Treatment experience for opioid use disorder during COVID-19 in India: Learning from patients.

The COVID-19 pandemic and its containment strategies have presented unique challenges to India's healthcare infrastructure. While a national lockdown initially resulted in the closure of all licensed liquor shops, it also made healthcare facilities dedicated to the treatment of substance use disorders challenging to access. Addiction treatment services have been functioning at limited capacity with a lack of consensus on operating procedures. In this article, we present actual case scenarios where lockdown affected substance use and the treatment process, and discuss the policy implications and considerations for both.

Introduction

In this time of universal crisis due to COVID-19, the world has been challenged in many ways, with the healthcare sector at the epicenter (Sheriff, 2020). India's response to the COVID-19 pandemic is one of the most stringent in the world—a total lockdown barring essential services. India also suspended all travel—domestic as well as international—as part of its lockdown (Chatterje, 2020). Sealing off state borders made accessibility of treatment services for substance use disorders difficult. Practitioners also anticipated consequent changes in the availability of psychoactive substances (both licit and illicit), especially since liquor shops were closed during the initial lockdown in India (Department of Excise; Narasimha, Shukla, Mukherjee, et al., 2020). As an addiction treatment center, we continued to provide outpatient services during the lockdown and encountered new challenges that our patients had to face in their treatment process due to the prevailing situation (Chick, 2020). We present a few cases of patients with substance use disorder at our center that we selected purposively, specifically looking at issues pertaining to supply of substances and access to treatment services.

Case descriptions

Case 1

A 45-year-old man presented for treatment of opioid use disorder about four years ago and had a history of heroin use for ten years. He was also using tobacco in a dependent manner and was consuming country-made alcohol (i.e., locally produced) about 3 to 4 times per month. He usually spent about (Indian Rupees) INR 350 per day on heroin, which was about a third of a gram of street heroin or smack, and about INR 70 on about 180 mL of alcohol. During the initial phase of lockdown, due to the sealing of state borders, he was unable to reach the center and began using heroin again. He reported that during the lockdown, the cost of heroin from the same peddler increased by about 10 to 20%, but the price of a bottle of alcohol increased by about three times. He continued to use the same amount of heroin as he had previously, as the availability of that drug was unchanged. But the patient did not use alcohol for the first few weeks due to unavailability. He reported that, compared to when many people could gather in one place, the heroin peddler now allowed only two people to come near his place of operation. The patient presented for reinstitution of treatment after a hiatus of more than three years and we prescribed him tramadol to manage opioid withdrawal symptoms.

Case 2

A 31-year-old man with a history of heroin use in a dependent pattern for 5 years came for treatment about a year ago. We prescribed him buprenorphine but he relapsed to heroin use after about a period of 1 year, and was taking one-fourth of a gram of heroin worth INR 300–320 per day. He reported abstaining from both heroin and alcohol for the first 2 or 3 weeks of lockdown due to their unavailability, but consumed these substances subsequently, as he began venturing out, looking for ways to find relief from cravings. He said that the cost of heroin remained largely the same, while the price of a bottle of alcohol was about 2.5 to 3 times what it was before the pandemic. When travel restrictions were relaxed, the patient came back for treatment for heroin dependence, and we prescribed him medications for the treatment of opioid withdrawal symptoms.

Case 3

A 31-year-old man with a family history of alcohol and opioid use came for treatment in March 2020 for the first time before the lockdown came into force. He had a history of alcohol use in a dependent pattern for six years, followed by opioid use in the form of injecting tablet buprenorphine and pheniramine in a dependent pattern. On presenting for treatment, he reported using the buprenorphine and pheniramine (a “set”) 2 to 3 times in a day and alcohol about 4 to 6 times a month. Before lockdown, he would purchase a “set” from a peddler for about INR 150–180 with an additional cost of INR 10 per syringe. He reported that a bottle of country-made liquor would cost INR 100–120 prior to the pandemic. He reported that during initial weeks of implementation of lockdown, the price for a “set” had increased to INR 200–250, and the following few weeks, fell back to the previous retail price. On the other hand, the price of country-made liquor had doubled before liquor shops were allowed to reopen. However, he denied any change in his pattern of substance use. We prescribed him tramadol, 400 mg per day.

Case 4

A 36-year-old man came in with a history of dependent use of heroin, by chasing route, for 12 years. He would use alcohol and cannabis about once a week when heroin was not available. He had been visiting our center for two years but his treatment was irregular. Before lockdown, he would spend INR 1200–1500 for a gram of heroin. He reported that he was not abstinent from opioids for even a single day during the lockdown, rather he informed the treatment team that he was getting heroin more easily because there were fewer people in queues and fewer policemen on patrol. He also remarked that there was no change to quantity and purity of the available heroin. However, during this time, he paid about three times the original price for the same amount of country-made liquor. We gave him tramadol to relieve withdrawal symptoms.

Discussion

These cases demonstrate that individuals with opioid dependence largely continued to get opioids from their peddlers at almost the same prices as before the pandemic, after a brief period of disruption in the supply chain. However, patients noted steep increases in the price of alcohol. This lends credence to the idea that because supply chains for illicit drugs are clandestine, they may work even during periods of lockdown. A steep price increase for licit substances (alcohol), while only a temporary change in the price of illicit substances (opioids) during this period, suggests that illicit supply chains can quickly increase their costs when legal supply routes are closed. Patients' descriptions also suggest that the illicit drug markets operated largely as before despite national lockdown. The World Drug Report, on the other hand, suggests that the trafficking of heroin to India, which happens mainly through the country's western borders, is likely to slow as individuals are unable to travel across borders (World Drug Report, 2020) In India, alcohol sales are controlled at the state level. While the initial federal lockdown led to the closure of licensed alcohol shops for about six weeks, states subsequently determined the availability and pricing of alcohol.

Travel and related restrictions meant patients could not easily or immediately seek treatment for opioid dependence. Also, when patients did come, we usually gave them tramadol for relief of withdrawal symptoms, because the initiation of buprenorphine from our center requires close monitoring, at least in the initial phase of treatment. Therefore, many patients may not be able to get suitable medications for opioid withdrawals. On the other hand, the risk of diversion remains if dispensing opioid agonist medications like buprenorphine is relaxed. Thus, future policies should consider ways to enhance our capability to provide medication-assisted treatment more easily to patients—who have constrained resources, transport, skills, or willingness to quit—through alternative methods of supervision (including electronic pillboxes or tele-supervision through video calls).

Other issues might have resulted in challenges for patients with opioid use disorders in this period, including increased risk of criminal charges due to increased policing, fear of contracting COVID 19 and transmitting it to family members, and stress due to occupational disruption and financial difficulties. Practitioners' cognizance of the current problems affecting those with substance use disorders is important so that effective treatment can be implemented and appraised (Arya & Gupta, 2020; Basu, Ghosh, Subodh, & Mattoo, 2020; Clay & Parker, 2020; SAMHSA, 2020).

CRediT authorship contribution statement

The authors express their heartfelt gratitude to the reviewers for their consideration and their valuable suggestions. These have been invaluable in the improvement of this manuscript. Best efforts have been made to incorporate the suggestions that have been provided.