ORIGINAL ARTICLE |
https://doi.org/10.5005/jp-journals-11001-0076 |
The Trend of Utilization of Opioid Substitution Therapy Services in the Prepandemic Era in a Tertiary Medical College in India
1–5Department of Psychiatry, Murshidabad Medical College and Hospital, Berhampore, West Bengal, India
Corresponding Author: Ranjan Bhattacharya, Department of Psychiatry, Murshidabad Medical College and Hospital, Berhampore, West Bengal, India, e-mail: drrbcal@gmail.com
Received: 08 March 2024; Accepted: 29 May 2024; Published on: 08 June 2024
ABSTRACT
Introduction: Human immunodeficiency virus (HIV) prevention among intravenous drug user (IDU) is the ultimate goal of National AIDS Control Organization (NACO). The government hospitals across India are expanding with opioid substitution therapy (OST) services.
Aims and objectives: The primary aim was to find out the pattern of hopsacking behavior in a newly functional OST clinic in a government setup in India. As the prevalence of HIV infection is on rise, requirement of opening OST clinic are also emerging.
Materials and methods: The datasheet has been made in accordance with guidelines, and the descriptive and analytical statistics study has been carried out in a tertiary medical college of a government setup in India. The new patients enrolled, total clients registered, active client load, and total client load have increased at the beginning and end of the study period. The data were analyzed using IBM Statistical Package for the Social Sciences (SPSS) version 20.0.
Results: New clients enrolled during the study period are n = 62. From inception, total clients raised to 202. Very regular, regular, and irregular clients were n = 27, 10, and 72 changed to n = 56, 22, and 13, respectively from beginning to end of the study which is statistically not significant χ2 = 0.0792, p = 0.961. Total number of client vs active clients during beginning and end of the study shows significance, χ2 = 25.3311, p < 0.001. The relationship between new clients, total clients, treatment completed, clients with other outcome and active client shows significance in 2 × 5 contingency table, χ2 = 99.3704, p < 0. 001.The relationship between sexually transmitted infection (STI) referral, HIV tested, and condoms dispensed has shown significance with χ2 = 6.071, p < 0.048.
Conclusion: Opioid substitution therapy is an effective therapeutic option to manage IV drug users. The screening with stringent criteria is essential before client selection.
How to cite this article: Bhattacharya R, Mondal SK, Mondal S, et al. The Trend of Utilization of Opioid Substitution Therapy Services in the Prepandemic Era in a Tertiary Medical College in India. East J Psychiatry 2024;24(1):16–21.
Source of support: Nil
Conflict of interest: Dr Ranjan Bhattacharya is associated as Editorial board memeber of this journal and this manuscript was subjected to this journal’s standard review procedures, with this peer review handled independently of the Editor-in-Chief and his research group.
Keywords: Buprenorphine substitution, Cumulative service, Opioid substitution therapy, Regular attendance, Sexually transmitted infection clinic, Tertiary care.
INTRODUCTION
India has successfully managed to control the spread of human immunodeficiency virus (HIV) infection with the guidance of the National AIDS Control Organization (NACO). However, in some high-risk groups, the prevalence of HIV infection is increasing. In several sentinel surveillance studies, it has been found that the prevalence of HIV infection can be as high as 5% among intravenous drug users (IDUs). This document is a review of the document “Buprenorphine Substitution Therapy for Opioid Injection Drug Users: Practice Guidelines” which was developed to guide the implementation of the NACO-assisted opioid substitution therapy (OST) program in India. HIV prevalence among IDUs in India is 7.2%, the highest among all population groups.
The targeted interventions for risk reduction include: (1) needle-syringe exchange programs, (2) antiretroviral therapy (ART), (3) OST, (4) integrated counseling and testing centers (ICTC), (5) primary and secondary level prevention for sexually transmitted infections (STIs), (6) free distribution of condoms (barrier contraceptives) for IDUs and their partners, (7) providing information, education, and communication (IEC) materials to the targeted and high-risk groups, (8) primary and secondary prevention of more prevalent tropical infectious diseases like tuberculosis, and (9) early diagnosis and treatment as well as prevention of viral hepatitis.1,2
Opioid substitution therapy was incorporated into the National AIDS Control Programme (NACP) in 2007, during the third phase. Since 2010, OST centers have been operated in a public health model in some government hospitals in a collaborative approach with full-time dedicated manpower comprising a doctor, a nursing professional, a counselor or clinical psychologist, and a data manager. By virtue of the OST program, it was targeted to reduce injecting behavior, reduce risk, and encourage adherence to treatment for HIV, tuberculosis, and viral hepatitis. Also, OST will have other direct impacts by reducing opioid use, preventing overdoses and related catastrophes, including death, law and order problems, criminality, domestic abuse, better family life, child care, and productivity.
