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

BACKGROUND OBJECTIVES: This systematic review evaluates the human immunodeficiency virus (HIV), hepatitis C virus (HCV) and hepatitis B virus (HBV) burden among people who inject drugs (PWIDs) in India. In addition, we selectively examined research on opioid substitution treatment (OST)-related services due to their role in antiviral treatment uptake and adherence. METHODS: Data were sourced from peer-reviewed and government publications between 1991 and September 20, 2023, searched in MEDLINE, Scopus and EBSCOhost. English language studies reporting weighted prevalence or raw numbers and recruitment sites were included for review. Quality was assessed using the Joanna Briggs Institute tool. Data synthesis was done in graphs and tables. RESULTS: We included 50 reports, yielding 150 HIV, 68 HCV and 24 HBV prevalence estimates across India, revealing significant regional heterogeneity. Notably, 16 States had a single community-based HIV estimate, and 19 States had limited or no HCV data. The highest HIV and HCV prevalence was in Manipur (74.7% and 97.5%, respectively) in 1996. Recent spikes included 50.2 per cent HIV prevalence in Punjab (2010) and 73 per cent HCV in Uttar Pradesh (2021). Nationally, OST coverage in 2020 was under five per cent, with some northeast, north and central States exceeding this, but most others were falling below two per cent. No studies on the cost-effectiveness of directly observed treatment models for OST were identified. INTERPRETATION CONCLUSIONS: There is a lack of sufficiently granular and generalizable estimates for HIV prevalence and any estimates for HCV and HBV among PWIDs in large parts of the country. Community-based representative studies are required to quantify the prevalence and severity of these diseases and allocate resources.

A descriptive study of hepatitis C in people who inject drugs.

BACKGROUND OBJECTIVES: The seroprevalence of the hepatitis C virus (HCV) in general population is higher than that of human immunodeficiency virus (HIV) in India. People who inject drugs (PWIDs) constitute a high-risk group for all blood-borne infections. Multiple behavioural surveillance surveys have provided a rich typology of HIV-infected PWIDs, but this information is missing for HCV infection. We describe awareness, transmission risk factors and the treatment continuum for HCV infection among PWID. We also report spatial clustering of HCV infection in PWIDs residing in Bengaluru. METHODS: Information from clinical records was collected and telephonic interviews of retrospectively identified PWIDs who received treatment at a tertiary-level addiction treatment facility between 2016 and 2021 were conducted. RESULTS: We identified 391 PWIDs; 220 (56.26%) received an anti-HCV antibody test (4 th Generation HCV-Tridot). Individuals reporting unsafe injection practices were more often tested than those who did not ( χ2 =44.9, df=1, P <0.01). Almost half of the tested and more than a quarter of the whole sample (109/220, 49.9%; 109/391, 27.9%) were seropositive for HCV infection. The projected seropositivity in this group was between 27.9 per cent (best case scenario, all untested assumed negative) and 71.6 per cent (worst case scenario, all untested assumed positive). Only a minority of participants interviewed were aware of HCV (27/183, 14.7%). HCV infection and its associated risk behaviour (PWID) were clustered in certain localities (Diggle and Chetwynd Test; P =0.001) in Bengaluru in the southern district of Karnataka. INTERPRETATION CONCLUSIONS: Undetected HCV infection is common in PWIDs; awareness and treatment uptake is poor in this group. Spatial clustering of infections in a district shows transmission in close networks and provides opportunities for targeted interventions.

Complicated Alcohol Withdrawal-An Unintended Consequence of COVID-19 Lockdown.

AIM: To assess the impact of COVID-19-related lockdown in India on alcohol-dependent persons. METHOD: We examined the change in the incidence of severe alcohol withdrawal syndrome presenting to hospitals in the city of Bangalore. RESULTS: A changepoint analysis of the time series data (between 01.01.20 to 11.04.20) showed an increase in the average number of cases from 4 to 8 per day (likelihood ratio test: χ2 = 72, df = 2, P < 0.001). CONCLUSION: An unintended consequence of the lockdown was serious illness in some patients with alcohol use disorders.

Innovative virtual mentoring using the Extension for Community Healthcare Outcomes model for primary care providers for the management of alcohol use disorders.

