (AST, ALT, GGT, and CDT) to assess alcohol use in OST patients from three community clinics. The biomarkers were categorized based on the reported frequency of alcohol use. The association of the biomarkers with the frequency of alcohol consumption was determined using the post hoc (Mann-Whitney) test. Results: Forty-five patients with a mean (SD) age of 37.04 (10.7) years were included in the study. Alcohol intake was reported in daily, weekly, and monthly patterns by 22, 63, and 16% of the patients, respectively. High levels of ALT, GGT, and CDT were measured in patients with daily use of alcohol. Serum CDT levels significantly differentiate daily and weekly use from monthly consumption of alcohol. Conclusions: Alcohol biomarkers significantly predict the pattern of alcohol use among OST patients. These results can be prudent in low-resource community clinics to improve the overall outcomes of OST in India.

An Exploratory Study of the Differences in Attitudes and Motives Regarding COVID-19 Plasma Donation.

Background: Understanding the attitude and motives and differences between voluntary and replacement blood donation is the key to the sustainable availability of this precious resource. This study aimed to assess the attitude and motives for convalescent plasma (CP) donation in the recovered COVID-19 plasma donors and further understand the differences between voluntary and replacement donation. Materials and Methods: This prospective cross-sectional survey-based study was conducted among500 COVID-19 recovered blood donors who visited for CP donation at a tertiary care super-speciality centre in northern India. Data were collected using a structured questionnaire based on donor attitude, motives, and belief, which was validated by the experts of Psychiatry, Transfusion Medicine, and Epidemiology and was administered by the online medium. Results: The study's findings depicted that voluntary plasma donors were previously regular blood donors (36.8%) compared to replacement plasma donors (26.4%). Almost all voluntary donors (99.5%) showed altruistic reasons to donate plasma and expressed that donating plasma is a good way to save a life, and it was more than for replacement plasma donors (p=0.004). The motives of most voluntary plasma donors were to contribute to society, and they believed that donating plasma is a good way, while it was not the case for most replacement plasma donors (p=0.02). Voluntary donors were more eagerly willing to donate plasma to help COVID sufferers (40.9%) when compared to replacement donors (33.2%) (p=0.037). Conclusion: Most voluntary plasma donors were regular whole blood donors and were keen to contribute to society. Convalescent plasma donation during this time of grief and loss was considered a moral responsibility by voluntary donors. The impact of media was more highly perceived in voluntary plasma donors when compared to replacement donors.

Impact of covid-19 pandemic on quality of life and psychosocial difficulties among liver transplant recipients.

Background: The first wave of the COVID-19 pandemic affected health in all domains i.e., physical, mental, and social aspects. Liver transplant (LT) recipients faced a multitude of challenges during the first wave of lockdown. The aim was to identify the psychosocial difficulties and quality of life during the first year of the pandemic. Methods: A cross-sectional survey was conducted on LT recipients with a predefined structured questionnaire that included clinical, COVID-19 anxiety scale, and Post-Transplant Quality of life questionnaire (pLTQ). Results: A total of 109 patients were studied; with a mean age of 50.5 ± 11.1 years, with a median post-transplant follow-up of 52.4 months and a live donor transplant in the majority (79.8%). Almost all (99.1%) could come to the hospital for regular follow-up, prior to the pandemic. But during the first wave only 57% could maintain planned hospital visits and about 88% could not pursue their regular activities, and 39% missed their routine exercise because of imposed restrictions. Similarly, financial implications were responsible for 4% defaulting from treatment; while 7.3% managed by curtailing supportive drugs (on their own) leading to deranged liver tests in 4.6%; requiring immediate attention. The psychosocial difficulties raised the stress of pandemic (median score 18), and impacted quality of life (mean total pLTQ score 4.7 ± 0.9). Conclusions: For LT recipients, the first wave of COVID-19 pandemic affected their physical, mental, financial, and social wellbeing; in addition to the disease itself. Awareness, psychosocial support, and comprehensive care are some unmet needs for this special group; especially when it is expected that subsequent waves may continue to occur.

Empowering in-service nurses in management of viral hepatitis through Programmed Approach to Knowledge and Sensitization on Hepatitis (PRAKASH): An experience from a capacity building initiative.

