Ravindra Rao

Psychiatric morbidity in HIV-infected children

Abstract After the introduction of antiretroviral therapy, HIV infection in children has been transformed from an acute to a chronic illness. The number of HIV-infected children has also increased in recent years. The routes of transmission and clinical manifestation of HIV infection in children are unique and different from those of adults. There are a number of biological, psychological and social factors associated with HIV-infected child that may predispose him/her to develop psychiatric illness. However, there are very few studies on psychiatric morbidity in HIV-infected children. In the existing studies, a number of psychiatric illnesses including: depression, anxiety, disruptive disorders and hyperactive disorders have been observed in HIV-infected children. A number of variables have a bearing on psychiatric morbidity, including experience and expression of physical illness as well as adherence to medications. The physician dealing with HIV-infected children should be aware of the psychological manifestations so that appropriate interventions and referral may be made as needed.

Baclofen-Induced Psychosis

Objective: To report a case of psychosis induced by therapeutic doses of baclofen. Case Summary: A 32-year-old Hindu man was prescribed oral baclofen 10 mg twice daily for relief of muscular spasms secondary to tetanus. After 4 weeks of baclofen use, he presented to the psychiatry emergency facility with a 4 day history of third-person auditory hallucinations and persecutory and referential delusions without underlying mood symptoms. These symptoms resolved within 1 week of discontinuing baclofen. Rechallenge with baclofen resulted in reemergence of psychotic symptoms, which disappeared after discontinuing baclofen. Discussion: Reemergence of psychotic symptoms after rechallenge with baclofen suggests baclofen-induced psychosis. Use of the Naranjo probability scale indicates a probable association of baclofen with this patients psychosis. The absence of underlying mood disorder makes this case different from previously reported ones. Conclusions: Baclofen may be associated with the occurrence of psychosis. Clinicians should consider baclofen-induced psychosis as a differential diagnosis in patients presenting with psychosis during treatment with this drug.

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.

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.

Opioid maintenance therapy with slow release oral morphine: Experience from India

It is well known that opiate dependence is a chronic relapsing disorder and pharmacological treatment often has to be continued beyond the phase of detoxification to maintain abstinence. The focus of this maintenance treatment phase is to reduce/eliminate drug use, restore socio-occupational functioning and reduce risk-taking behaviour. Substitution on an agonist agent is a well accepted treatment strategy for the maintenance phase of treatment. Over decades, it has been proved that methadone is an effective agonist agent to treat opioid dependent patients and improve their functioning (Ward, Mattick, & Hall, 1994). The alternative agent for agonist maintenance is buprenorphine, a partial m agonist (Johnson et al., 2000). In India, methadone is not available and buprenorphine has been used as a maintenance drug in a few treatment centres. It is thought that if an economical alternative is available, it may be possible to have agonist maintenance available on a wider scale. Thus, the need for an agonist which is cheaper with a wide range of acceptability and long duration of action has been felt. Slow release oral morphine (SROM), a natural derivative of opium and a m receptor agonist, is relatively cheap with long duration of action. The pharmacokinetics of SROM shows that it can be conveniently administered as a once a day preparation (Maccarone, West, Broomhead, & Hodsman, 1994). It is being used as a pain-relieving agent in cases of patients suffering from cancer (Gourlay et al., 1997). SROM has been used as a maintenance agent in methadone intolerant individuals dependent on opioid with favourable results in countries such as the UK, Austria and Australia (Brewer, 1995; Eder et al., 2002; Fischer et al., 1999; Kraigher, Ortner, Eder, Schindler, & Fischer, 2002; Sherman, 1996). However, these studies were conducted in few countries and need replication across various centres. We hereby report our experience with sustained release morphine as an agonist maintenance drug in a community treatment centre in Delhi, India. Patients who fulfilled the criteria for opioid dependence syndrome and were willing to visit the centre daily were administered SROM after obtaining informed consent. Thus, a total of 74 patients were started on SROM. Out of these 74 patients, 33 patients (45%) regularly followed up in the clinic for 4 weeks and more. These 33 patients were interviewed by the third author to record their experience with SROM. A semi-structured Performa was used to collect the information. The details of drug use before the start of maintenance treatment as well as the details of the dose and duration of SROM were collected from the record files of the patients. The mean age of the 33 patients was 39 years with an age range of 22–55 years. Most (51.0%, n 5 17) were in the age range of 31–40 years. All the patients were males. About 54.5% (n 5 18) of the patients were married and 60.0% (n 5 20) had received formal education. The majority of the patients were unskilled workers (63.6%, n 5 21). Journal of Substance Use, October 2005; 10(5): 259–261