The number of experts available for the management of alcohol use disorders (AUDs) in rural and underserved areas in India is limited. In this study, a blended training programme was conducted for 26 primary care providers (PCPs) from nine districts of Bihar, in best practices for the management of AUDs. A two weeks on-site training was followed by fortnightly online tele-Extension for Community Healthcare Outcomes (ECHO) clinics for six months using the 'Hub and Spokes' ECHO model, accessible through internet-enabled smartphones. A questionnaire administered at baseline and after six months assessed changes in the PCPs compliance with principles of AUD management. Significant improvements were noted in compliance to principles in the management of AUDs based on self-report. Over the six months period 2695 individuals were screened, of whom 832 (30.8%) had an AUD Identification Test score of more than 16, indicating harmful use or dependence. The PCPs reported retaining 49.1 per cent of the cases for at least one follow up and needed to refer only 80 (3%) cases to specialists for further management. The ECHO model was found to be effective in training PCPs to provide quality healthcare. To confirm these findings, it needs to be tested in a large number of PCPs with a robust study design.

Pellagra and Alcohol Dependence Syndrome: Findings From a Tertiary Care Addiction Treatment Centre in India.

AIM: To define the prevalence and clinical presentation of pellagra, a multi-systemic disease caused by the deficiency of niacin, in patients admitted to a tertiary addiction treatment centre in southern India, with alcohol dependence syndrome (ADS)-(ICD10). METHODS: Review of the health records of 2947 patients who received inpatient care for ADS between 2015 and 2017. RESULTS: Out of 2947, 31 (1%) were diagnosed with pellagra. Nearly two-thirds (64.5%) of those with pellagra were from a low-income group. Of the clinical-triad of pellagra, all patients had dermatitis, more than half (58%) had delirium, a minority (19%) had diarrhoea. Nearly two-thirds (61%) had presented in a complicated-withdrawal state. Associated conditions included peripheral neuropathy (32%); Wernicke's encephalopathy (26%); seizures (16%).Seventeen (54%) had BMI <18.5 kg/m2. Treatment was a high dose of parenteral vitamins including niacin (mean dose: 1500 mg/day) for an average of 7.5 days followed by oral multivitamin supplements. All had complete resolution of pellagrous symptoms by the end of the three weeks of inpatient care. CONCLUSIONS: Pellagra is an acute medical condition, frequently encountered in the context of alcohol dependence and poverty. It often presents with other disabling and life-threatening comorbidities like delirium tremens and Wernicke's encephalopathy. The classical triad of pellagra is only seen in a minority of cases. Thus a high index of suspicion is required lest pellagra may remain undiagnosed. Prompt identification and treatment with a high dose of niacin in combination with other vitamins result in complete recovery.

Phenomenology and Course of Alcoholic Hallucinosis.

Objective: The objective of the study was to examine the correlates, phenomenology, and short-term treatment response to benzodiazepines and antipsychotics in an inpatient sample with alcohol-induced psychotic disorder, predominant hallucinations i.e., F10.52. Methods: We reviewed the charts of the patients admitted in a tertiary care addiction treatment center between 2010 and 2016 with the diagnosis of alcoholic hallucinosis. Results: Among 6,493 patients admitted with alcohol dependence during the study period, 61 patients (0.9%) had alcoholic hallucinosis. Among them, 41 (67.2%) had alcoholic hallucinosis in the past; 26 (42.6%) had a family history of psychosis. Only auditory hallucinations were found in 46 patients (75.4%), only visual hallucinations in 3 patients (5%), and both auditory and visual hallucinations in 12 (19.7%). Thirty-four (55.7%) had delusions, which were secondary to hallucinations. Suicidality which includes suicidal ideas and attempts was noted in 12 (19.7%) patients. Fifty-three (86.9%) patients had hallucinations exclusively during alcohol withdrawal, while 8 (13.1%) had them during withdrawal as well as while consuming alcohol. At the end of six months, 13.1% of the patients had an independent psychotic disorder diagnosed. The primary mode of management was treatment with only benzodiazepines (n = 37, 60.7%) or benzodiazepines and antipsychotics (n = 24, 39.3%). The reasons for starting antipsychotics were the presence of florid psychotic symptoms (26.2%) and incomplete symptom resolution with benzodiazepines (9.8%). The median duration of response was four days, with 25th to 75th quartile range at two to seven days. Conclusions: Alcoholic hallucinosis is an acute short-lasting psychotic disorder which lasts for less than a week when treated. Suicidality is high in this group, which needs attention. Benzodiazepines as part of withdrawal management may be sufficient for a majority of cases. Antipsychotics may be required in selected cases. A high degree of recurrence and morbidity indicates a need to intervene early with an abstinence-oriented management goal.

