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Experiential account: experience as a private
practitionerDr. Ashwin Mohan
M.D. Psychiatry (PGI)Chandigarh
Presented at the national CME "OST: Policy and Practice" on 18th-19th April 2015 at AIIMS, New Delhi
The Facts Completed MD in 2000 Practice since 2001 OPD set up mainly; Attachment to Multi specialty
hospitals for admission
Presented at the national CME "OST: Policy and Practice" on 18th-19th April 2015 at AIIMS, New Delhi
Senior Residency in DDTC, PGI for one yearMultiple relapses and admissions of patientsProblems in controlling withdrawalPoor follow up and compliance to naltrexoneExtremely frustrating for the treatment provider, patient and the familymember and very limited options available
First exposure to OST in PGI Chandigarh underguidance of Dr. D. Basu
Patient was heroin user for 18 years including IV use and was admitted for third time in DDTC, PGI and was put on OST even after discharge. He continues to be relapse
free till date
Presented at the national CME "OST: Policy and Practice" on 18th-19th April 2015 at AIIMS, New Delhi
The Beginning: First 4 years – only 3 patients on OST; good follow up
and no relapse Around 2005: scaling up started after multiple failures
using traditional treatment methods, both OPD and inpatient.
In this initial period: used for detoxification and short term maintenance – few weeks to about three months
Selectively in patients of IV use and multiple relapses
Presented at the national CME "OST: Policy and Practice" on 18th-19th April 2015 at AIIMS, New Delhi
The Journey:
Relapse rates were still high with short term use With more experience: After evaluation and clinical
need, increase in doses and duration of treatment-initially used 2-8 mg/d for detoxification and tapered off on follow up after a few months
Mainly used plain BPN and not FDC of BPN/NLX
Presented at the national CME "OST: Policy and Practice" on 18th-19th April 2015 at AIIMS, New Delhi
The Journey: Encouraging results and positive feedback.
.. “to hell and back” is how most patients describe their journey
Shifted from detoxification and short term maintenance to long term maintenance therapy while monitoring the patients functioning and drug history
Patients were educated beforehand about the rationale for the therapy as well as need of the longer term therapy
Presented at the national CME "OST: Policy and Practice" on 18th-19th April 2015 at AIIMS, New Delhi
The journey: Progressive increase in number of patients as word
spread- availability of treatment without need for admission, smooth withdrawal, improved functionality, less relapse rates and less legal problems
Since last 10 years – treated approx. many thousands of patients, both with short term and maintenance treatment using BPN
High patient numbers - a reflection of the high degree and decades of drug abuse in the catchment region
Presented at the national CME "OST: Policy and Practice" on 18th-19th April 2015 at AIIMS, New Delhi
The logistics Private Clinic- limited space and infrastructure and
resources Initially dispensed on my own but kept additional staff
later on as number increased Consultation : specified number of tablets and written
(and later stamped) on prescription; patient would enter his name, address and
phone number and sign in the designated register No reports of abuse or diversion, esp. in the initial
years and no reports of patients injecting sublingual BPN after crushing.
