SELF AND COMMUNITY BASED OPIOID SUBSTITUTION AMONG OPIOID DEPENDENT
POPULATIONS IN THE INDIAN SUB-CONTINENT
Presented by Jimmy Dorabjee, SHARAN, New Delhhi,
India
Background
The phenomenon of
'traditional' drug use in Asia has been well documented since the presence of
the British in the region. Substances
such as cannabinoids and opioids have found their way to Western markets at
substantial profit margins which resulted in International pressure for Supply
Reduction and crop eradication measures.
In Asia traditional forms of
opioids gave way to the manufacture of heroin in the Golden Crescent
regions. The purity of the heroin
manufactured in the SE Asian region, as well as the reduced availability of
opium products, resulted in the switch to a more cost effective mode of
use. Hong Kong (1950's) first saw a
shift from smoking to injecting of heroin with Thailand (1960's), Laos (1970's)
and North East India (1980's) following suit (Crofts et al, 1995.). The cruder products from the Golden Crescent
region were more suited to ingestion through inhalation and cheap and abundant
supplies of brown sugar flooded the Indian markets by the mid 1980's.
Introduction
Brown sugar was introduced
into the Indian opioid market in the early 80's at a street cost of 30 Rupees
(Rs) per gram (around US$2) and effectively displaced the opium and cannabis
market. This resulted in traditional
opium users succumbing to the aggressive marketing ploys of the National and
International drug Mafia and by the mid 80's opium and cannabis dens in major
cities turned into retain outlets for brown sugar. However, the introductory price soon doubled and kept rising
making it unaffordable to the street using populations, with the resultant
phobia of withdrawals due to the high tolerance levels.
The continuing price spiral
led to an increase in criminal activities related to addiction and the demand
for detoxification and treatment services.
Some of these detoxification centres utilised buprenorphine in the
management of heroin withdrawals and street wise drug users soon capitalised on
its widespread availability in the 'grey market', where it was indicated as a
post operative analgesic, available mainly in ampoule form.
By the late 80's and early
1990's, injectable buprenorphine gained popularity as an alternative among the
heroin users and this mushroomed into epidemics of injecting in the larger
cities of the India Subcontinent (Biswas et al, 1994; Panda, 1997; Kumar &
Daniels, 1994; Dorabjee, 1994; Bharadwaj, 1995). While buprenorphine effectively managed opioid dependency, it
also gave rise to the vulnerability of injecting related harms, especially HIV,
HBV and HCV. The equipment and related
information. Rampant reuse of unsterile
equipment, high frequency of needle sharing and extremely poor health status,
all contribute to potential epidemics of endemic proportions. The density of slum populations involved in
injecting drug use (IDU) coupled with
high frequency of sexual contacts raise the prospect of an explosive and
uncontrolled epidemic of HIV ,which in turn threatens hard won public health
gains.
By 1992, injecting drug use
had filtered down to the smaller cities (Self Injecting of drugs gains
popularity in Punjab, TOI, July 95) and injecting drug users (IDUs) began to
'cocktail' Buprenorphine with Pheniramine and Promthazine as well as with
Diazepam, in an effort to enhance and prolong the effects (Biswas, 1994). A recent UNDCP report expressed concern that
'in India there are increased use of injecting techniques, a major factor
contributing to the spread of HIV among drug users in that country'.
The rise in IDU in the cities
has been attributed to price increase as well as the reduction in availability
of heroin, mainly due to supply reduction efforts. In the North East, injecting of an opioid analgesic
dextropropoxyphene, which is available in capsule form, has resulted in major
health hazards (Eicher, 1996, pp 56-57).
By 1995, reports of the spread of buprenorphine injecting, with the
resultant public health concerns, were available from Nepal (Shreshtra,
1995) buprenorphine abuse in Nepal and
Bangladesh (UNDCP, 1996) and received mention in the 1995 and 1996 Reports of
the International Narcotics Control Board, which expressed concerns about
"the serious consequences of the increased abuse of buprenorphine .... and
the further spread of buprenorphine abuse in Bangladesh and Nepal, or even in
India itself. In Bangladesh
buprenorphine is abused by 90% of injecting drug users".
