Characteristics Associated with Substance Use and Non-use Among Street Children in Delhi, India: A Community-based Cross-sectional Epidemiological Study.

Background: Street children are vulnerable to adverse health and risk behaviors and drug use. Substance use among street children has been well documented in several countries. This study reports sociodemographic and peer, family, and stress-related factors associated with substance use and non-use in a representative sample of street children of Delhi. Methods: This cross-sectional survey was conducted through six NGOs working with street children, using Respondent Driven Sampling, in nine districts of Delhi (n = 766, 7-18 years). The multivariable model was developed by applying binary logistic regression analysis. Results: The rate of substance use was 49%. Significant association was found between substance use in the past year and increasing age [Odds Ratio: OR (95% Confidence Interval)] [1.22(1.12,1.33)], male sex [4.34 (2.28,8.26)], lacking psychosocial support from family/relatives [3.27(1.84,5.80)], being engaged in earning from illegal sources, [3.04(1.75,5.29)], family use of substance [2.59(1.38,4.89)], presence of substance-using peers [29.86(14.38,62.01)], lack of non-drug-using peers [2.35(1.46,3.79)], and not possessing basic amenities [2.26(1.31,3.93)]. Conclusion: Multiple modifiable factors exist within the family and peer group, including risk and protective factors or a consequence of substance use. Some challenges in the form of difficulty in reaching out to them and poor treatment seeking by those using substances warrant intensification in both primary and secondary prevention initiatives.

World addiction medicine reports: formation of the International Society of Addiction Medicine Global Expert Network (ISAM-GEN) and its global surveys.

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.

Experience of patients on methadone maintenance treatment receiving take-home methadone doses during COVID-19 pandemic: A multi-site study from India.

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.

A comparative study of sexual behavior, dysfunction, satisfaction, relationship, and sexual quality of life amongst treatment-naïve and abstinent men (buprenorphine-maintained) with Opioid (heroin) dependence syndrome.

Background: Association between opioid use and sexual functioning is well-known. However, data evaluating the influence of treatment on different aspects of sexuality are lacking. Aim: To compare sexual behavior, functioning, relationship, satisfaction, and sexual quality of life (sQoL) among treatment naïve patients (GROUP-I) with Opioid (heroin) dependence syndrome (ODS-H) with those maintained on buprenorphine (GROUP-II). Methods: Married adult males diagnosed with ODS-H, currently sexually active, and living with their partner were recruited. They were assessed for their sexual practices and high-risk sexual behavior (HRSB) through a semi-structured questionnaire and sexual functioning, relationships, satisfaction, and sQoL through structured questionnaires. Results: A total of 112 individuals (GROUP-I: 63; GROUP-II: 49) were recruited from the outpatient settings. Mean age and employment in GROUP-II were higher (p < 0.05) than in GROUP-I (37 vs 32 years; 94% vs 70%, respectively). Other sociodemographic variables and the age of onset of heroin use were comparable. The current practice of HRSB (e.g., engaging in casual partner sex, sex with commercial sex workers, and sex under intoxication) was higher in GROUP-I while almost no differences were seen in lifetime HRSB. The frequency of erectile dysfunction and premature ejaculation in the two groups were: 78% vs 39% (p < 0.001), and 30% vs 6% (p = 0.001), respectively. GROUP-II had significantly higher scores in all the scales (p < 0.05) as compared to GROUP-I, indicating better sexual satisfaction, quality of life, and sexual relationship. Conclusion: Heroin use is associated with HRSB, poorer sexual functioning, overall satisfaction, and sQoL. Maintenance of Buprenorphine helps with improvement in all these parameters. Comprehensive management for substance use should target sexual problems as well.

Key implementation factors in telemedicine-delivered medications for opioid use disorder: a scoping review informed by normalisation process theory.

Telemedicine could improve access to medications for opioid use disorder (MOUD). Telemedicine-delivered MOUD (TMOUD) has expanded substantially in response to the restrictions imposed by the COVID-19 pandemic on in-person clinical contact, yet this expansion has not happened consistently across all health systems and countries. This Review aims to understand key factors in TMOUD implementation that might explain variations in uptake. We did a scoping review using three English language databases for articles reporting on the implementation of TMOUD services. 57 peer-reviewed articles were identified, subjected to open coding and thematic analysis, and further interpreted through normalisation process theory (NPT). NPT was originally used to evaluate telehealth innovations and has been applied extensively to describe, assess, and develop the implementation potential of a broad range of complex health-care interventions. By categorising our findings according to the four core NPT constructs of coherence, cognitive participation, collective action, and reflexive monitoring, we aim to rationalise the current evidence base to show the workability of TMOUD in practice. We find that variations in TMOUD models in practice depend on organisations' attitudes towards risk, clinicians' tensions around giving up control over standard practices, organisation-level support in overcoming operational and technological challenges, and evaluation methods that might neglect a potential widening of the digital divide.

