Rely on evidence to tackle opioid dependence in Punjab
THE recent spate of drug overdose deaths has been flagged as alarming. And alarming, indeed, is each death. Each life is precious. I recall being visited by a devastated couple seeking treatment for grief after losing their 20-year-old son to a drug overdose. He had been under treatment and had recently quit heroin. Unfortunately, he possibly took the same dose that he used to take prior to the treatment, which turned out to be inordinately high, killing him.
The scourge of opioid dependence is gnawing away at families. Its tentacles are enveloping entire communities in its financial burden and health consequences (ie HIV, Hepatitis B and C, etc). People who use opioids and other substances often develop tolerance to them, meaning that they need higher doses of the same substance to get the effect they used to before. As a result, when they stay off the substance for a period of time after undergoing treatment, their tolerance to it decreases. And if they resume the same dose, they may suffer an overdose.
There are many other factors leading to an overdose death. Some people may mix one substance with another or use a low-potency substance and then get a higher-potency opioid, which may prove fatal.
How well-equipped are we to deal with this? Punjab, Haryana and Delhi have a high substance dependence problem. The 2015 Punjab Opioid Dependence Survey (PODS) found over (average estimate) 2.32 lakh opioid dependents in the state, ie four out of 100 men in the age group of 18-35 years. Fifty-three per cent of them used heroin, while 33 per cent took intravenous opioids.
The Ministry of Social Justice and Empowerment, Government of India, got the ‘National Survey on Extent and Pattern of Substance Use in India’ conducted through the National Drug Dependence Treatment Centre, AIIMS; it was published in 2019. It found that after Uttar Pradesh, Punjab had the highest number of opioid dependents. In terms of the percentage of population affected, the worst-hit states are those in the Northeast (Mizoram, Nagaland, Arunachal Pradesh, Sikkim and Manipur), along with Punjab, Haryana and Delhi.
Even though the Punjab Government has set up five model government-run de-addiction centres and 208 Outpatient Opioid Assisted Treatment Centres, and there are around 100 private addiction centres, there remain many flaws and loopholes. For instance, even though the state government is supposed to provide a licence on an online application for a de-addiction centre run by a psychiatrist, it does not do so. Therefore, a few have a monopoly over the current running of de-addiction centres. This means that patients do not get quality treatment nearby — a local psychiatrist is more likely to provide psychoeducation regarding an illness, medication, duration of treatment, etc, to a patient and his family members than an out-of-state psychiatrist, who is probably seeing 150 to 250 patients every day and is there for a tenure of one to two years only.
Secondly, even though standard operating procedures have been worked out, OPD-based de-addiction centres have still not been given licences. If a psychiatrist running an OPD addiction centre is given a licence, he or she can reduce the patient load on other centres, which leads to better quality services.
Managing any illness requires primary (for example, spreading awareness through the media) and secondary prevention (an early identification and access to treatment facilities). In Punjab, as in many other states, stigma is still associated with the use of substitute medicines (methadone and buprenorphine), of which the buprenorphine-naloxone combination is mainly available as treatment. This combination is used across the world and is on the WHO list of essential drugs. Many studies have shown that its regular use reduces relapses, thus bringing down the number of overdose deaths.
Indispensable items, such as kits containing naloxone and flumazenil, should be made available in all district and civil hospitals and at the tehsil level. Flow charts of identification and treatment of suspected overdose can be arranged at all government and private hospitals.
Psychoeducation about the risk of overdose after quitting and where the patient should be taken must be available. We have still not been able to convince the public about the treatment value of buprenorphine-naloxone combination, which is used worldwide. Often in India, low doses are used. As a result, many patients relapse, often putting them at risk of an overdose. If a person receives adequate medication, he or she is less likely to relapse.
In many countries, doctors are reluctant to reduce substitute medicine once a patient is stable on the medicine. However, in India, due to political pressure and a lack of awareness, doctors are compelled by ill-informed families and the government to reduce the medicine, thereby leading to frequent relapses. Training doctors to understand that opioid dependence is a chronic relapsing disorder is essential. The POD survey recommended measures such as providing both short-term (detoxification) and long-term treatment (such as the Opioid Substitution Therapy).
Another recommendation was to provide treatment in both outpatient and inpatient settings. Consequently, it would be imperative to shift the focus from de-addiction centres (providing inpatient services) and to expand the basket of services by establishing drug dependence treatment clinics that provide long-term outpatient treatment. It also suggested a spirit of helping the affected people as opposed to punishing those who are guilty of using drugs.
We have come a long way in the treatment of opioid dependence. Yet, the battle ahead is fraught with challenges. Evidence-based measures and spreading awareness about treatment among the community are the key. But it will happen only when the administration understands the nature of opioid dependence and puts in place measures used worldwide.