The positive aspects of
injections of Buprenorphine are that it is cheaper than heroin, a 2 ml (0.6 mg)
vial costing (Rs 12), around 1/5 the price of an average dose of heroin. Buprenorphine is also clinically safe, the
ampoules are unadulterated and manufactured with strict quality controls,
besides having little overdoes potential and are readily available in
pharmacies. In light of this situation
SHARAN began a pilot management of drug abuse and HIV prevention programme
among opioid using populations in Delhi slums in early 1993. the low threshold intervention utilises
between 2 & 6 mg sublingual buprenorphine among its street clients. Feedback from clients on the
non-availability in pharmacies and chemists of sublingual tablets as compared
to injectable buprenorphine in 0.3 and 0.6 mg doses is a matter of serious
concern.
Research prior to development
of the intervention showed that buprenorphine was available in sublingual form
although far less easily than injectables. Literature review also showed that
buprenorphine maintenance "reduces illicit opioid use, suppresses
withdrawal symptomatology and retains clients in treatment in a manner
comparable to methadone, providing an additional pharmaco-therapeutic tool to
treat opioid addiction".
More specifically, buprenorphine:
·
has been demonstrated to be acceptable to heroin
addicts (Kosten et al 1993; Johnson, Jaffe & Fudala 1992; Fudala et al
1990; Jasinski, Pevnick & Griffith 1978);
·
had few side effects (Lange et al, 1990);
·
blocked the effects of subsequently administered doses
of morphine (Bickel et al 1988; Pevnick & Griffith, 1978);
·
binds tightly to the opioid receptors (Lewis 1985; Neil
1984);
·
significantly diminishes the self administration of
heroin (Mello, Mendelson & Kuehnle, 1982; Mello & Mendelson, 1980).
The Programme
In India few treatment
services address the issue of IDU, the main focus being 'abstinence' and the 12
step NA Recovery programme for voluntary agencies and 'detoxification' for
medical institutions. The SHARAN programme
had already established contact with drug users and the community through
periodic detoxification camps and later through AIDS awareness programmes that
discussed the dangers of needle sharing.
It was in the detoxification camps that the spread of injecting was
documented and the need for substitution of injectables with sublingual
medication was subsequently addressed.
Beginning in early '93 as an
outreach and street delivery system, the programme encouraged discussion of
substances being used and included focus group discussions on 'topping
up'. Dosage of substitute medication
was open to negotiation and the opinion of the clients was continually taken
into consideration. Having received a
positive response from the clients and the community in the pilot phase, we
began to expand the reach from 30 to reach a target of 300. Feedback of some clients on withdrawals due
to low dosages was accepted and, following a literature review, an increase in
dosing up to 8 mg commenced. The
medical officer associated with the programme relied on feedback and opinion of
outreach staff when prescribing.
The focus of the programme, a
drop in centre proving a non judgmental and safe environment was opened in the
slum most affected by drug dependency which was also a major drug dealing and using
area. A doctor visits the centre thrice
weekly providing wider health treatments such as TB and this was also made
available to family members of clients.
Open 12 hours daily, the centre provides the following:
·
Oral substitution therapy
·
Medical Services
·
Specialist health care referrals
·
Individual and Family Counselling
·
Detoxification through structured reduction of doses as
well as in detoxification camps
·
Health education
·
Drug awareness programmes
·
HIV/AIDS education (safe sex and drug use)
·
HIV pre & post test counselling
·
Free needles/syringes
·
Free condoms and regular condom use demonstrations
·
Recreational facilities (indoor games)
·
Outreach support
·
Weekly client group discussions
·
Peer educator sessions
·
Home/community based detoxification
Results
From February 1995 till
January 1997 the programme has serviced 1320 clients of whom 315 regularly
attend the drop in centre. 447 (34%)
clients are IDUs injecting buprenorphine and cocktails, and 873 (66%) are heroin
chasers and/or occasional IDUs. Out of
447 IDUs, 148 (33%) have stopped injecting while 158 (35%) have reduced the
frequency of injecting and sharing of equipment. Hence, a positive impact has been made on 306 (68%) of the IDUs. Retention on the programme is more for older
clients with a longer history of drug use and few detoxification attempts and
in treatment clients frequently opt for detoxification/rehabilitation services,
indicating a compatibility with other treatment methodologies.