BACKGROUND: Nursing fraternity are at an increased risk of acquiring hepatitis B and hepatitis C infections mainly attributable to occupational risk and close contact with the patients while treatment. However, unawareness and negligence about the severity, mode of transmission and preventive measures about the disease can further predispose the nursing fraternity to a higher risk of infection. To overcome these lacunae in knowledge, a training program named Project PRAKASH was initiated for in-service nurses across the country. The objective of the program was to impart up-to-date knowledge to the nursing professionals in the management of viral hepatitis and to assess the effectiveness of the training program through pre-post-knowledge assessment survey. METHODOLOGY: One-day training program titled 'Hepatitis Induction Program' was conducted for a period of 2 years (2018-2020) among nursing professionals. It was accompanied by administration of 54-item knowledge, attitude and practice (KAP) questionnaire with four sections: demographic details, knowledge (30 items), attitude (11 items) and practice (13 items), followed by post-knowledge assessment. An Impact Assessment Survey (IAS) was also administered to assess the change in attitude and practice among 10% of the attendees, at least 6 months post training. RESULT: A total of 32 one-day training programmes were organised which witnessed the training of 5,253 nursing professionals from 292 institutions across 12 states. A data of 4,474 participants were included in the final analysis: improvement in the knowledge score was significant (P-value < 0.001) with mean knowledge score of 19.3 ± 4.4 in pre-test and 25.7 ± 3.9 in the post-test. CONCLUSION: The one-day training resulted in improvement of knowledge and significant changes in the attitude and practices of the nursing professionals.

Comparative efficacy versus effectiveness of initial antiretroviral therapy in clinical trials versus routine care.

BACKGROUND: The applicability of clinical trial findings (efficacy) to the routine care setting (effectiveness) may be limited because of study eligibility criteria and volunteer bias. Although well-chronicled in many conditions, the efficacy versus effectiveness of antiretroviral therapy (ART) remains understudied. METHODS: A retrospective study of the University of Alabama at Birmingham 1917 Clinic Cohort evaluated ART-naive patients who started ART from 1 January 2000 through 31 December 2006. Patients received ART through clinical trials or routine care. Multivariable logistic and linear regression models were fit to evaluate factors associated with virological failure (virological failure was defined as a viral load >50 copies/mL) and change from baseline CD4+ cell count 6 and 12 months after ART initiation. Sensitivity analyses evaluated the impact of missing data on outcomes. RESULTS: Among 570 patients starting ART during the study period, 121 (21%) enrolled in clinical trials, and 449 (79%) received ART via routine care. ART receipt through routine care was not associated with viral failure at either 6 months (odds ratio [OR], 1.00; 95% confidence interval [CI], 0.54-1.86) or 12 months (OR, 1.56; 95% CI, 0.80-3.05) in primary analyses. No statistically significant differences in CD4+ cell count responses at 6 and 12 months were observed. CONCLUSIONS: Although marked differences in efficacy versus effectiveness have been observed in the therapeutic outcomes of other conditions, our analyses found no evidence of such divergence among our patients who initiated antiretroviral therapy for human immunodeficiency virus infection.

Initial psychological impact of COVID-19 and its correlates in Indian Community: An online (FEEL-COVID) survey.

BACKGROUND: The pandemic of Corona Virus (COVID-19) hit India recently; and the associated uncertainty is increasingly testing psychological resilience of the masses. When the global focus has mostly been on testing, finding a cure and preventing transmission; people are going through a myriad of psychological problems in adjusting to the current lifestyles and fear of the disease. Since there is a severe dearth of researches on this issue, we decided to conduct an online survey to evaluate its psychological impact. METHODS: From 26th to 29th March an online survey (FEEL-COVID) was conducted using principles of snowballing, and by invitation through text messages to participate. The survey collected data on socio-demographic and clinical variables related to COVID-19 (based on the current knowledge); along with measuring psychological impact with the help of Impact of Event-revised (IES-R) scale. RESULTS: There were a total of 1106 responses from around 64 cities in the country. Out of these 453 responses had at least one item missing; and were excluded from the analysis. The mean age of the respondents was around 41 years with a male female ratio of 3:1 and around 22% respondents were health care professionals. Overall approximately one third of respondents had significant psychological impact (IES-R score > 24). Higher psychological impact was predicted with younger age, female gender and comorbid physical illness. Presence of physical symptoms and contact history predicted higher psychological impact, but did not reach statistical significance. CONCLUSION: During the initial stages of COVID-19 in India, almost one-third respondents had a significant psychological impact. This indicates a need for more systematic and longitudinal assessment of psychological needs of the population, which can help the government in formulating holistic interventions for affected individuals.