The prospective cohort studies, which have been conducted over 1.5 years, found that the odds ratio of having HIV infection was 5.4 in comparison to non-IDUs.3,4 A meta-analysis of relevant publications from >2 decades showed that OST clinic patients using methadone were four times less likely to die than those without treatments.5 Buprenorphine has 25–50 times more potent analgesic effects than morphine. Intravenous 0.3 mg of buprenorphine is equivalent to 10 mg of morphine. If a client is a minor, <18 years old, OST should not be denied blatantly.6,7
MATERIALS AND METHODS
The cumulative service uptake is defined as the total number of clients registered from the beginning until the reporting month. The service uptake, injecting drug use, targeted interventions (IDU-TI), is defined as the total number of patients started on OST by the canter till reporting month referred by IDU-TI. By definition, monthly treatment completion is defined as the number of patients who completed OST and were taken off medication in the reporting month. The cumulative treatment completion may be defined as the same as the total number since the beginning, and the patients with other outcomes are defined as those who haven’t received even a single dose during the reporting month due to many reasons like death, migration, imprisonment, or transfer to other places. The active client load may be defined as the number of individual clients receiving OST in the reporting month currently if the patient is receiving medicine for >25 days, 15–24 days, or <15 days (received at least a single dose) as defined for very regular, regular, and irregular clients, respectively. Out of the expected clients, the number who has not even received OST for a single day is the lost to follow-up (LFU).
The study was conducted in an OST clinic attached to a tertiary care government medical college. The OST center is managed by State AIDS Control Societies (SACS) and NACO. After obtaining approval from the Institutional Ethics Committee, the retrospective data chart of 1 year from 1 April 2019 to 31 March 2020 has been reviewed. The data has been analyzed by descriptive and analytical statistical methods using Statistical Package for the Social Sciences (SPSS) (version 20.0).8
RESULTS
The total number of new clients enrolled during this period of study (from April 2019 to March 2020) is 62 (5 in the month of April 2019, 57 in the rest of the months) (Fig. 1). The total client loads at the beginning of the month of April 2019 were 145. The total number of clients found to be registered in the OST clinic at the end of March 2020 is 202 (Fig. 2). The register shows the following figures with other outcomes (n = 35), active client load (n = 91), very regular clients (n = 56), regular clients (n = 22), and irregular clients (n = 13), respectively, at the end of March 2020. The total number of condoms distributed from the OST center during this period was 215. Only one patient has completed this treatment during this tenure. The clients with other outcomes have been reduced from n = 100 to n = 35 from April 2019 to March 2020. The active client load has increased from n = 44 (April 2019) to 166 (March 2020) (Fig. 3). The very regular, regular, and irregular clients have been increased (n = 27–56; n = 10–22; and n = 7–13), respectively. There are 10 clients who have reentered themselves during this period. The total number of visits, including multiple visits by the same clients, has increased from n = 1,033 (April 2019) to n = 2,175 (March 2020) (Fig. 4). The maximum number of new cases entered into the treatment process was in the month of January 2020 (n = 23) (Table 1).