Biochemical measures in the diagnosis of alcohol dependence using discriminant analysis

BACKGROUND Alcohol dependence often cannot be diagnosed based on self-report alone. Various biochemical and haematological parameters have been used to screen alcohol use disorders. AIM To develop discriminant equations based on lipid and liver measures independently for identifying alcohol dependent and non-dependent subjects. SETTINGS AND DESIGN Case control study in a tertiary care hospital. METHODS AND MATERIALS One hundred subjects fulfilling the criteria of alcohol dependence and seventy healthy controls were included. The socio-demographic details, caloric intake, height, weight and blood pressure were recorded. Samples were analysed for various lipid measures as well as liver function. STATISTICAL ANALYSIS USED Diagnostic values such as sensitivity, specificity, positive predictive value (PV+), negative predictive value (PV-) and discriminant analysis. RESULTS Using discriminant analysis, two equations were constructed based on liver and lipid measures independently. 84.7% of the subjects on the basis of total cholesterol (TC), apolipoprotein B (ApoB) and low density lipoprotein/high density lipoprotein-cholesterol (LDL/HDL-c and 89.1% on the basis of aspartate amino transferase (AST) and gamma glutamyl transferase (GGT) were correctly classified into their respective groups. CONCLUSIONS This study demonstrates the ability of TC, ApoB and LDL/HDL-c (among lipid measures) and AST and GGT (among liver measures) in discriminating alcohol dependents from non-dependent subjects.

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.

Pattern of Drug Use and Associated Behaviors Among Female Injecting Drug Users From Northeast India: A Multi-Centric, Cross-Sectional, Comparative Study

Background: Studies from developed countries document the presence of injecting drug use among females and significantly higher vulnerabilities and risks as compared with male injecting drug users (IDUs). Studies comparing vulnerabilities and drug use patterns between female and male IDUs are not available for developing countries. Objectives: The aim of the study was to assess the drug use pattern and related HIV vulnerabilities among female IDUs and compare these findings with those from male IDUs from four states of Northeast India. Method: The study used data collected as part of a nationwide study of drug use pattern and related HIV vulnerabilities among IDUs. Ninety-eight female and 202 male IDUs accessing services from harm reduction sites across the four states of Northeast region of India were chosen through random sampling methodology. Drug use pattern, injecting practices, and knowledge of HIV were assessed using a structured questionnaire. Results: Significantly higher proportion of female IDUs was uneducated, unemployed, reported their occupation as sex workers, and switched to injecting drug use faster as compared with male IDUs. Female IDUs practicing sex work differed significantly from those who did not with respect to frequency of daily injections, choice of drugs injected, and concomitant use of non-injecting drugs. More than half of female IDUs initiated sharing within the first month of injecting. Conclusions: The study demonstrates that female IDUs differ from male IDUs in their drug use pattern, initiation into injection as well as injecting behavior, which would be an important consideration during designing of female-specific interventions.

The Journey of Opioid Substitution Therapy in India: Achievements and Challenges

Opioids are one of the most problematic illegal substances globally. Opioid abuse is associated with complications in various spheres of the users life, his/her family, and the society. Injecting drug use (IDU) is also linked to public health problems such as HIV infection and viral hepatitis. Medications form an important cornerstone in the treatment of opioid dependence. Treatment strategies such as “detoxification” alone or long-term treatment with opioid antagonist have limited acceptability and retention rates. Opioid substitution therapy (OST) has demonstrated better retention rates than other existing treatment strategies and helps improve the individuals functioning as well as his/her quality of life. The use of OST in India spans three decades, with initial use of low-dose buprenorphine followed by higher strength buprenorphine and buprenorphine-naloxone. Other medications such as slow-release oral morphine, and recently, methadone have also been introduced. Indian research also confirms the findings from Western literature on the effectiveness as well as acceptability of this treatment modality. OST received its biggest thrust when it became a part of the National AIDS Control Programme. In recent years, the number of OST centers in India has increased manifold. Practice guidelines, standard operating procedures, and capacity-building mechanisms have been put in place for effective OST implementation. Despite such widespread use, many challenges exist for OST implementation. The targets for ensuring adequate coverage of the population with this treatment are still far away. There is concern of OST being branded as a “harm reduction” intervention reserved only for injecting drug users. Despite three decades of advancements, certain sections of policymakers and practitioners still have reservations with this treatment modality. There is a need to overcome these barriers for OST to become easily accessible to those who need it.