* Revive And Reminisce Your Old Memories *
The Addiction Psychiatry Service started in 1978 as a weekly outpatient Alcohol and Drug Dependence Clinic (ADDC). Later in 1988-89, following the implementation of the Drug De-addiction Program (DDAP) of the Ministry of Health and Family welfare, the Drug De-addiction and Treatment Centre (DDTC) was established as a specialty section of the Department. With this, the services gradually expanded to daily OPD, inpatient service, community service, laboratory service, teaching and training, liaison with other agencies, and policy making. Since 2014, DDTC has been running its
DM Addiction Psychiatry course the first in the country.
The OPD runs from Monday to Saturday forenoons (excluding public holidays) and Tuesdays, Wednesdays and Friday afternoons. Forenoon registrations start at 8:00 am and continue till 11 am (except on Saturdays when it stops at 10:30 am) and afternoon registration starts at 2 pm and stops at 3:30 pm.
The formal registration is done in the DDTC OPD. After registration coordinated multi-disciplinary team consisting of Psychiatrists, Clinical Psychologist, PSW and a trained counsellor take care of patient’s clinical and psychosocial needs. The SR, following discussion with a Faculty member, may admit the patient to the DDTC Ward after obtaining a written consent from patient/family members for following the rules and the requirements of the DDTC Ward. Otherwise, treatment is initiated and continued on OPD basis. For detailed evaluation, the patient and a close family member are called on a specified date and time (8 to 8:30 am). The appointments given are recorded in an Appointment Register by the SR dealing with the patient in the WIC. The patients with a dual diagnosis are given appointments for detailed evaluation on Fridays. DM (Addiction Psychiatry) SRs also do D/W/U on specific days. On all other days, D/W/U are done by the JRs. In both the cases, after discussion with a Faculty, diagnosis is finalized and further management is planned and initiated. Follow up of patients after the D/W/U is done by the JR (Tuesdays and Fridays afternoon) till they are posted out of DDTC. Once the JRs are posted out from DDTC the OPD SRs take care of these patients.
Opioid Substitution Therapy clinic: The OST clinic is run on two days a week basis (Tuesdaya and Wednesdays) by a coordinated multi-disciplinary team of Psychiatrists, Psychologist, PSW, trained addiction Counselor, and the Pharmacists. It uses buprenorphine-naloxone (BNX) fixed dose combination (2/0.5 mg). All OST patients are encouraged and incentivized to attend weekly manual based group therapy sessions. It consists of initial psycho-education, management of craving, imparting stress and anger management skills, and relapse prevention
A DD clinic runs on a weekly basis (on Friday) by a multidisciplinary team. All cases, for which detailed evaluations are done, are given a specialty clinic number (DD No). Group sessions for the DD patients are conducted every Friday afternoon
Please see the record maintenance section of General Adult Psychiatry OPD
Responsibilities of Senior Resident
OPD SR
Forenoon DDTC OPD runs six days in a week from Monday to Saturday. There are afternoon OPDs on Tuesdays, Wednesdays and Fridays. Two special clinics namely the Opioid Substitution Therapy (OST) and the Dual Diagnosis (DD) also run in the OPD, on Wednesday and Friday afternoon, respectively. Detailed evaluation of the patients Registered in DDTC OPD is done from Wednesday to Saturday mornings
Academic and Research Duties: Duties are similar to the Psychiatry OPD SR
The JRs are posted to the DDTC out of a common pool from the Department of Psychiatry, usually for a period of four months. During their posting in the DDTC, they are supposed to follow-up their Psychiatry cases on Wednesday afternoon in Psychiatry OPD
Essentials of Record-Keeping in the Ward: Similar to the General Adult Psychiatry Ward
DDTC Ward SR
DDTC ward can accommodate a maximum of 50 inpatients
Academic and Research Duties: Duties are similar to the Psychiatry Ward SR
The Centre has been actively participating in increasing the awareness of the general public towards the issues related to drug addiction and to provide education to the general public in it. This is in the form of presentations and interactive discussions at many levels in the community using various forms of media
Personnel from the law enforcement agencies (Narcotics Bureau and Police) are trained periodically, on request
The DDTC maintains active liaison with the community. This includes active consultation with self-help groups such as Alcoholics Anonymous (AA), Narcotics Anonymous (NA), and Al-Anon and also with other local NGOs voluntary and other counselingcenters (including those supported by the government of India, Ministry of Social Justice and empowerment). In addition to accepting C-L from these sources and from general medical practitioners, advice and guidance is extended towards their handling of drug addicts. Also, on request, the facility of our laboratory is extended for the cases referred by them. Treatment camps and awareness programs on drug addiction are organized on a monthly in the community (villages/slums, school/ colleges, factories etc.)
[/item] [item title=”COMMUNITY SERVICES”]
Please see the Community Psychiatry Services section
The team comprises of SR who is posted in community services along with a PSW.
Role of SRs in community de-addiction clinics: Clinical duties are similar to Community Psychiatry SR. Additional points are mentioned below
Please see the Community Psychiatry Services section
The team comprises of SR who is posted in community services along with a PSW.
