COVID-19 outbreak: Challenges for Addiction services in India.

In a very short span of time, COVID-19 has taken the form of a pandemic, affecting countries globally. Europe and North America have become the new epicentre of the pandemic and SARS-CoV-2 is expected to rapidly expand in regions relatively unaffected until now (Bedford et al., 2020). The first COVID-19 case in India was identified in January end, and after a quiet phase numbers are now rising exponentially (Anon, 2020). As a containment strategy, the government opted for a three week nationwide lockdown, closing all non-essential services and instructing citizens to ‘self-quarantine’ themselves inside their houses. While a nationwide lockdown presents several difficulties, I would like to outline the potential challenges expected in managing patients with substance use disorders (SUDs) under such circumstances in India.

Firstly, pneumonia is one of the severe presentations of SARS-CoV-2 and is responsible for the majority of admissions to intensive care (Zhou et al., 2020). The study also found that patients with comorbidities (e.g. hypertension, diabetes, coronary heart diseases) had worse outcomes. Smoking cigarettes/bidis, hookah smoking and vaping are known risk factors for compromised lung functions and opioid use can lead to respiratory depression and hypoxia. In addition, SUDs are associated with a wide range of physical comorbidities. Pre-existing lung conditions and co-occurring comorbidities in SUDs may increase the risk of complications due to SARS-CoV-2 infection, thus increasing the likelihood of poor outcomes when compared to the general population (Volkow, 2020). Furthermore, India has a significant population of hookah smokers and betelnut users which could be a potential risk in community spread of COVID-19.

Secondly, with the nationwide lockdown health care facilities have become much more difficult to access for people with SUDs, particularly for vulnerable populations (adolescents, females and older adults). A significant number of service users are from socioeconomically disadvantaged backgrounds and the lack of availability of public transport will become a major obstacle to reach treatment centres. This is particularly concerning for patients who are on daily prescriptions of opioid substitution therapy. During the initial two days of lockdown, I came across several patients who travelled 15−20 km each way by foot to obtain their methadone doses. Even for those who can manage to reach treatment centres, there remains a constant threat of harassment or physical assault by authorities responsible for ensuring complete lockdown. Furthermore, strict implementation of government policies will make it very difficult for the family members to accompany patients, hence limiting psychosocial interventions.

Thirdly, lockdown will result in closure of licensed liquor shops, leading to several adverse outcomes. Due to the lack of availability of liquor, alcohol users may shift to country/homemade liquor, which can cause severe health related complications (including death) or they may end up in complicated alcohol withdrawal due to forced abstinence. A previous study from India has reported increased presentation of complicated alcohol withdrawal cases due to forced abstinence caused by liquor ban during elections (Narasimha et al., 2018). Complicated alcohol withdrawal will likely present as altered behaviour, and unreliable history with uncertain COVID-19 status will pose a management challenge for emergency health workers. Furthermore, closure of treatment centres due to lockdown will significantly increase the workload on those treatment centres remaining open. Confusion around COVID-19 status and overloading of existing services will likely result in substandard care and poor outcomes as compared to usual settings.

Fourthly, there is no clarity regarding the running of opioid substitution treatment centres. In response to the unforeseen circumstances, flexible dosing of buprenorphine (take home doses for 1–2 weeks) and methadone (biweekly refill, in some exceptional cases for 5 days) has been suggested (personal communication with National Drug Dependence Treatment Centre, March 25, 2020). This will help in improving their treatment compliance as well reduce the number of visits during the lockdown. However, since the introduction of methadone in 2015 in India, there is no experience with take home or flexible doses (Ambekar et al., 2018). COVID-19 spread and the associated lockdown can give rise to psychological distress in patients with SUDs, who in turn are likely to take higher doses of methadone available to them as a coping strategy. Thus, there are chances that patients may overdose or mix several drugs available to them. The situation gets further complicated as naloxone is scarcely available and there is no provision of take home naloxone in India.

Fifthly, telehealth/online services has been projected as one of the promising approaches for health service delivery during the COVID-19 pandemic (Yao et al., 2020). Indian psychiatric society (IPS) and numerous other institutes have started reaching out to patients via telehealth services. While such initiatives are praiseworthy, there are concerns regarding feasibility and acceptability of such approaches for those with SUDs in Indian Settings. Most treatment centres lack dedicated helplines, as well as workforce trained in delivering such services. In addition, patients are not used to services delivered through helplines or online and may fail to utilise such services adequately.

Sixthly, closure of rehabilitation centres due to lockdown has resulted in patients being discharged prematurely. Patients with SUDs who have been partially treated are at higher risk of relapse, or overdosing themselves. Further challenging circumstances are expected once situation improves and lockdown is called off. In the aftermath of the crisis, people are likely to seek more drugs and relapse. Unfortunately during those times, rather than upscaling of SUD services to meet extra demand, these services are likely to be subjected to significantly reduced funding due to crisis, limiting their availability and provisions.

The COVID-19 pandemic is having a profound effect on the health services globally. For people with SUDs, accessing treatment services has become more difficult. World over including India, there is an urgent need for treatment services to adapt to daily changing scenarios with emphasis on practical approaches to help people with SUDs. Relevant national organisations need to formulate strategies to overcome the obstacles posed by COVID 19 pandemic so as to ensure seamless treatment services are available to people with SUDs.

Financial disclosure

Nothing to disclose.

Declaration of Competing Interest

None.