Atul Ambekar

HIV prevention, treatment, and care services for people who inject drugs: a systematic review of global, regional, and national coverage

BACKGROUND Previous reviews have examined the existence of HIV prevention, treatment, and care services for injecting drug users (IDUs) worldwide, but they did not quantify the scale of coverage. We undertook a systematic review to estimate national, regional, and global coverage of HIV services in IDUs. METHODS We did a systematic search of peer-reviewed (Medline, BioMed Central), internet, and grey-literature databases for data published in 2004 or later. A multistage process of data requests and verification was undertaken, involving UN agencies and national experts. National data were obtained for the extent of provision of the following core interventions for IDUs: needle and syringe programmes (NSPs), opioid substitution therapy (OST) and other drug treatment, HIV testing and counselling, antiretroviral therapy (ART), and condom programmes. We calculated national, regional, and global coverage of NSPs, OST, and ART on the basis of available estimates of IDU population sizes. FINDINGS By 2009, NSPs had been implemented in 82 countries and OST in 70 countries; both interventions were available in 66 countries. Regional and national coverage varied substantially. Australasia (202 needle-syringes per IDU per year) had by far the greatest rate of needle-syringe distribution; Latin America and the Caribbean (0.3 needle-syringes per IDU per year), Middle East and north Africa (0.5 needle-syringes per IDU per year), and sub-Saharan Africa (0.1 needle-syringes per IDU per year) had the lowest rates. OST coverage varied from less than or equal to one recipient per 100 IDUs in central Asia, Latin America, and sub-Saharan Africa, to very high levels in western Europe (61 recipients per 100 IDUs). The number of IDUs receiving ART varied from less than one per 100 HIV-positive IDUs (Chile, Kenya, Pakistan, Russia, and Uzbekistan) to more than 100 per 100 HIV-positive IDUs in six European countries. Worldwide, an estimated two needle-syringes (range 1-4) were distributed per IDU per month, there were eight recipients (6-12) of OST per 100 IDUs, and four IDUs (range 2-18) received ART per 100 HIV-positive IDUs. INTERPRETATION Worldwide coverage of HIV prevention, treatment, and care services in IDU populations is very low. There is an urgent need to improve coverage of these services in this at-risk population. FUNDING UN Office on Drugs and Crime; Australian National Drug and Alcohol Research Centre, University of New South Wales; and Australian National Health and Medical Research Council.

Dopamine D2 receptor polymorphisms and susceptibility to alcohol dependence in Indian males: a preliminary study

BackgroundDopamine is an important neurotransmitter involved in reward mechanism in the brain and thereby influences development and relapse of alcohol dependence. The dopamine D2 receptor (DRD2) gene on chromosome 11 (q22-q23) has been found to be associated with increased alcohol consumption through mechanisms involving incentive salience attributions and craving in alcoholic patients. Therefore, we investigated the association of three single nucleotide polymorphisms (SNP) in DRD2 gene with alcohol dependence in the north Indian subjects.MethodsIn a retrospective analysis, genetic association of three polymorphisms from DRD2 gene with alcohol dependence was investigated using a case-control approach. Alcohol dependence was determined by DSM-IV criteria and a total of 90 alcoholics and 60 healthy unrelated age-matched control subjects were recruited. Odds ratio and confidence interval was calculated to determine risk conferred by a predisposing allele/genotype/haplotype. Logistic regression analysis was carried out to correlate various clinical parameters with genotypes, and to study pair-wise interactions between SNPs.ResultsThe study showed a significant association of -141C Ins allele and a trend of association of TaqI A1 allele of DRD2 with alcohol dependence. Haplotype with the predisposing -141C Ins and TaqI A1 alleles (-141C Ins-A-A1) seems to confer ≈ 2.5 times more risk to develop alcohol dependence.ConclusionsThe study provides preliminary insight into genetic risk to alcohol dependence in Indian males. Two polymorphisms namely, -141C Ins/Del and TaqI A in DRD2 gene may have clinical implications among Indian alcoholic subjects.