Of clinical pharmacological
relevance, we found that sublingually 2 to 6 mg buprenorphine was an effective
dose for maintenance of IDUs using up to 3 mg buprenorphine daily and heroin
inhalers using up to 2 gms per day.
The heroin smokers suffered minimal discomfort in the switch from heroin
to buprenorphine, while IDUs injecting buprenorphine cocktails reported a short
period of anxiety before adjustment to sublingual. This maintenance dose is significantly lower than in reported
clinical experiments where doses of upon to 16 mg have had the best results,
and may be due to differences in client population profile.
Discussion
This intervention appears to
impact severely stigmatised, criminalised (under the Narcotics Drugs and
Psychotropic Substance Act 1985) and under served opioid users who have little
or no access to treatment. Although
buprenorphine is 1.5 the price dose for does of heroin, it is till too
expensive to be sustainable as a substitution therapy in developing countries. However, there is still a considerable cost
effective factor when considerations of public health and criminalisation are
taken into account. Further, initiation
and retention rates on the programme are high especially when compared with
other treatment modalities.
Reports and informal
assessments done in Bombay, Madras, Calcutta and Delhi indicate that the
profile of clients on the SHARAN programme tallies with the all India client
profile excepting that of the North Eastern States of Manipur, Mizoran and
Nagaland. Over 95% are males from the
lower socio-economic strata with little or no education, live in unsanitary,
overcrowded conditions, suffer from respiratory conditions, have little HIV
risk perception and are earning members of their families.
Self medication incorporating
the injecting of crushed and partially soluble capsules of dextroproproxyphene
in the North Eastern States has become prevalent due to pricing and no
availability of heroin. Such
substitution behaviour raises serious questions about uninformed legislation
that affects the availability of buprenorphine for currently dependent
populations. Inversely, sublingual
buprenorphine substitution could well be can appropriate treatment to address
hazardous self medication/substitution and injecting behaviours in the North
Eastern States.
Conclusions
·
Programmes using a similar methodology of buprenorphine
substitution are attractive and acceptable to out of treatment opioid dependent
populations.
·
The immense need of the development and replication of
the programme in the Indian subcontinent (Eicher, 1996 pp 66-67). to this effect evaluation of the cost
effectiveness of sublingual buprenorphine therapy and the need for higher (2 mg
to 4 mg ) than the present 0.2 mg doses is necessary.
·
The alarming health risks including increased frequency
of injecting episodes, swollen limbs which become gangrenous leading to
amputation, occluded veins and the rapid deterioration in venous architecture,
associated with self substitution of dextroproproxyphene in the Northwest
(Eicher, 1996, pp 52-58) need to be considered and harm reduction efforts in
this area are imperative.
·
Sustainability
of similar programmes is a key question especially in the context of
behaviour change interventions and the need for such interventions to be
considered on a long term basis is crucial to its success.
·
The promotion of an alternative behaviours against one
off intervention depends on:
1. Political
commitment based on evaluation of the public health gains and
decriminalisation;
2. the
cost effectiveness factor in terms of higher does preparation, thereby reducing
cost;
3. regular
and widespread availability of sublingual tablets.
This paper was written by Jimmy Dorabjee and Luke J Samson
Acknowledgement
This programme has been made
possible with financial assistance from The Commission of the European
Communities. The view expressed in this
paper are those of the authors and do not represent any official view of the
Commission.
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