Poisoning with Drugs of Abuse: Identification and Management.

Substances of abuse include alcohol, nicotine, cannabinoids, opioids, sedatives, volatile solvents, stimulants, and hallucinogens. With the increasing prevalence of drug abuse in India, intensivists are likely to encounter more cases of intentional and accidental poisoning due to drugs of abuse. We aim to sensitize the intensivists to challenges involved in diagnosing and treating poisoning with drugs of abuse. We also aim to provide a hands-on primer that can augment the usual protocols of "approach to life-threatening poisoning". A toxidrome approach along with urine drug testing can help in speedily arriving at a diagnosis and instituting definitive treatment. In this article, we discuss spurious alcohol poisoning (methanol poisoning), benzodiazepine, opioid, and stimulant poisoning in detail and poisoning due to other substances including newer psychoactive substances is discussed briefly. HOW TO CITE THIS ARTICLE: Shukla L, Ghadigaonkar DS, Murthy P. Poisoning with Drugs of Abuse: Identification and Management. Indian J Crit Care Med 2019;23(Suppl 4):S296-S304.

ECT and Pronounced Impairment in Spatial Cognition: The Fallacy of Drawing Conclusions From a Single Case.

INTRODUCTION: Electroconvulsive therapy (ECT) is associated with memory deficits on neuropsychological assessment. The association of ECT with nonmemory cognitive deficits has been poorly studied. METHODS: We present a 40-year-old woman who showed a bizarre form of spatial cognition impairment on a subtest of the Tactual Performance Test (TPT) after recovering from depression with 6 alternate day, thrice-weekly, inpatient ECT treatments. This woman was part of a naturalistic, nonblind study that examined nonmemory cognitive deficits in antidepressant-treated depressed patients who did and did not receive ECT. RESULTS: The impairment was in the form of bizarrely drawn reproductions of differently shaped wooden blocks that had been presented to the patient when she was blindfolded. The impairment was still evident when she was retested (3 hours later) under substantially simplified conditions but was much attenuated approximately 2.5 weeks later. CONCLUSIONS: On the surface, it seems that ECT had induced severe impairment in spatial cognition and that the impairment showed the familiar pattern of attenuation with the passage of time. However, another recovered patient in the study, who did not receive ECT, also showed substantial spatial deficits on the same subtest of the TPT, and the attenuation of the deficits across time in the ECT-treated patient was probably a result of repeated exposure to the task. We suggest that not all patients who seem to experience spectacular cognitive impairment after ECT have deficits that are attributable to ECT.

Electroconvulsive therapy for the treatment of organic catatonia due to viral encephalitis.

Catatonia is a common presentation to psychiatric services in developing countries. Medical causes of catatonia are common and are difficult to treat. A 20-year-old woman presented with an acute illness consisting of fever, delirium, perceptual abnormalities, and catatonic state. After trials with antiviral medications, benzodiazepines, and atypical antipsychotic medications, she was treated with 6 sessions of electroconvulsive therapy with complete recovery and no complications. Catatonia arising in the background of organic pathology can be treated on similar lines as in other psychiatric disorders. Electroconvulsive therapy can be a safe option that needs consideration in such cases after ruling out the contraindications.

Traumatic brain injury during COVID-19 pandemic-time-series analysis of a natural experiment.

OBJECTIVES: This study aims to find if the incidence and pattern of traumatic brain injury (TBI) changed during the COVID-19pandemic. We also aim to build an explanatory model for change in TBI incidence using Google community mobility and alcohol sales data. DESIGN: A retrospective time-series analysis. SETTING: Emergency department of a tertiary level hospital located in a metropolitan city of southern India. This centre is dedicated to neurological, neurosurgical and psychiatric care. PARTICIPANTS: Daily counts of TBI patients seen between 1 December 2019 and 3 January 2021 (400 days); n=8893. To compare the profile of TBI cases seen before and during the pandemic, a subset of these cases seen between 1 December 2019 and 31 July 2020 (244 days), n=5259, are studied in detail. RESULTS: An optimal changepoint is detected on 20 March 2020 following which the mean number of TBI cases seen every day has decreased and variance has increased (mean 1=29.4, variance 1=50.1; mean 2=19.5, variance 2=59.7, loglikelihood ratio test: χ2=130, df=1, p<0.001). Two principal components of community mobility, alcohol sales and weekday explain the change in the number of TBI cases (pseudo R2=58.1). A significant decrease in traffic accidents, falls, mild/moderate injuries and, an increase in assault and severe injuries is seen during the pandemic period. CONCLUSIONS: Decongestion of roads and regulation of alcohol sales can decrease TBI occurrence substantially. An increase in violent trauma during lockdown needs further research in the light of domestic violence. Acute care facilities for TBI should be maintained even during a strict lockdown as the proportion of severe TBI requiring admission increases.