Sexual Dysfunction among Male Patients Receiving Buprenorphine and Naltrexone Maintenance Therapy for Opioid Dependence

INTRODUCTION Opioid-dependent men suffer from sexual dysfunctions in the short and long term. The medications used for long-term pharmacotherapy of opioid dependence also affect sexual functioning, though this has been a poorly investigated area so far. AIM To study the sexual dysfunction in opioid-dependent men receiving buprenorphine and naltrexone maintenance therapy. METHODS A semistructured questionnaire and Brief Male Sexual Functioning Inventory (BMFSI) was administered to a sample of 60 sexually active men, receiving buprenorphine (n = 30) and naltrexone (n = 30) maintenance therapy for opioid dependence. MAIN OUTCOME MEASURES Prevalence of premature ejaculation, erectile dysfunction, low sexual desire, weakness due to semen loss, and overall satisfaction. RESULTS About 83% of the men on buprenorphine and 90% on naltrexone reported at least one of the sexual dysfunction symptoms. The commonly reported dysfunctions were premature ejaculation (83% in buprenorphine and 87% in naltrexone), erectile dysfunction (43% in buprenorphine and 67% in naltrexone), and loss/reduction in sexual desire (33% in buprenorphine and 47% in naltrexone). On BMSFI however, there were no significant differences among both the groups. CONCLUSIONS Opioid dependence as well as its pharmacological treatment is associated with sexual dysfunctions, which has clinical implication. Future research should explore this further using biochemical analyses.

Gaming disorder: Its delineation as an important condition for diagnosis, management, and prevention

Online gaming has greatly increased in popularity in recent years, and with this has come a multiplicity of problems due to excessive involvement in gaming. Gaming disorder, both online and offline, has been defined for the first time in the draft of 11th revision of the International Classification of Diseases (ICD-11). National surveys have shown prevalence rates of gaming disorder/addiction of 10%–15% among young people in several Asian countries and of 1%–10% in their counterparts in some Western countries. Several diseases related to excessive gaming are now recognized, and clinics are being established to respond to individual, family, and community concerns, but many cases remain hidden. Gaming disorder shares many features with addictions due to psychoactive substances and with gambling disorder, and functional neuroimaging shows that similar areas of the brain are activated. Governments and health agencies worldwide are seeking for the effects of online gaming to be addressed, and for preventive approaches to be developed. Central to this effort is a need to delineate the nature of the problem, which is the purpose of the definitions in the draft of ICD-11.

Ketamine dependence in an anesthesiologist: an occupational hazard?

Substance abuse among medical professionals is a cause for concern. Certain psychotropic substances such as ketamine are at easy dispense to anesthesiologists increasing the likelihood of misuse and dependence and raise several issues including safety of patients. We discuss a case demonstrating ketamine dependence in an anesthesiologist from India. The reported psychotropic effects of ketamine ranged from dissociation and depersonalization to psychotic experiences. There was also development of significant tolerance to ketamine without prominent physical withdrawal symptoms and cyclical use of very high doses was observed. Issues related to management of health professionals are also discussed.

Delivery models of opioid agonist maintenance treatment in South Asia: a good beginning

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.

Type of opioids injected: does it matter? A multicentric cross-sectional study of people who inject drugs.

INTRODUCTION AND AIMS Injecting pharmaceutical opioids for non-medical purposes is a major concern globally. Though pharmaceutical opioids injection is reported in India, the exact proportion of people who inject drugs (PWID) using pharmaceutical opioids is unknown. The objectives of this study were to describe the various types of drugs that are injected by people in India and to analyse the differences between the commonly injected drugs. DESIGN AND METHODS A cross-sectional, multicentric study covering 22 harm-reduction sites from different regions of the country was conducted. First 50 subjects, chosen randomly from a list of PWIDs accessing services from each site and fulfilling study criteria, were interviewed using a structured questionnaire. Data from 902 male subjects are presented here. RESULTS Pharmaceutical opioid injectors (POI) accounted for 65% of PWIDs (buprenorphine: 30.8%, pentazocine: 21.8% and dextropropoxyphene: 11.9%). Heroin, injected by 34.3%, was prevalent in most states surveyed. Buprenorphine and pentazocine were not injected in the north-east region, whereas dextropropoxyphene was injected in the north-east alone. Univariate and multivariate logistic regression showed that, compared with heroin injectors, the POI group was more likely to consume alcohol and pharmaceutical opioids orally, inject frequently, share needle/syringes and develop injection-site complications. Among individual POIs, buprenorphine injectors had significantly higher proportion of subjects injecting frequently, sharing needle/syringes and developing local complications. Irrespective of the opioid type, majority of subjects were opioid dependent. DISCUSSION AND CONCLUSIONS Pharmaceutical opioids are the most common drugs injected in India currently and have greater injection-related risks and complications. Significant differences exist between different pharmaceutical opioids, which would be important considerations for interventions.