Mental Healthcare Act, 2017, and addiction treatment: Potential pitfalls and trepidations.

The Mental Healthcare Act (MHCA), 2017, is enacted with an aim to promote and protect the rights of and improve the care and treatment for people affected by mental illness in India. The Act purportedly includes substance use disorder (SUD) specifically in the definition of mental illness itself. However, some of the phrases used in the definition such as "abuse" are not clear, as the current classificatory systems of mental illnesses do not have any diagnostic category termed "abuse." Another important issue is the lack of clarity on which categories of SUD would be covered under MHCA. Simple reading of the text of the Act seems to suggest that SUD is a single entity for the purpose of this law. In such case, many provisions of the act such as supported admission that are meant for the treatment of people with severe mental illnesses with gross impairment may become applicable to all types of SUD. This can create potential problems for addiction treatment providers. On the other hand, certain other provisions of the Act are good news for patients suffering from SUD. The Act lays down various rights that include, among others, protection from cruel, inhuman, or degrading treatment in any mental health establishment. This is very important from the perspective of treatment of SUD in the context of India, where human rights violations in the name of addiction treatment are often reported. The inclusion of SUD in MHCA, 2017, slots SUD as a health issue, rather than a law-and-order issue alone. This displays the intent of policymakers toward SUD, which, in itself, is laudable. There are certain ways in which the potential pitfalls mentioned earlier can be addressed, which is discussed in the article.

Use of Filter Paper to Measure Alcohol Biomarkers among Opioid-Dependent Patients on Agonist Maintenance Treatment: A Community-Based Study.

BACKGROUND: Harmful Alcohol use is frequent among opioid dependents patients undergoing agonist maintenance treatment. The objective assessment of harmful alcohol use can be done using laboratory measures of serum biomarkers. For community-based patients, there is often a requirement of an alternative method due to lack of onsite laboratory services. The aim of the study was to examine filter paper as a matrix to measure serum biomarkers of harmful alcohol use. METHODS: The initial phase involved standardization of the filter-paper-based assay. Conditions were optimised for extraction and estimation of alcohol biomarkers (Aspartate Aminotransferase; AST, Alanine Aminotransferase; ALT, Gamma Glutamyl transferase; GGT and Carbohydrate Deficient Transferrin; CDT) from the filter paper. For clinical validation, serum samples were collected from community clinics. Biomarker levels obtained from both the methods were correlated using linear regression analysis. Limits of agreement between the two methods was estimated using the Intraclass Correlation Coefficient (ICC). RESULTS: The extraction of enzymes (AST, ALT and GGT) from filter paper was carried out using the substrate buffer available with the reagent kit (Randox, UK). CDT was readily extracted from filter paper using deionised water. Serum biomarker levels measured from samples collected from community clinics correlated well with filter paper extracted levels (ICC 0.97-0.99). More than 90% of alcohol biomarker levels were recovered from the filter paper matrix using this method. CONCLUSION: Filter paper has the potential to be used as a matrix to objectively measure alcohol biomarkers among opioid-dependent patients from community settings lacking onsite laboratory facilities.

Yoga and substance use disorders: A narrative review.

Yoga has been utilized for promotion of health and alleviating distress. It has also been used as a therapeutic measure in the field of mental health, including substance use disorders. This narrative review discusses the literature pertaining to use of yoga in the treatment of substance use disorders. The evidence base especially with regards to randomized trials is presented. The possible mechanisms how yoga might be helpful in the treatment of substance use disorders are explored. Subsequently, implications of yoga in clinical practice are elaborated, followed by examination of the issues in interpretation of the literature of published yoga related studies.

Maintainence Treatment of Opioid Dependence with Tramadol.

