1. Opioid Substitution Therapy (OST) 1

2. Hierarchy of Harm Reduction If injecting, assistance to stop injecting drugs Never start using drugs Even if using drugs, don’t inject If injecting, get assistance to stop injecting drugs If not able to stop injecting, don’t share If not able to stop sharing, ensure clean equipment before every use Never start using drugs Even if using drugs, don’t inject If injecting, get assistance to stop injecting drugs If not able to stop injecting, don’t share If not able to stop sharing, ensure clean equipment before every use 2 Contd…

3. If injecting, get assistance to stop injecting drugs Those who are motivated & want to stop drugs altogether Those who are motivated but are not able/willing to stop drugs altogether Detoxification / Rehabilitation Opioid Substitution Therapy Hierarchy of Harm Reduction 3

4. What is OST ? Defined as: Administration of daily dosage of opioid medicines with long-lasting effects to patients with opioid dependence under medical supervision (prescribed) 4

5. Philosophy of OST 5 An illicit, medically unsafe, short-acting, more addictive, opioid, taken by injecting route… is substituted with… … legal, safer, long-acting agonist medication of known purity and potency along with psychosocial rehabilitation

6. OST Under NACP III Is a medical intervention Includes following medicines: Buprenorphine (available in India) Methadone (soon to be available in India) Administration of buprenorphine sublingually (under the tongue); doses used in OST are not available in pharmacies Regulated under the Narcotics Drugs and Psychotropic Substances (NDPS) Act, can be dispensed only in approved centres OST is not currently available in all the TI NGOs 6

7. Benefits of OST 7

8. Injecting vs. OST High chances of HIV & other BBV Not prescribed medically Severe withdrawal symptoms High chances of overdose Craving 8 contd…

9. Why OST? ● Life of an IDU is chaotic ● Life revolves around drugs – procuring, using & recovering from its effects ● Hence, not able to focus on other activities, responsibilities ● Involved in illegal activities to procure drugs 9 Contd…

10. Why OST? 10 Contd…

11. Why OST? OST medicines have long period of action Help in breaking the chain of opioid use (shown in earlier slide) Dose is adjusted  no cravings or withdrawals  no high Patient able to focus on other areas of life because of stabilisation 11 Contd…

12. Why OST? Decreased violence Decreased demand for money Quality time spent Family Increased employment Increased productivity Less thefts/crime Responsible citizen Society 12

13. Process to Start Client on OST 13

14. OST: Basic Facts OST is given ONLY to those who use opioids and are dependent on them Those who are not dependent on opioids but are dependent on other drugs, do not benefit from OST Specific inclusion and exclusion criteria for OST Initiated only by a physician, after examination Patient has to visit the centre daily for receiving the dose, in front of the nurse OST medicine alone does not suffice: additional psychosocial counselling helps in increasing retention 14

15. Criteria for OST Inclusion Criteria Diagnosed case of opioid dependence with injecting drug > 18 years of age Attempted detoxification earlier Willing to provide informed consent Exclusion Criteria ● Severe medical illness ● Established history of severe side-effects to buprenorphine ● Unable/incapable of providing informed consent ● Concomitant use of other drug(s) 15

16. Steps to Initiate OST Detailed history-taking and physical examination by a doctor Assess the client to initiate OST Initiate OST after fulfilling inclusion and exclusion criteria Explain concept of OST to client 16 Contd…

17. Steps to Initiate OST Consent form signed by the client before starting OST Administration of medicines by nurse Daily attendance at clinic for receiving medicine (Daily Observed Treatment – DOT) Regular follow-up by doctor and nurse Regular psychosocial therapy with counsellor 17

18. Client on OST Also Requires… Psychosocial intervention: Information about treatment including dosage, duration, relapse, etc. Referrals to ICTC, TB, ART, etc. Motivational support Counselling for employment, harm reduction, etc. Family Support: Enhances retention of IDUs to treatment & improves their chances of staying away from drugs 18

19. Termination of Treatment Treatment continues till the client Is stabilized psychologically & socially Stops injecting (drugs) Starts working and being productive Duration of treatment Usually 9 to 12 months; some may require longer time to stabilize 19

20. OST Alone is not Enough… OST is a facility based program and should be provided in addition to: NSEP BCC General health care Linkages/referrals  ART  DOTS  ICTC, etc. 20

21. Myths About Substitution Treatment 21

22. Myth #1: Patients are Still Addicted Fact: Addiction is pathologic use of a substance and may or may not include physical dependence Physical dependence on a medication for treatment of a medical problem does not mean the person is engaging in pathologic use and other behaviours 22

23. Myth #2: Buprenorphine is Simply a Substitute for Illegal Drugs Fact: Buprenorphine is a replacement medication; it is not simply a substitute Buprenorphine is a legally prescribed medication, not illegally obtained Buprenorphine is a medication taken sublingually, a very safe route of administration Buprenorphine allows the person to function normally 23

24. Myth #3: Providing Medication Alone is Sufficient for Opioid Addiction Fact: Buprenorphine is an important treatment option. However, the complete treatment package must include other elements, as well Combining pharmaco-therapy with counselling and other ancillary services increases the likelihood of success 24

25. Role of Project Manager 25

26. Key Areas of Work Role of PM in OST-TIs: The PM is a key person in the OST team Co-ordinating and communicating with all stakeholders (clients, their families, staff, SACS, NACO, other service providers, local administration, law enforcement, media and the general community) Maintaining stock registers for buprenorphine Supervision of record maintenance Procurement & storage of buprenorphine 26 Contd…

27. Key Areas of Work Role of PM in TIs which do not have OST: Educate staff on the benefits of OST Liaise with centres providing OST Establish a system of referrals with the OST centre Ensure OST clients in the project area are followed up Ensure drop-out clients are re-initiated to OST/provided NSEP if the client relapses Advocate for greater acceptance of OST 27

28. Conclusion OST: Is cost-effective Is simple Has minimal side-effects Has minimal chances of overdose Requires regular follow-up, family support & acceptance Does not require extensive clinical set-up Acts best if provided supplementarily with other services 28

29. 29 THANK YOU!