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

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

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.

System-level policies on appropriate opioid use, a multi-stakeholder consensus.

BACKGROUND: This consensus statement was developed because there are concerns about the appropriate use of opioids for acute pain management, with opposing views in the literature. Consensus statement on policies for system-level interventions may help inform organisations such as management structures, government agencies and funding bodies. METHODS: We conducted a multi-stakeholder survey using a modified Delphi methodology focusing on policies, at the system level, rather than at the prescriber or patient level. We aimed to provide consensus statements for current developments and priorities for future developments. RESULTS: Twenty-five experts from a variety of fields with experience in acute pain management were invited to join a review panel, of whom 23 completed a modified Delphi survey of policies designed to improve the safety and quality of opioids prescribing for acute pain in the secondary care setting. Strong agreement, defined as consistent among> 75% of panellists, was observed for ten statements. CONCLUSIONS: Using a modified Delphi study, we found agreement among a multidisciplinary panel, including patient representation, on prioritisation of policies for system-level interventions, to improve governance, pain management, patient/consumers care, safety and engagement.

Opioid Use Disorders among Patients on Long-Term Morphine for Management of Chronic Cancer Pain: A Pilot Study from a Tertiary Palliative Care Facility.

OBJECTIVES: Long-term opioid use can be associated with misuse and addiction. In the backdrop of increasing burden of cancer patients in India, it is important to assess the rate of opioid use disorders among those with chronic cancer pain. The objectives were to measure the rate of opioid use disorder in chronic cancer pain patients being managed with morphine and to assess its association with demographic and clinical characteristics. MATERIALS AND METHODS: A cross-sectional study was conducted on chronic cancer pain patients who were prescribed morphine for ≥12 months, dosage of ≥60 mg/day. They were assessed using MINI version 7.0.0, WHO-ASSIST Hindi questionnaire, Addiction Behavior Checklist, and DSM-5 for opioid use disorder. RESULTS: Forty patients who were treated with morphine for a total of 1479 months participated. The average morphine consumption was 159.50 ± 327.90 mg/day. Six (15%) showed possible inappropriate opioid analgesic use and none of the patients had opioid use disorder. CONCLUSION: This study reports the absence of opioid use disorder due to vigilant use of morphine in chronic cancer patients.

The Effectiveness of a Web-Based Self-Help Program to Reduce Alcohol Use Among Adults With Drinking Patterns Considered Harmful, Hazardous, or Suggestive of Dependence in Four Low- and Middle-Income Countries: Randomized Controlled Trial.

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.

Influence of catechol-O-methyltransferase enzyme gene polymorphism on alcohol and tobacco consumption in North Indian treatment seeking population.

BACKGROUND: The co-occurrence of alcohol and tobacco dependence is frequently witnessed in treatment settings. It is a challenge for clinicians to treat such patients due to their powerful biological association. AIM: The study is aimed to assess the relationship of Catechol-O-methyltransferase (COMT) Val158Met polymorphism with substance intake among individuals who are dependent on both alcohol and tobacco. MATERIALS AND METHODS: A cross-sectional study involving patients coming to the outpatient department was planned. Brief information on their sociodemographic and substance use profile was recorded. Genotyping of COMT Val158Met was carried out using established polymerase chain reaction-restriction fragment length polymorphism method. The COMT genotyping was classified based on the presence or absence of Met allele using the dominant model. Descriptive statistics, Chi-square test, Mann-Whitney test, and Binary logistic regression analysis were performed to analyze the data. RESULTS: The study included 104 alcohol and nicotine co-dependent subjects. More than eighty percent of the participants were educated above secondary level, married, and employed. The allele frequencies of met and Val were found to be 0.23 and 0.77, respectively. Forty percent of the participants reported tobacco-related health problems. The odds of consuming alcohol and nicotine were four times high among Met allele carriers. While the Fagerström test for nicotine dependence and heaviness of smoking index scores were up to four and eight times higher among met allele (odds ratio 4.3 and 8.9, respectively). CONCLUSION: Patients carrying Met allele are reported to consume higher amounts of alcohol and tobacco and were likely to score high among measures of nicotine dependence. Thus met allele carriers needs additional attention for a successful treatment outcome.