Presented at the national CME "OST: Policy and Practice" on 18th-19th April 2015 at AIIMS, New Delhi
Patient Profile: Majority (75%)- poppy husk, opium and heroin
Remainder (25%)- CCCS, dextropropoxyphene, diphenoxylate and IV Buprenorphine and pentazocine
Most from Punjab; followed by Haryana and Rajasthan. Lesser number of patients from Delhi, Himachal, Gujarat and Maharashtra
Mostly males, age range from 18-90 years. Duration of use ranged from few months to 70 years of use Both rural and urban background
Presented at the national CME "OST: Policy and Practice" on 18th-19th April 2015 at AIIMS, New Delhi
Starting treatment: Opioid dependent patients suffer from multiple
misconceptions and fears re using, treatment and withdrawal- need to allay fears
Prevention of precipitated withdrawal –key to treatment success
Logistical issues- difficult to start treatment under observation; problem overcome by ensuring adequate time gap
Developed my own method- instructed patients to stop using all opioids by 4 pm and start treatment next morning- a gap of about 12-16 hours
Presented at the national CME "OST: Policy and Practice" on 18th-19th April 2015 at AIIMS, New Delhi
Starting treatment: Time gap - strict rule to be followed; most adhered except
heroin users Day 1 of treatment - start low dose as withdrawals start and
increase, as instructed, within a few hours Most experienced smooth and painless withdrawal Those with more severe withdrawal – managed with
reassurance and dose titration, depending on symptoms Was accessible and available. Most settled within 6-8 hours Less than 1% admitted; most treated on OPD basis No major complications; no fatalities
Presented at the national CME "OST: Policy and Practice" on 18th-19th April 2015 at AIIMS, New Delhi
The doses and duration:DOSE Initiation phase: 2 mg/d to 24 mg/d, rarely upto 30 mg/d Stabilization phase: 2 mg/d to 16 mg/d Maintenance phase: 0.4 to 12 mg/d
DURATION A few weeks to many years Functionality, and control of craving were key
“ how well the patient was doing” Decision collaborative and not unilateral- to increase
abstinence ratesPresented at the national CME "OST: Policy and Practice" on 18th-19th April 2015 at AIIMS, New Delhi
Termination or …… People often ask – “do you ever stop Buprenorphine”
The answer is YES.Substance Dependence is a chronic, relapsing medical
illness. Maintenance treatments are used for a large number of medical and psychiatric disorders- Do we Question them so vehemently.
Can categorize the patients in the following :• The most important- majority follow up and reduce the
dose of medication under medical supervision and eventually stop and many remain relapse free.
Able to manage without any sort of treatment later
Presented at the national CME "OST: Policy and Practice" on 18th-19th April 2015 at AIIMS, New Delhi
The other categories Those who use it to facilitate treatment for short term
withdrawal and then stop using Bpn Those using it for longer periods of time for months and then
gradually taper off on their own and don’t follow up Those who continue to use relatively higher doses and maintain
well on that so as to control craving Those tapering it off to as low as 0.4 mg and continue using it as
a form of psychological support in order not to get back to using. Those using Bpn intermittently and shift from using to
abstinence Those using bpn on an sos basis Those who start but don’t find complete benefit so they seesaw
between treatments Those who take higher doses and want to reduce but are unable
to do so despite multiple attempts as withdrawal is painful for them – least common
Categories not mutually exclusivePresented at the national CME "OST: Policy and Practice" on 18th-19th April 2015 at AIIMS, New Delhi
The crisis: March 2014, before General Elections - Tightened controls,
forces deployed, trans border and cross border vigilance increased
Politics to the fore with blame games, accusations and counter accusations
Sudden crackdown without adequate treatment infrastructure in place - Gross underestimation of the problem by authorities
A massive tsunami of patients …thousands suddenly deprived of their fix, supply lines cut
Huge numbers registered in both govt. and private set ups LOGISTICAL NIGHTMARE Extraordinary problems with no clear solution
Presented at the national CME "OST: Policy and Practice" on 18th-19th April 2015 at AIIMS, New Delhi
The crisis: Unparalled environment of FEAR, PERSECUTION and
PROSECUTION prevailed Cases registered against patients; threats and coercion;
people forced to go for treatment Chemists raided….medication availability virtually
stopped in some districts Psychiatrists were overwhelmed, both govt. and
private sectors…most places were not equipped to deal with the situation
Presented at the national CME "OST: Policy and Practice" on 18th-19th April 2015 at AIIMS, New Delhi
Psychiatry’s dilemma Harm reduction: deeply polarizing issue - No consensus,
Emotive issue, Sharp divisions. Fraternity itself plays negative role in damning and demeaning Harm Reduction.