Alcohol controls in the aftermath of the COVID-19 pandemic in India: Commentary on Stockwell et al.

The COVID-19 pandemic and subsequent restrictions have resulted in additional challenges for persons with alcohol use disorders as well as for the effective operation of alcohol controls in different societies. The challenges are different in different systems and economies. Crises such as these often provide governments with opportunities to remake systems. We use the recent experience from India, which rapidly shifted between total countrywide prohibition of alcohol and unrestricted sales during this brief period, to argue against using the present crisis to bring about quick changes in alcohol policy in India. Instead, we advocate sustained, incremental pressure to develop and enforce alcohol control measures in public health delivery systems, in addition to demand reduction measures.

Tapentadol abuse and dependence in India.

BACKGROUND: Tapentadol is a synthetic opioid analgesic available in India since 2011. International evidence suggests a low risk of abuse and diversion. Our study aims to question this perception in Indian context. METHOD: We report the trend and profile of Tapentadol abuse cases that were treated at a tertiary level addiction treatment centre in southern India. We also describe the ease of repurposing oral tablets of Tapentadol into an injection. At the national level, we have examined the temporal and spatial trends of online interest in Tapentadol and compared it with a non-opioid drug Ilaprazole and an opioid drug Tramadol using Google Trends. We have used the National Drug Use Survey 2019 to illustrate the regional data. RESULTS: 23 cases of Tapentadol abuse sought treatment between 01/01/2011 and 30/08/2019. In last one year, the number of cases has more than doubled. A majority (N = 19, 83 %) of cases had intravenous Tapentadol abuse, needle sharing and 60 % were diagnosed with Hepatitis C. Tapentadol is attracting new users (N = 13, 56.5 %) as well as replacing other opioids (N = 10, 43.5 %) amongst drug users. Tapentadol has received more online interest than Ilaprazole. Temporal and spatial trends of online interest in Tapentadol parallel Tramadol. States with high prevalence of opioid users have shown high online interest in both opioid drugs. CONCLUSION: Tapentadol is being widely abused, and urgent regulatory measures are required.

'Too little dose - too early discontinuation?'-Effect of buprenorphine dose on short term treatment adherence in opioid dependence.

BACKGROUND: Opioid substitution therapy is an evidence-based treatment for opioid dependence syndrome. Retention in treatment is a crucial mediator of treatment success. Our study aims to examine factors associated with early treatment non-compliance among patients who are initiated on office-based Buprenorphine Maintenance Treatment (BMT). METHOD: This is a prospective observational study conducted among 89 subjects who were initiated on BMT and were followed up to 6 weeks. At baseline, we evaluated subjects using: Mini International Neuropsychiatric Interview Plus, Addiction Severity Index-Lite, Multi-Dimensional Scale of Perceived Social Support, Heroin Craving Questionnaire, and urine toxicological analysis. Treatment adherence for six weeks was noted. RESULTS: Among Eighty-nine subjects, 57 per cent of the sample reported addiction to pharmaceutical opioids. The mean dose of Buprenorphine was 6.7 mg (SD = 4.1). During follow up 67 per cent (n = 62) patients were adherent to treatment while 33 per cent (n = 27) non-adherent to treatment. The mean dose of buprenorphine in the non-adherent group was significantly lower than the adherent group (4.3 mg and 7.7 mg, respectively, t [87] = 3.8, p < 0.001). A comparison of groups based on the dose of Buprenorphine (6 mg or higher vs lower than 6 mg) revealed that odds of treatment non-adherence were three times higher in patients receiving 6 mg or lesser dose (Odds Ratio = 3.15 [95% CI = 2.0-8.6],χ2 [1] = 4.75, p = 0.035). CONCLUSION: Dose of Buprenorphine prescribed by the treating clinician influences early treatment compliance significantly.

Relative effectiveness of N-acetylcysteine and baclofen as anticraving agents in cannabis dependence - A retrospective study with telephonic follow-up.

