2013/02/01 by Ravindra Rao, Alok Agrawal, Kunal Kishore +1
Medicine · #HIV, Drug Use, Sexual Risk #Opioid Use Disorder Treatment #HIV/AIDS Research and Interventions
paper · pdf · doi:10.2471/blt.12.111815
An estimated 6.5 to 13.2 million people with opioid dependence, representing more than half of the world’s estimated number, live in Asia.1 Although most people in Asia who are opioid dependent use heroin or opium, the use of pharmaceutical opioids, mainly through the injecting route, has raised concern in recent years.2 In South Asia – Bangladesh, Bhutan, India, the Maldives, Nepal, Pakistan and Sri Lanka – the estimated number of people who inject drugs illicitly ranges from 434 000 to 726 500. Of these people, from 34 500 to 135 500 are infected with the human immunodeficiency virus (HIV).3 Three countries in South Asia – Bangladesh, India and Nepal – have large numbers of people who inject drugs, many of whom are infected with HIV. In the Maldives, the population of people who inject drugs is also large.4 In response to the large burden of opioid injection, Bangladesh, India and Nepal have established needle and syringe programmes. In Bangladesh and India these programmes have been rapidly scaled up.2,5 However, this cannot be said for the use of opioid agonist maintenance treatment (alternatively known in South Asia as “opioid substitution therapy”), which is lagging far behind. This form of treatment for opioid dependence has been recognized as effective in preventing infection with HIV and in increasing adherence to antiretroviral treatment (ART); accordingly, it has been endorsed by different United Nations agencies, including the United Nations Office on Drugs and Crime (UNODC) and the World Health Organization (WHO).6–9 The two opioid agonists most commonly used to treat opioid dependence, buprenorphine and methadone, are on WHO’s model list of essential medicines.10 A WHO collaborative multi-country study has established the effectiveness of opioid agonist maintenance treatment in developing countries.11 Different delivery models have been implemented across the world, and studies have several positive outcomes, including reductions in drug use, injecting behaviour, incidence of HIV infection, criminality and drug overdose.12,13 Opioid agonist maintenance treatment has not yet been integrated into routine health care in South Asia, a term used in this paper to refer to the six countries represented by the UNODC’s Regional Office for South Asia: Bangladesh, Bhutan, India, the Maldives, Nepal and Sri Lanka. A global review in 2010 showed that opioid agonist maintenance treatment is available in India, the Maldives and Nepal.5 Bangladesh also initiated opioid agonist maintenance treatment in 2010.2,14 In our experience while working closely with these six South Asian countries and as revealed by a review of the published literature, only four of them – Bangladesh, India, the Maldives and Nepal – have implemented opioid agonist maintenance treatment. Coverage, however, has been abysmally low; according to the global review, the percentage of people injecting opioids who receive opioid agonist maintenance treatment is only 1 to 3%.5 Ensuring optimal coverage is vital to these countries’ efforts to maximize HIV prevention among people who inject opioids. In countries of South Asia, opioid dependence has been traditionally considered a psychosocial rather than a biopsychosocial problem. The conventional approach to reducing the demand for opioids has centred on prevention and abstinence and on short-term withdrawal management followed by psychosocial intervention or rehabilitation. A report published in 2000 documented different types of interventions in South Asia, from preventive education to placement in therapeutic communities.15 Long-term pharmacotherapy, which is the mainstay of treatment for opioid dependence, was not mentioned among them except for an anecdotal mention of a methadone maintenance treatment clinic in Nepal.15 Most interventions based on short-term treatment or rehabilitation are run by nongovernmental organizations (NGOs) with some support from the government. The concept of drug dependence as a chronic, relapsing condition requiring medical treatment is poorly understood, as reflected in the limited availability of treatment services or qualitative policy research studies on the subject.16 Equally misunderstood is the concept behind opioid agonist maintenance treatment, which involves administering narcotics or psychotropics for the long term. This lack of understanding is also manifested in the low availability of narcotics or psychotropics for the treatment of other chronic medical symptoms and conditions, such as pain in cancer patients.17 Another problem is that existing models based on the delivery of opioid agonist maintenance treatment through exclusive clinics, licensed pharmacies or office-based prescription, which are typical of high-income countries, cannot be directly applied in South Asia. The infrastructure, availability of health-care professionals and regulatory mechanisms for pharmacies and health-care practitioners in countries of this region seldom allow it. Through one of its projects, the United Nations Office on Drugs and Crime in South Asia has assisted most countries in developing models for the delivery of opioid agonist maintenance treatment. Although the models adopted by these countries have certain similarities, they differ in terms of setting, human resources for treatment delivery, and location of medical, psychosocial and outreach services for clients. In the following section we briefly present an overview of models – as case examples – adopted for the delivery of opioid agonist maintenance treatment in those four countries of South Asia where this intervention is in place.