Cognitive functioning in patients maintained on buprenorphine at peak and trough buprenorphine levels: An experimental study.

OBJECTIVES: To assess the cognitive functions in participants maintained on buprenorphine for opioid dependence at peak and trough buprenorphine levels. METHODS: This was a double-blind, randomized, experimental study. Sixty participants maintained on buprenorphine were matched for age and education and randomly allocated to "peak" group or "trough" group. The "peak" group received buprenorphine two hours before assessment, whereas the trough group received placebo. The cognitive domains of attention, learning and memory, and executive function including fluency, working memory, response inhibition and set shifting were tested. RESULTS: The two groups were comparable on socio-demographic, substance use profile and opioid agonist treatment-related characteristics. Significant differences in performance of peak and trough group were observed on Wisconsin Card Sorting Test parameters of number of correct responses (U = 289.00, p = 0.03), number of errors (t = 02.26, df = 58, p = 0.03), and perseverative errors (U = 301.50, p = 0.04). CONCLUSIONS: The time since buprenorphine dose has significant relation on specific cognitive tasks in patients maintained on buprenorphine for opioid dependence.

Impact of a Psychodermatological Education Package on the Subjective Distress, Family Burden, and Quality of Life among the Primary Caregivers of Children Affected with Epidermolysis Bullosa.

BACKGROUND: Epidermolysis bullosa (EB) has profound effect on the subjective distress, family burden, and quality of life (QOL) of the primary caregivers (PCG). Knowledgeable PCG can efficiently manage children with these skin diseases and also improve their QOL. OBJECTIVES: To assess the subjective distress, family burden, and QOL, to develop and assess the short-term effectiveness of a psycho-dermatological education package (PDEP) for the PCG of children with EB. METHODS: In this interventional study, 30 PCG of EB were assessed for subjective distress, family burden, and QOL. PDEP, a structured educational tool explaining the disease and its care and stress management, was developed by the authors for the PCG and administered to them after one month of enrolment. They were reassessed after three months and compared with the baseline assessment scores. For comparison, 37 PCG of CI were also studied. RESULTS: The mean age (years) of the subjects was 28.7 ± 6.7 for EB and 30.5 ± 4.6 for CI. The mean or median (range) baseline scores for subjective distress, family burden and QOL of PCG (n = 20) of EB were 8.4 ± 7.9, 6.5 (0-30); 28.5 ± 17.5, 24 (7-77) and 12.6 ± 6.7, 11.5 (4-28) and for PCG (n = 14) of CI were 12 ± 4.3, 38.9 ± 16.2 and 17.7 ± 3.6 respectively. The PDEP improved the QOL (p = 0.01), knowledge (p < 0.01) and practices (p < 0.001) for PCG of EB and it improved subjective distress (p < 0.001), QOL (p < 0.01) and knowledge (p < 0.01) for PCG of CI. CONCLUSIONS: PDEP is an effective educational tool in improving the QOL and knowledge of PCG, which in turn provides efficient management and psychological support to children affected with EB and CI. It should, therefore, be routinely used for educating the PCG of children with EB and CI.

Sexual relationship, self-esteem, dysfunction, and sexual satisfaction in treatment naïve men with heroin dependence.

Heroin use, a prevalent and disabling condition, affects sexual functioning and the sexual quality of life. While there is adequate literature on sexual dysfunction with heroin use, the literature is scarce on the emotional aspects of sex, like the perception of sexual relationship, self-esteem, and satisfaction amongst heroin users. The study assessed these parameters among treatment-naïve, sexually active, married, male patients with heroin dependence. We interviewed 63 treatment-naïve men seeking treatment for heroin dependence using Self-esteem and Relationship Questionnaire (SEAR), New Sexual Satisfaction Scale-Short form (NSSS-S), Sexual Quality of Life Questionnaire-Male (SQoL-M), Index of Premature Ejaculation (IPE), and International Index of Erectile Function (IIEF). Overall scores in SEAR, NSSS-S, SQoL-M, IIEF, and IPE were low, suggesting poor self-esteem and relationship, poor sexual quality of life and sexual satisfaction, higher premature ejaculation, and erectile dysfunction. Injecting drug use was associated with lower scores on confidence domain of SEAR, partner activity focused domain of NSSS-S, intercourse-satisfaction, and overall sexual quality of life. Sexual dysfunctions, poor sexual relationship, and sexual quality of life are common among men seeking treatment for heroin dependence. Treatment strategies must not lose focus on this dimension of health during the treatment process.

