key: cord-0833120-nngh2fuf authors: Ghosh, Abhishek; Singh, Shubhmohan; Dutta, Anirban title: OPIOID AGONIST TREATMENT DURING SARS- COV2 & EXTENDED LOCKDOWN: ADAPTATIONS & CHALLENGES IN THE INDIAN CONTEXT date: 2020-08-27 journal: Asian J Psychiatr DOI: 10.1016/j.ajp.2020.102377 sha: a5ba1cf818602473ad4bdf9bdea334f76107f970 doc_id: 833120 cord_uid: nngh2fuf nan India went into a lockdown on the 24 th of March 2020 to contain the spread of SARS-CoV2 and augment healthcare infrastructure. The lockdown imposed restrictions on both human and vehicular movement and curbed the availability of out-patient based medical services in both public and private sectors. The pandemic, inflicting more than 200 countries, has exposed weaknesses in our public health preparedness and structure of our healthcare systems. However, it has also given an opportunity to learn from each other's experience (Tandon, 2020) . The impact of restriction of access to treatment is likely to be disproportionate for patients with substance use disorders (SUD). According to the World Mental Health survey, only 39% patients with SUD recognized a treatment need and 7% received minimally adequate treatment (Degenhardt et al., 2017) . A nation-wide survey, published last year, revealed a treatment-gap of 75-80% for patients with drug use disorders (MSJE, 2019) . An extended lockdown is likely to widen the treatment-gap further. As per a recent survey, in India there are around 7.7 million people with opioid use disorders and only 25% of those 'motivated to quit' received 'any help,' which included care in the informal sector, by self-help groups, and other alternative care of medicine (MSJE, 2019). Treatment options for opioid dependence have mainly focussed on abstinence-based strategies. Opioid agonist treatment (OAT) is a relatively recent development in India, the impetus for which was initially provided by the HIV epidemic which was fuelled by the intravenous consumption of heroin. However, the access to opioid agonist treatment (OAT) remains limited. The latest systematic review reported out of 100, only 2-5 individuals who inject drugs receive opioid substitution therapy in India (Larney et al., 2017) . There are four sources of OAT in the national healthcare system-a) National AIDS Control Organization Both the clients and treatment providers have met with several challenges. The availability and access of both buprenorphine and methadone are severely limited because these drugs fall under the category of psychotropic substance and narcotic drugs, respectively, as per the Narcotic Drugs and Psychotropic Prevention Act of India. Although J o u r n a l P r e -p r o o f methadone has been brought under the ambit of essential narcotic drugs by an amendment buprenorphine has not figured in the list. Methadone can be stocked and dispensed by any publicly funded "recognized medical institution," whereas buprenorphine has been approved "for supply to Deaddiction Centres only." Therefore, neither of these agonist medications is available readily. Hence, clients have to come to the clinics. A large majority of our clients do not have their own conveyance and the public transport system is either non-functional or limited. The two possible alternatives are: tele prescription and door-step delivery. The recently drafted telemedicine guideline does not allow prescription of controlled substances through teleconsultation (Telemedicine Practice Guideline, 2020). The door-step delivery of controlled substances too is not approved by the law. Several clients have reported to us that they were intercepted by the police at the state borders. In all the cases they were required to show their out-patient records to prove the genuineness of their reason to travel during lockdown. This practice impinges upon the privacy and confidentiality of this vulnerable group. The movement restriction has unduly affected the staff mobility to the clinics. For our clinic, all the professional and support staff are provided with 'special passes' to ensure free movement within and outside the city. In spite of these measures, some staff have still faced questioning while crossing the state borders. The scarcity of personal protective equipment is another perpetual issue. Maintaining adequate physical distance among clients is an important consideration in crowded out-patient settings. Finally, short-supply of agonist medications, in view of non-functioning postal service is creating further challenges. Increasing availability: In India, there is a gross mismatch between the people in need for OAT and people receive it. There are a handful of centres and mechanisms to deliver OAT, which are geographically scattered, forcing clients to travel far and wide. The pandemic has J o u r n a l P r e -p r o o f unmasked this problem by superimposed travel restrictions. India needs more centers, more trained professionals, and investment from the government. Increasing the access to treatment: It is essential to develop alternative and more accessible models of OAT delivery such as, the mobile dispensing, doorstep delivery, and postal delivery of medications. However, one should be cognizant of measures to minimize misuse and harms. Improving the acceptability: the pandemic has shown us adaptation and flexibility are the keys to OAT program. Allowing take-away and dispensing medications for longer durations could improve the acceptability of the treatment. These measures should be tested systematically to examine its feasibility and effectiveness. Limiting barriers to treatment: We witnessed legal and attitudinal barriers for OAT. Advocacy and frequent and multi-pronged public awareness campaigns could minimize these barriers. All stakeholders (clinicians, experts, policymakers, patients, and families) with a common goal of increasing the access, availability, affordability, and acceptability of OAT should come together and build up a consensual action plan to mitigate the challenges and frame a user-friendly OAT policy centred around public health. The pandemic and resultant lockdown is a learning lesson for the policymakers. In spite of the challenges brought about by the unprecedented lockdown, the OAT programs in India are trying to adapt to the emergency by devising locally relevant and practical guidelines. Opioid substitution therapy with buprenorphine naloxone during COVID-19 outbreak in India: Sharing our experience and interim standard operating procedure 19: ACMD advice on proposed legislative changes to enable supply of controlled drugs during a pandemic. London; 2020 Estimating treatment coverage for people with substance use disorders: an analysis of data from the World Mental Health Surveys Global, regional, and country-level coverage of interventions to prevent and manage HIV and hepatitis C among people who inject drugs: a systematic review New Delhi: MSJE, Government of India Opioid Substitution Therapy (OST) during COVID-19 outbreak in India: Interim Guidelines Enhancing the functioning of Drug De-Addiction Centres under DDAP. Drug De-Addiction Programme (DDAP) Ministry of Health and Family Welfare (MOH&FW), Government of India COVID-19 and mental health: preserving humanity, maintaining sanity, and promoting health Ministry of Health & Family Welfare: New Delhi; 2020