BACKGROUND: Although tramadol has been used in the management of acute withdrawal in patients with opioid dependence, its use for maintenance treatment as a harm reduction approach has not been assessed systematically. This case series describes patients with opioid dependence who were treated with tramadol for long-term maintenance. METHODS: Patients with opioid dependence who received treatment at the National Drug Dependence Treatment Centre of All India Institute of Medical Sciences, New Delhi, were included in the study. Patients who received at least 6 months of tramadol and had follow-up adherence of more than 80% were included in the case series. RESULTS: A total of 25 cases were included, all of whom were males. The types of opioids being taken at the time of initiation of tramadol were natural opiates (poppy husk and raw opium), followed by heroin. The median dose of tramadol at initiation and maintenance was 300 mg/day. Nineteen patients were able to achieve complete abstinence to other opiates on tramadol. CONCLUSION: Tramadol may be an effective option in the long-term management of patients with opioid dependence. Further studies are required for establishing the efficacy of tramadol for agonist management of patients with opioid dependence.

Tramadol for maintenance in opioid dependence: A retrospective chart review.

BACKGROUND AND AIMS: Tramadol is an opioid agonist which can be potentially used for maintenance treatment of patients with opioid use disorders. This chart review presents the characteristics of individuals with an ICD 10 diagnosis of opioid dependence who were maintained on tramadol for a period of at least 6 months. METHODS: Records of patients seeking treatment for opioid dependence from the outpatient clinic of the National Drug Dependence Treatment Centre, Ghaziabad, India were screened. One hundred consecutive patients who received tramadol for more than 6 months were included. RESULTS: The sample comprised exclusively of males and had a mean age of 40.9 years. The median dose of tramadol at initiation and continuation was 300 mg/day. Sixty-two patients achieved complete abstinence during the course of treatment. Greater age, longer duration of opioid use, and better follow-up adherence were associated with abstinent status. The rates of abstinence were higher among those presenting with natural opioid use as compared to others (prescription opioid use or heroin use). CONCLUSION: Tramadol can be an alternative medication for harm reduction in select group of patients with opioid dependence. Further research is required to strengthen the evidence base of rational use of tramadol for maintenance treatment of patients with opioid dependence.

Direct-Acting Antivirals in Kidney Transplant Patients: Successful Hepatitis C Treatment and Short-Term Reduction in Urinary Protein/Creatinine Ratios.

BACKGROUND: The role of Hepatitis C Virus (HCV) clearance in kidney graft survival is unknown. We examined short-term trends of protein/creatinine (P/C) ratios in HCV-infected kidney transplant recipients treated with direct-acting antivirals (DAAs). METHODS: This is a retrospective study of 19 kidney transplant patients with HCV infection treated with DAAs at the University of Alabama at Birmingham between January 2013 and June 2016. Markers of glomerular damage were assessed using average urinary protein/creatinine (P/C) ratios measured pretreatment and posttreatment. Treatment efficacy was defined as sustained virologic response at 12 weeks post-HCV treatment (SVR12). RESULTS: The median age of the 19 patients included was 59 years (Q1 = 58, Q3 = 64). Of these patients, 68% were African American, 32% were White and 63% were male. The median time between kidney transplant and initiation of DAA therapy was 2.25 years (Q1 = 0.79, Q3 = 3.79). Posttreatment P/C ratios (median = 0.127, Q1=0.090, Q3 = 0.220) were significantly lower (P = 0.01) than pretreatment ratios (median = 0.168, Q1 = 0.118, Q3 = 0.385). P/C ratios decreased in 14 of 19 patients (74%) with a median change of -0.072 (median percent change = -40%). Posttreatment estimated glomerular filtration rates (median = 58.9, Q1 = 48.9, Q3 = 72.3) were not significantly different (P = 0.82) than the pretreatment values (median = 57.0, Q1 = 48.8, Q3 = 67.8). All patients achieved SVR12. CONCLUSIONS: In this preliminary study, there was a statistically significant decrease in P/C ratios associated with HCV clearance, suggesting a potential role for DAAs in improving kidney graft survival. Larger cohort studies will be needed to assess the clinical and long-term benefits of DAAs in this population.

A rare case of imitation injury.

The impact of media on cognitions and behaviors of adolescents is well-known. High frequency of exposure to media may distort the reality testing among predisposed youth, hence the rise in risk taking behaviors among this population. We present a rare manifestation of risk taking behavior in an adolescent who injected mercury in his body after exposure to a Hollywood film. The results of investigations and possible explanation to understand risk taking behavior in the present case are discussed.