COVID-19 Pandemic and People Who Use Opioids in India: Opportunities and Evolutions.

The COVID-19 pandemic has caused an unprecedented impact across the globe. India is the second worst-hit country, with the highest single-day COVID-19 positive case spikes worldwide.[1] A comparative grid of policy measures implemented by countries to contain the spread of novel coronavirus shows that India has the strictest lockdown in the world.[2] The COVID-19 pandemic has affected all facets of our lives and every segment of society. Public healthcare has been underfunded in India and is among the lowest worldwide; just 1.29% of the country’s gross domestic product was earmarked for healthcare in 2019–2020, compared to a global average of 6%.[3] The healthcare sector further fell in the cataclysm, with many non-emergency services getting shut to prevent the spread of the contagion. However, this pandemic has also provided us with opportunities to revolutionize healthcare in India. We hereby discuss some potentially beneficial evolutions in the mental health care sector in India concerning the treatment for opioid use.

As per a recent national survey, 2.1% of people in India currently use opioids for recreational purposes. Almost 0.8 million use drugs via the intravenous route, commonest being the opioids (heroin or pharmaceutical opioids).[4] Though opioid substitution therapy (OST) has been available in India for many years, the major provider of OST is National AIDS Control Organization (NACO)-run OST centers that provide buprenorphine as a directly observed treatment to people who inject drugs (PWID), in the context of prevention of human immunodeficiency virus (HIV) infection .[5] However, those who do not inject drugs (and use them by other routes) are not eligible for OST at these centers. Recently, under the Drug De-Addiction Programme (DDAP) of the Government of India, “Drug Treatment Clinics” (DTC) were established in government hospitals, which also dispense OST (for all opioid use disorder [OUD] clients) along with treatment for other substance use disorders. However, the number of such clinics is limited.[6] Thus, there is a disharmony between the demand for drug treatment and the availability of services. As per the National Mental Health Survey 2016, the treatment gap for drug use disorders was 73%; the finding was reiterated by the recent national substance use survey.[4, 7] Thus, Indian clients with drug use disorders face big challenges.

Evidence suggests the possible negative impacts of COVID-19 on people who use opioids (PWUO), including a higher risk of contracting the infection (due to homelessness, poor nutrition, drug use in a group setting, overcrowding in prison settings where such patients are overrepresented, and so on), higher risk of morbidity and mortality associated with COVID-19 (because of associated medical comorbidities found among PWUO, such as HIV and acquired immunodeficiency syndrome (AIDS), hepatitis B and C, tuberculosis, chronic obstructive pulmonary disease, and other medical illnesses), and a higher risk of opioid overdose among PWID with comorbid COVID-19.[8-12] Disruptions were noted in the healthcare related to the treatment of PWUO due to the COVID-19 cases overburdening the health system or due to the COVID-19 response measures undertaken to limit the spread of the infection hindering other services.[13]

However, the COVID-19 pandemic led to the following structural and functional changes and propitious evolution in Indian mental health care related to PWUO, which might be beneficial to such patients even in the post-COVID-19 era:

At a time when healthcare services are affected severely in the country due to the pandemic, various OST centers provided continuous treatment and care to people with OUD. Many organizations, including the Indian Psychiatric Society, called for dispensing take-home OST for extended periods.[14] A paradigm shift was noted in the NACO OST strategy, where take-home dosing of buprenorphine for 7-14 days began for the first time.[15] Although methadone as an OST is used, as a directly observed treatment, only in selected centers of the country, the take-home of methadone (liquid) has been initiated, too.

The NACO has implemented doorstep delivery of medications for select clients during the COVID-19 pandemic. This may become an important tool for successful outreach to clients who face difficulty in accessing treatment due to any reason.