| Variable | April 2019 | May 2019 | June 2019 | July 2019 | August 2019 | September 2019 | October 2019 | November 2019 | December 2019 | January 2020 | February 2020 | March 2020 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| New clients enrolled | 5 | 2 | 0 | 7 | 0 | 1 | 0 | 0 | 20 | 23 | 4 | 0 |
| Total clients registered (cumulative) | 145 | 147 | 147 | 154 | 154 | 155 | 155 | 155 | 175 | 198 | 202 | 202 |
| Treatment completed (cumulative) | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 |
| Clients with other outcomes | 28 | 28 | 30 | 31 | 31 | 31 | 31 | 32 | 32 | 33 | 34 | 35 |
| Active client Load | 44 | 44 | 42 | 52 | 52 | 53 | 49 | 45 | 66 | 89 | 93 | 91 |
| Very regular clients | 27 | 29 | 27 | 32 | 36 | 27 | 27 | 28 | 28 | 52 | 55 | 56 |
| Regular clients | 10 | 9 | 10 | 12 | 10 | 15 | 14 | 10 | 11 | 22 | 22 | 22 |
| Irregular clients | 7 | 6 | 5 | 8 | 6 | 11 | 8 | 7 | 27 | 15 | 16 | 13 |
| Reentry into treatment | 1 | 0 | 0 | 4 | 1 | 0 | 0 | 0 | 2 | 1 | 1 | 0 |
| Total number of OST clients visited | 1,033 | 1,110 | 1,030 | 1,225 | 1,313 | 1,171 | 1,123 | 1,075 | 1,153 | 2,070 | 2,054 | 2,175 |
Fig. 1: Line chart of new patients enrolled
Fig. 2: Total clients registered cumulative
Fig. 3: Line chart of active client load
Fig. 4: Total number of clients visited in OST
A significant number of clients (n = 66) have been referred to an STI clinic during the last year, and no patients have been diagnosed with an STI or reproductive tract infection (RTI) during this month. Only health education has been provided. All those who have been referred to an STI clinic have been tested for HIV, but none of them have been found to be seropositive. Nobody in the cohort has been diagnosed with tuberculosis in the last year. The use of the barrier method of contraception (condom use) among male subjects has significantly increased, from (n = 175) on April 2019 to (n = 215) on March 2020 (Table 2).
| Variable | April 2019 | May 2019 | June 2019 | July 2019 | August 2019 | September 2019 | October 2019 | November 2019 | December 2019 | January 2020 | February 2020 | March 2020 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Number of OST clients referred to STI clinic during the month | 7 | 2 | 0 | 11 | 1 | 1 | 0 | 39 | 3 | 1 | 1 | 0 |
| Of those referred to the clinic, number of clients treated for STI/RTI during the month | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 |
| Number of OST clients tested for HIV during the month | 7 | 2 | 0 | 11 | 1 | 1 | 0 | 39 | 12 | 7 | 29 | 11 |
| Number of HIV-positive cases detected out of those tested for HIV during the month | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 |
| Number of OST clients diagnosed with TB till reporting month (cumulative) | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 |
| Number of condoms distributed to OST clients during the month | 175 | 155 | 175 | 195 | 225 | 150 | 165 | 180 | 220 | 205 | 218 | 215 |
During this annual period of assessments, the differences between very regular, regular, and irregular clients have not been found to be statistically significant (χ2 = 0.07923311, p-value < 0.001) (Table 3). Both the number of active clients and total clients rose steeply over the course of 1 year, just before the lockdown started (Table 4). When the head-to-head comparison has been done between new clients, total clients, treatment completed, clients with other outcomes, and active client load, it has been found that the relationship is highly statistically significant (χ2= 6.071; p-value < 0.048) (Table 5), which signifies that STI referrals, awareness of safe sex practices, acceptance of contraception methods, and overall social acceptance are increasing and paving the way for the success of the OST program (Table 6).