Issues of Diversion and Abuse cropped up and selective feeding by enforcement agencies fuelled this issue; blown out of proportion relative to benefits of the medication
Also provided a welcome distraction from the “real issue” at hand- decades of facilitation and poor enforcement and narco-money used for funding political ambitions
Psychiatrists inspected, persecuted and prosecuted to no end; Blamed for the whole situation as if they were the ones responsible for its creation
Presented at the national CME "OST: Policy and Practice" on 18th-19th April 2015 at AIIMS, New Delhi
The crisis: Diversion occurred during this period : reason was
huge Demand – Supply gap between number of patients and treatment services, and irrational restriction of medication availability
More a case of ‘para-prescribing and ‘unobserved treatment’ and hoarding by panic stricken patients
Vicious media campaign started against OST modality and psychiatrists practicing it
Presented at the national CME "OST: Policy and Practice" on 18th-19th April 2015 at AIIMS, New Delhi
The crisis: Psychiatrists esp. private sector equated to drug
peddlers and blamed for diversion Govt. supply reduced further and even govt.
psychiatrists threatened..restricted to inpatient use Apart from BPN, even tramadol use was severely
restricted Convoluted, irrational and unscientific cobweb of
rules, policies and laws invoked to prosecute psychiatrists
Presented at the national CME "OST: Policy and Practice" on 18th-19th April 2015 at AIIMS, New Delhi
The result:“BUPRENORPHINE BECAME A GREAT MEDICATION WITH A BAD PRESS”
Psychiatrists stopped using BPN in many centres Those using it, reduced dispensing doses and duration
such that it was inadequate to control withdrawal/ craving No medication was available for treatment. In some
districts, even benzodiazepines were stopped There was an aversion towards treatment of opioid
dependence by doctors. Many did not want to treat themPresented at the national CME "OST: Policy and Practice" on 18th-19th April 2015 at AIIMS, New Delhi
The result Illicit drugs still available- cost increased to 2-4 times. Treatment avenues and modalities reduced. No medications to address the crucial issue of craving No maintenance treatments, naltrexone a failure. The number of addicts registering at centres show a dramatic
fall. This statistic has been used to “show success” of the campaign
Many patients either relapsed or flocked to Haryana and Rajasthan where treatment is still available
Newer Epidemics- IV heroin use increased dramatically; Tramadol and Tapentadol Dependence have emerged as the newer drugs of abuse
Presented at the national CME "OST: Policy and Practice" on 18th-19th April 2015 at AIIMS, New Delhi
My opinion- the way forward OST is a wonderful treatment - one of the best tools Use can reduce the demand for illicit drugs significantly The principle of harm reduction needs better
understanding, publicity and coverage. This is where we have failed miserably.
All psychiatrists by way of their qualification need to be allowed to use BPN and other treatments irrespective of the setting in which they practice- Govt. Hospital, Community health centres, Nursing homes or clinics. The setting should not matter
Checks and balances can be made - All psychiatrists desirous of using OST can be registered, if required, rather than persecuted.
Presented at the national CME "OST: Policy and Practice" on 18th-19th April 2015 at AIIMS, New Delhi
My opinion- the way forward Other treatment modalities like methadone should
also be widely available Urgent scaling up of services is the need of the hour There may also a case for opening up of low strength
poppy husk vends which can be taxed, with direct supply from Govt. factories and fixed quotas
Will take care of diversion to a large extent
Presented at the national CME "OST: Policy and Practice" on 18th-19th April 2015 at AIIMS, New Delhi
Conclusion Roller coaster ride with a current low as far as OST is
concerned Substance Dependence is treated with disdain and
repugnance; Need to change fraternity’s own approach to dependence
More patient friendly policies required All stakeholders need to be taken into confidence and
knee jerk reactions avoidedThough my experience can be described as
BITTER- SWEET, I continue to have faith in OST and remain a firm advocate of the same
Presented at the national CME "OST: Policy and Practice" on 18th-19th April 2015 at AIIMS, New Delhi