A welcome change has been the use of an online platform for the training of the OST doctors for the treatment of substance use disorders (the first author was directly involved in providing training to more than 600 NACO OST centers’ doctors and other health professionals in April 2020).[16] The treatment for OUD in NACO OST centers and DTCs is provided by medical officers, who are usually medical graduates (with MBBS). Questions have been raised about the effectiveness of the seven-day program for the training of these medical officers.[17] The use of online training methods may be an option, especially for the regular refresher training of the various staff involved in PWUO-related healthcare delivery.

Other commodities such as needles and syringes are also being provided for extended periods under the NACO’s harm reduction program.[15] The World Health Organization has emphasized physical distancing as an effective preventive measure for COVID-19.[18] All healthcare agencies also propagate this message to those who seek treatment. This may lead to PWID injecting drugs less in group settings and more in isolation, especially during times of lockdown. Even if PWID may use it in group settings, the reuse and sharing might become less likely in the background of extended distribution of needles and syringes. Finally, the travel restrictions and the provision of extended periods of commodities and medications may lead to less contact of PWID with their peers as compared to the pre-COVID-19 era.[19] Whether or not this may have any impact on the transmission of blood-borne viral infections needs to be seen.

Numerous web-based educative materials have been developed on an urgent basis. For example, the National Drug Dependence Treatment Centre of All India Institute of Medical Sciences, New Delhi, and the National Institute of Mental Health and Neuro-Sciences Digital Academy, Bengaluru, developed online training programs for health professionals on the management of OUDs, which can be accessed freely.[16, 20]

To address mental health issues, free mental health helplines have been initiated across the nation by various institutions and government bodies. The Ministry of Social Justice and Empowerment, Government of India, started a mental health rehabilitation helpline, Kiran, recently.[21] Most helplines deal with stress, anxiety, depression, and other general mental health issues. One study reported the comorbidity of depression, anxiety, and suicidality among PWID (injecting opioids primarily) to be as high as 61.9%, 41%, and 11.4%, respectively.[22] Thus, such mental health helplines may be helpful to PWUO with psychiatric comorbidities. Such helplines can provide emergency aid without delay and, hence, may also be a blessing for the family members of such individuals who may be distressed. Also, the helpline numbers and other details are widely disseminated during the COVID-19 era and are associated with a fruitful impact on help-seeking among people who use drugs; The National Drug De-Addiction helpline saw an unprecedented surge in the number of callers seeking help during the lockdown.[23] These helplines, which might be one of the non-stigmatizing modes of seeking help for such patients and family members, should be continued and strengthened further even in the post-COVID-19 era.

Finally, many professional organizations, including those working in the field of addiction medicine, have now shifted to online conferences and webinars. In low- and middle-income countries like India where training in addiction medicine during undergraduation and postgraduation is not up to the mark[17] and financial constraints severely limit the participation in international events, such a shift may prove beneficial to addiction medicine academics (especially trainees) who are under constrained circumstances.[24] Such academic events may provide an insight into the prevailing circumstance and become an important tool for training in addiction medicine.

Although many countries have included buprenorphine under prescription using telemedicine services, recent telemedicine guidelines of the Ministry of Health and Family Welfare, Government of India, prohibits prescribing drugs listed under the Narcotic Drugs and Psychotropic Substances (NDPS) Act, 1985, using telemedicine.[25] Thus, at a time when prominent researchers across the world laud telemedicine services, a barrier still exists in the Indian scenario.[26]

There are many challenges in India for PWUO. The OST coverage in India is inadequate. With the introduction of take-home buprenorphine, the number of PWUO seeking treatment may escalate. For developing countries like India, increasing the coverage of OST is of paramount importance. It seems that the COVID-19 pandemic may be a blessing in disguise to enhance the horizons of OST in India. The step is well received and as per our experience, appreciated by drug users of the country. On the one hand, this pandemic has created multiple challenges to PWUO[13]; on the other hand, glancing over the grim reality of PWUO in India, it has also introduced promising opportunities and propitious evolutions that should be further strengthened during the post-COVID-19 era.