| Month | Very regular (expected, χ2) | Regular (expected, χ2) | Irregular (expected, χ2) |
|---|---|---|---|
| April 2019 | 27 (27.05) (0.00) | 10 (10.43) (0.02) | 7 (6.52) (0.04) |
| March 2020 | 56 (55.95) (0.00) | 22 (21.57) (0.01) | 13 (13.48) (0.02) |
Chi-square statistics = 0.0792; p-value = 0.961; the result is not statistically significant
| Month | April 2019 (expected, χ2) | March 2020 (expected, χ2) |
|---|---|---|
| Total clients | 145 (117.74) (6.31) | 202 (229.26) (3.24) |
| Active clients | 44 (71.26) (10.43) | 166 (138.74) (5.35) |
Chi-square statistics = 25.3311; p-value < 0.001; highly significant statistically
| Month | New clients (expected, χ2) | Total clients (expected, χ2) | Treatment completed (expected, χ2) | Clients with other outcomes (expected, χ2) | Active client load (expected, χ2) |
|---|---|---|---|---|---|
| April 2019 | 5 (2.53) (2.42) | 145 (146.24) (0.03) | 1 (0.84) (0.03) | 100 (56.89) (32.66) | 44 (88.50) (22.38) |
| March 2020 | 1 (3.47) (1.76) | 202.76 (0.01) | 1 (1.16) (0.02) | 35 (78.11) (23.79) | 166 (121.5) (16.30) |
Chi-square statistics = 99.3704; p-value < 0.001, highly significant statistically; the 2 × 5 contingency table
| Month | STI referral | HIV tested | Condoms dispensed |
|---|---|---|---|
| April 2019 | 7 (3.63) (3.12) | 7 (8.18) (0.17) | 175 (177.19) (0.03) |
| March 2020 | 1 (4.37) (2.59) | 11 (9.82) (0.14) | 215 (212.81) (0.02) |
Chi-square statistics = 6.071; p-value < 0.048; significant statistically
DISCUSSION
Buprenorphine, a partial agonist of the mu opioid receptor, is used in India; some evidence exists for slow-release oral morphine; and methadone is used for long-term oral maintenance therapy.9 Dorabjee and Samson described their experience using buprenorphine in a community setting and reported that 33% of 447 IDUs treated with buprenorphine stopped injecting completely and 35% reduced the frequency of injections and discontinued needle sharing.10 Kumar reported that the OST implemented in Manipur and Nagaland covered approximately 1,200 IDUs, and the OST was found to be acceptable to clients, families, and the community at large, among religious leaders and among groups militants.11 Armstrong et al. conducted a study on OST customers in Manipur and Nagaland and found high retention rates of around 73 and 63%, respectively, at 3 and 6 months Intervals. Significant statistical differences were found in the following domains: needle sharing, unprotected sex, detention episodes, and quality of life measures.12 Similar multisite studies demonstrated that OST retention rates were approximately 70% at the end of 9 months. It also showed statistically significant reductions in opioid use, high-risk behaviors, severity of addiction, and improved quality of life.13 In a multicenter study conducted across 42 centers by Rao et al., OST was found to be implemented in accordance with guidelines published by the Department of AIDS Control (DAC); most patients reported being satisfied with the treatment they received. slow-release oral morphine (SROM) studies conducted in New Delhi showed that methadone maintenance therapy (MMT) was associated with a reduction in illicit opioid use, improved functioning, and a reduction in illegal activities. Multicentric research on methadone implementation in five research centers has shown that MMT and SROM programs are viable options in India and may be conducted under supervision.
The trend of recruitment and successfully adhering to treatment in OST centers has been found to increase with time. The trend of clients to abide by OST can be assessed as having very regular, regular, and irregular patterns that have not been found to be statistically significant, and they were not affected by the initial part of the coronavirus disease 2019 pandemic. The study is important from a social perspective to learn about knowledge, attitude, and practice about the risk of the spread of HIV infection among IDU) and the treatment available with the help of OST. The trend of attendance in OST clinics in the prepandemic period over a year also reflects the increasing acceptance and indirectly reflects the magnitude of the problem of IDU. The attendance in OST clinics is just the tip of the iceberg.14
CONCLUSION
Opioid substitution therapy is an effective treatment option for opioid addiction, as well as an HIV prevention intervention for opioid-dependent IDUs.15,16 The clinical practice of buprenorphine-based OST is simple and can be provided by physicians with appropriate training.17,18 An appropriate assessment and screening for OST criteria must be conducted before starting a client on OST. Buprenorphine is a relatively safer medicine to use. Appropriate client selection, adequate dose of buprenorphine, and adequate duration are determining factors for a successful OST intervention. Staff attitudes toward clients, combined with other issues such as clinic dispensing hours and provision of ancillary services, are other important determinants of OST intervention success.19,20 The present study has generated potential sources of information, especially in the prepandemic era. However, the study has some limitations, especially regarding study duration, sample size, and limitation to a single center. A multicenter study with follow-up of a larger cohort for a longer duration could have improved the power of the study and collected more information. If manpower and logistics can be provided, the OST program will become a success story by preventing HIV infection and becoming the mainstay of treatment for opioid addiction.
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