Expert appraisal of criteria for assessing gaming disorder: an international Delphi study.

BACKGROUND AND AIMS: Following the recognition of 'internet gaming disorder' (IGD) as a condition requiring further study by the DSM-5, 'gaming disorder' (GD) was officially included as a diagnostic entity by the World Health Organization (WHO) in the 11th revision of the International Classification of Diseases (ICD-11). However, the proposed diagnostic criteria for gaming disorder remain the subject of debate, and there has been no systematic attempt to integrate the views of different groups of experts. To achieve a more systematic agreement on this new disorder, this study employed the Delphi expert consensus method to obtain expert agreement on the diagnostic validity, clinical utility and prognostic value of the DSM-5 criteria and ICD-11 clinical guidelines for GD. METHODS: A total of 29 international experts with clinical and/or research experience in GD completed three iterative rounds of a Delphi survey. Experts rated proposed criteria in progressive rounds until a pre-determined level of agreement was achieved. RESULTS: For DSM-5 IGD criteria, there was an agreement both that a subset had high diagnostic validity, clinical utility and prognostic value and that some (e.g. tolerance, deception) had low diagnostic validity, clinical utility and prognostic value. Crucially, some DSM-5 criteria (e.g. escapism/mood regulation, tolerance) were regarded as incapable of distinguishing between problematic and non-problematic gaming. In contrast, ICD-11 diagnostic guidelines for GD (except for the criterion relating to diminished non-gaming interests) were judged as presenting high diagnostic validity, clinical utility and prognostic value. CONCLUSIONS: This Delphi survey provides a foundation for identifying the most diagnostically valid and clinically useful criteria for GD. There was expert agreement that some DSM-5 criteria were not clinically relevant and may pathologize non-problematic patterns of gaming, whereas ICD-11 diagnostic guidelines are likely to diagnose GD adequately and avoid pathologizing.

Mental illnesses and related vulnerabilities in the Hijra community: A cross-sectional study from India.

PURPOSE: The Hijra community is a cultural and gender grouping in South Asia broadly similar to western transgender communities, but with literature suggesting some differences in gender experience and patterns of psychosocial adversity. The present study aims to describe patterns of mental illness and psychoactive substance use in Hijra subjects and study their association with gender experience and psychosocial adversity. METHODS: Fifty self-identified Hijras availing HIV-prevention services in New Delhi, India, were interviewed. Data on mental disorders, psychoactive substance use, quality of life, discrimination, empowerment, violence and gender identity were assessed using structured instruments. RESULTS: Subjects were mostly in their mid-twenties, and had joined the Hijra community in their mid-teens. More subjects (46%) were involved in begging than in traditional Hijra roles (38%). Sex work was reported by 28% subjects. The rates of lifetime mental illness was 38%, most commonly alcohol abuse (26%); others had anxiety or depressive disorders (8% each), somatoform disorders (6%) and bulimia nervosa (n = 1). Disempowerment was mostly experienced in domains of autonomy and community participation; 52% had experienced sexual or psychological violence. Discrimination was attributed to gender (100%), appearance (28%) or sexual orientation (28%). There were negative correlations between the physical domain of WHO-QOL and physical violence and depression scores; and between discrimination and WHO-QOL environmental, physical and psychological domains. CONCLUSIONS: This Hijra group showed high rates of mental disorder and substance involvement, related to QOL domains and experiences of discrimination and disempowerment.

Telepsychiatry and Addiction Treatment.

The need and the importance of telemedicine has been brought to the forefront during the ongoing pandemic of COVID-19. It has created another viable option for treatment delivery while reducing risks. However, there are major concerns regarding the delivery of services for treatment of substance use disorders using telepsychiatry. We discuss the various concerns and opportunities, the different international practices, and the Indian guidelines. We believe that there needs to be a balance between access to treatment and medication with reasonable checks and call for more patient and provider friendly practices. We also propose certain modifications in the Indian Telepsychiatry Guidelines.