BACKGROUND: Cannabis dependence is associated with psychiatric, social, and legal consequences. Currently, there is no approved pharmacological treatment for cannabis dependence. Recent studies have reported the utility of N-acetylcysteine (NAC) and baclofen (BAC) in the long-term treatment of cannabis dependence, primarily as anticraving agents. MATERIALS AND METHODS: We reviewed the records of all patients who received inpatient treatment during 2015-2017 for cannabis dependence syndrome. We included cases only if cannabis dependence was noted as the primary focus for seeking inpatient care. Data are collected up to 6 months following discharge and analyzed using Kaplan-Meier survival analysis. The time to the first use of cannabis (in days) following discharge is compared between three groups - psychosocial intervention (PSI) only, BAC in addition to PSI, and NAC in addition to PSI. RESULTS: During the study period, 238 inpatients were diagnosed with cannabis dependence syndrome. However, cannabis dependence was the primary focus of treatment in only 72 patients. Among these patients, 29 (40.2%) received PSI only while 25 (34.8%) received BAC (mean dose = 55 mg per day, standard deviation [SD] = 2.5 mg) and 18 (25%) received NAC (mean dose = 1800 mg per day, SD = 500 mg) in addition to PSI. While 47 (62.5%) of the patients had comorbid psychiatric disorders, it was comparably distributed in the three groups. A survival analysis shows that the probability of cannabis-free survival is significantly higher in the NAC group as compared to the BAC group which is in turn higher than the PSI group (χ2 = 12.1, P = 0.002). CONCLUSION: The use of anticraving medications, namely BAC and NAC, may be a useful option along with PSIs in patients with cannabis dependence and requires further exploration.

Election bans and alcohol banes: The impact of elections on treatment referrals at a tertiary addiction treatment facility in India.

Pattern of alcohol use and its related complications is determined by multiple factors. We studied the effects of sudden ban of alcohol during elections in a state of India. We found that unexpected election bans could lead to severe complications in alcohol dependent individuals. Impact of sudden policy changes needs to be thought prior to implementation.

What kills everyone, gives a high for some-Recreational Snake Envenomation.

There are multiple reports of recreational snake envenomation describing psychotropic effects in absence of any adverse effects. This is in contradiction with known effects of snake venom. We report a case of a young male who subjected himself to repeated envenomation by a snake purported to be 'Indian Cobra' and experienced a 'high'. However, a direct identification of snake revealed it was a benign 'Rat snake'. We attempt to explain the reported psychological effects as a result of high expectation of rewarding experience, strong suggestion, personality traits and most importantly the dangerous nature of willfully receiving snakebites.

A Case of Carbamazepine-induced Severe Cholestatic Hepatitis: Case Report and Review of Literature.

Carbamazepine (CBZ) is one of the widely prescribed drugs in the field of neuropsychiatry. We report a case of a 27-year-old female patient presenting with severe cholestatic hepatitis presenting after the initiation of CBZ. We establish the probability of drug-induced liver injury using Council for International Organizations of Medical Sciences/Roussel Uclaf Causality Assessment Method causality assessment scale, and the patient had high probability with a score of 9. We briefly review the literature in this field discussing the scope of the problem, etiopathogenesis, clinical manifestation, course, and management.

Value of Ethyl Glucuronide and Ethyl Sulfate in Serum as Biomarkers of Alcohol Consumption.

BACKGROUND: Urinary Ethyl glucuronide (EtG) and Ethyl sulfate (EtS) are established markers of alcohol conumption. Measurement of these markers in serum offers certain advantages. This outpatient department based study evaluated performance of serum Ethyl glucuronide (EtG) and Ethyl sulphate (EtS) as biomarkers of recent alcohol consumption in alcohol dependent subjects. It also evaluated effect of alcohol dose and time since consumption on serum EtG and EtS concentration. METHODS: Information regarding alcohol intake was collected using Time line follow back calendar method from 152 subjects. Blood samples were collected to determine serum EtG and EtS concentration. RESULTS: The results revealed that serum EtG (at a threshold of 45 ng/mL) could detect recent moderate to heavy alcohol consumption with 85 percent sensitivity and 89 percent specificity. The results also show that simultaneous measurement of EtS does not increase test accuracy. We found that dose of alcohol and time since alcohol consumption explain 68 and 62 percent variance in serum EtG and EtS levels. CONCLUSION: EtG testing in blood was found useful as a way to detect recent drinking. This sensitive and specific short-term biomarker provides valuable information about recent alcohol consumption.