Web-based self-help intervention reduces alcohol consumption in both heavy-drinking and dependent alcohol users: A pilot study.

As part of a multicenter project supported by the World Health Organization, we developed a web-based intervention to reduce alcohol use and related problems. We evaluated the predictors of adherence to, and the outcomes of the intervention. Success was defined as a reduction in consumption to low risk levels or to <50% of the baseline levels of number of drinks. From the 32,401 people who accessed the site, 3389 registered and 929 completed the full Alcohol Use Disorders Identification Test (AUDIT), a necessary condition to be considered eligible to take part in the intervention. Based on their AUDIT scores, these participants were classified into: low risk users (LRU; n=319) harmful/hazardous users (HHU; n=298) or suggestive of dependence users (SDU; n=312). 29.1% of the registered users (LRU=42; HHU=90; SDU=82) completed the evaluation form at the end of the six-week period, and 63.5% reported low-risk drinking levels. We observed a significant reduction in alcohol consumption in the HHU (62.5%) and SDU (64.5%) groups in relation to baseline. One month after the intervention, in the follow-up, 94 users filled out the evaluation form, and their rate of success was similar to the one observed in the previous evaluation. Logistic regression analyses indicated that HHU participants presented higher adherence than LRU. Despite a relatively low adherence to the program, its good outcomes and low cost, as well as the high number of people that can be reached by a web-based intervention, suggest it has good cost-effectiveness.

The trajectory of methadone maintenance treatment in Nepal

There are about 28,500 people who inject drugs (PWID) in Nepal and HIV prevalence among this group is high. Nepal introduced harm reduction services for PWID much earlier than other countries in South Asia. Methadone maintenance treatment (MMT) was first introduced in Nepal in 1994. This initial small scale MMT programme was closed in 2002 but reopened in 2007 as an emergency HIV prevention response. It has since been scaled up to include three MMT clinics and continuation of MMT is supported by the Ministry of Home Affairs (MOHA; the nodal ministry for drug supply reduction activities) and has been endorsed in the recent National Narcotics policy. Pressure from drug user groups has also helped its reintroduction. Interestingly, these developments have taken place during a period of political instability in Nepal, with the help of strong advocacy from multiple stakeholders. The MMT programme has also had to face resistance from those who were running drug treatment centres. Despite overcoming such troubles, the MMT programme faces a number of challenges. Coverage of MMT is low and high-risk injecting and sexual behaviour among PWID continues. The finance for MMT is largely from external donors and these donations have become scarce with the current global economic problems. With a multitude of developmental challenges for Nepal, the position of MMT in the national priority list is uncertain. Ownership of the programme by government, a cost-effective national MMT scale up plan and rigorous monitoring of its implementation is needed.

Factors Affecting Drug Use During Incarceration: A Cross-Sectional Study of Opioid-Dependent Persons from India

INTRODUCTION Substance abuse and criminality share a complex relationship. The rates of substance use among the prisoners, and that of criminal acts among substance users in community setting are high. Data from South Asian countries, including from India are inadequate. This study aimed to assess the pattern of criminal acts among opioid-dependent subjects and their substance use pattern in the month before, during and after imprisonment. METHODS Using a cross-sectional study design and purposive sampling, opioid-dependent subjects (n=101) attending two community drug treatment clinics who have had any contact with the law were assessed using a specifically-designed tool to record criminal acts and substance use before, during and after last imprisonment. RESULTS Most subjects (93%) had committed illegal acts in their lifetime. Physical assault was the most common illegal act, while 23% reported selling drugs and 9% reported committing serious crimes. About 95% were arrested and 92% had spent time in police lockups. About 29% were arrested for drugs possession or drug use, and 3% of injecting drug users arrested for carrying injection equipment. About 85% had been imprisoned at least once, of whom 88% used psychoactive substances in the 1-month period before their last imprisonment. Opioids were the most common substances used daily (68%), followed by cannabis (34%) and alcohol (22%). Ninety-seven percent reported the availability of substances in prisons, and 65% also used substances during their last imprisonment. Cannabis (35%) was the most common substances used in prison followed by opioids (19%). Seventy-six percent used substances soon after prison release, and 13% of opioid users experienced opioid overdose soon after prison release. Use of cannabis, injecting drugs, and opioid use before imprisonment were predictors of substance use in prison. CONCLUSION Opioid-dependent people have various contacts with the law, including imprisonment. Many users are dependent on substances during prison-entry, which is an important reason for their continued substance use in prisons. There is a need to provide substance abuse treatment across all stages of criminal justice system.