Challenges in the scale-up of opioid substitution treatment in India.

Abstract

Byline: Atul. Ambekar, Pratima. Murthy, Debasish. Basu, G. Rao, Ashwin. Mohan Opioids are one of the best known analgesics and euphoriants known to humankind. Their widespread use globally for such purposes has also led to opioids topping the list of “problem drugs.” In India, opium and its variants have been cultivated and used as household remedies, in medicinal preparations and as intoxicants for centuries. Advent of high potency, synthetic opioid preparations like heroin however, has changed the scenario drastically. Especially in the Northern and Northeastern parts of the country, the opioid use epidemic is well-established and opioid use disorders are among the commonest illicit-drug-related conditions, bringing patients to health care providers. Use of injectable opioids has added yet another grave dimension in the harms caused by opioids. In India, almost all injecting drug users (IDUs) are opioid dependent [sup][1] and the prevalence of HIV among this group is the highest (more than 9%) among all the high risk groups.[sup][2] For addiction treatment professionals, opioid use disorders present certain unique challenges. Short-term, stand-alone treatment of acute withdrawal symptoms (or “detoxification”) is almost invariably associated with relapse to opioid use.[sup][3],[4] Consequently most patients require a long-term, combined psychosocial and pharmacological approach for treatment. Two distinct approaches exist for the long term pharmacological treatment (1) agonist maintenance treatment or opioid substitution treatment (OST) and (2) antagonist treatment. The latter, involves long-term maintenance of opioid-dependent patients on an antagonist like naltrexone. This traditional approach is marred by poor evidence of its effectiveness. Naltrexone maintenance has been found to work in only a select sub-population of opioid dependence patients, mainly on account of poor compliance and retention in treatment.[sup][5] As a consequence, and with emergence of stronger evidence-base, agonist treatment or OST, is now the universally accepted treatment modality. Consequently, most treatment guidelines, including those of the Indian Psychiatric Society (IPS), recommend OST as the preferable option for long-term pharmacological treatment of opioid dependence.[sup][6] Globally, the most common treatment agents used for OST are methadone and buprenorphine. Methadone, as the agonist treatment option has existed for many decades and is widely used in many countries around the world, as compared to buprenorphine.[sup][7] Curiously, in India, it is buprenorphine which has been available as an analgesic and maintenance agent for OST for a very long time while methadone has been introduced only recently.[sup][8] Despite being available for around three decades, use of buprenorphine as OST has remained low in India. In this article, we discuss the reasons behind this and recommend certain steps, which would help in scaling-up this most evidence-based and effective treatment for opioid dependence in India. Opioid Substitution Treatment in India: Existing Situation Buprenorphine was launched as an analgesic in the late 1980s. Soon after the emergence of evidence regarding its effectiveness in international literature,[sup][9] some academic institutes as well as nongovernmental organizations (NGOs) started using the low-strength, sublingual buprenorphine tablets for treatment of opioid dependence. Use of buprenorphine got a further boost in India with the launch of higher strength (2 mg) tablets in 1999 and subsequently launch of buprenorphine and naloxone fixed dose combination (FDC) in 2004–2005. A big turning point however, was inclusion of OST as one of the components of National AIDS Control Programme (NACP) in 2007. Since then, the National AIDS Control Organization has been scaling-up OST in the country as a measure to prevent HIV/AIDS. …