Role of SRs in community de-addiction clinics: Clinical duties are similar to Community Psychiatry SR. Additional points are mentioned below
Counselors are one of the important members of the clinical treating team and should be actively involved in initial assessment and active surveillance during follow-up of the patients
Clinical Work Assignments
Academic
Research
Administrative
Pharmacists are one of the important members of the clinical treating team and should be actively involved in dispending of medicines to the patients
Clinical Work Assignments
Lab Technicians are one of the important members of the clinical treating team and should be actively involved in Biochemical assessments of patients in DDTC
Clinical Work Assignments
To attend various departmental administrative meetings
BACKGROUND
Opioid Substitution Therapy (OST) Clinic was started in October 2013 in the Drug De-addiction and Treatment Centre (DDTC), Department of Psychiatry, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh and has been continuing since then on a weekly basis. We had formulated initial guidelines in 2013 which laid down both the theoretical (ideological) and the practical (logistic) aspects of our OST programme. These initial guidelines have been revised several times since then in view of our growing experience as well as international and national scientific literature. The OST clinic has been expanded in March 2019 and this is the current version of the guidelines. We do not claim any superiority of these guidelines over any others, nor do we intend to set these in stone. Indeed, we envisage these guidelines to be a “living document” which is likely to undergo several revisions in the future as well. The guiding principle is to judiciously balance the many seemingly conflicting aspects of agonist treatment for opioid dependence, especially to ensure a hopefully correct balance of effectiveness and safety. References are not included in these guidelines but can be checked with the detailed OST group therapy manual.
PREAMBLE
The evidence for efficacy of OST is undisputed. Results from various studies on OST from all over the world, including India, not only demonstrate a reduction of illicit opioid use but also show a reduction of several harms, e.g., decrease in blood borne infections, legal complications, and mortality.
Among several controversies surrounding OST and its delivery models (not the least because opioid agonists are used for therapy, which are themselves controlled substances with risk of diversion and abuse), one particular bone of contention is regarding the duration of OST. Although the existing literature mostly suggest that time-limited OST increases the risk of relapse and thus also eliminates most of the gains achieved in terms of harm reduction, it nonetheless creates a huge contingent of people pharmacologically dependent on OST posing a burden on health care resources. At times, it has been also claimed that these people are effectively blocked from making further progress in the functioning of their life by remaining physically dependent on opioids for an indefinite term. This is known as the ‘Methadone Parking’ phenomenon. Moreover, in longitudinal observational studies it has been seen that only a fraction of patients could be retained in the treatment for one year. The exposure to OST seems to be an episodic phenomenon. Taking cognizance of all these facts, at many places in the world the current policy of OST is gradually moving towards ‘Recovery Oriented’ practice rather than remaining solely as medication dispensing agency. By ‘recovery’ we imply reintegration of the person with opioid dependence into the family and society and ensuring functional independence rather than simply stopping drug use. Our guidelines endorse such a ‘recovery oriented’ OST policy and programme.
The unique features of our OST is, this is neither time limited and rigid nor is this time unlimited and arbitrary. It would start with definitive short-term goals in mind and with a tentative deadline to achieve those to keep the patient’s motivation alive. The post-intervention psycho-social support and assessments are also distinctive for our OST programme.
In our OST clinic, sub-lingual tablets of buprenorphine-naloxone (BNX) fixed dose combination (2/0.5 mg) are used and the medication is dispensed on weekly basis (also fortnightly for patients in maintenance phase). With effect from March 2019, OST clinic is held on 2 days i.e. Tuesday and Wednesday every week at PGI DDTC OPD between 2 – 4 pm and is integrated with ongoing afternoon DDTC OPD.
A coordinated multi-disciplinary team consisting of at least two Psychiatrists, one Psychologist, one Psychiatric social worker (PSW) and one trained addiction Counselor works for the purpose of OST. The psychiatrists include 2 senior residents who are trainees in DM Addiction Psychiatry, on Wednesday, for managing the patients in stabilization phase. On Tuesday, junior residents would accompany senior residents for managing the patients in the maintenance phase. We follow the philosophy of recovery oriented OST where this has been used as a support rather than the sole form of treatment. The aim of our OST is to make the patient stabilize enough so that he could pursue the goal of recovery which along with ‘voluntary sobriety’ also includes ‘citizenship and personal health’. Our final aim is to get the patient out of OST and maintain his/her recovery even without medication assistance.
Decision to initiate OST will be taken after detail work up of patient by a senior or junior resident but only after discussion with a consultant.
Inclusion criteria for patients to be initiated on OST are as follows –
OST should not be used in patients who satisfy one or more of below mentioned criteria.
Be cautious while using in subjects with following
Severe medical illness –
The goal of OST in our programme is ‘recovery’ which is reintegration of the person with opioid dependence into the family and society and ensuring functional independence. Recovery is initially assisted by OST and later by helping them to learn to live without OST. Assessment is individualized and an ongoing process. It will start at the intake point and will be reviewed at least every three months to monitor the progress of our intervention and to observe whether the predetermined mutually agreed goals have been achieved.
1. Basic socio-demography and clinical data- to be recorded during the detail work-up of patients only at the entry point by a junior or senior resident
2. Assessment for recovery- to be done with the instrument ‘Assessment of Recovery Capital (ARC)’ applied by a social worker or counselor [See Appendix] Induction, Stabilization and maintenance phases of buprenorphine and naloxone combination
Targets of induction phase are to determine the correct dose of OST medicine to control opioid withdrawal symptoms, to address any medical or psychosocial crisis and to establish rapport with the patient.
During induction phase other issues also need to be covered and include enhancement of patient’s motivation to stop/reduce illicit opioids and continue OST. Address any medical priorities such as open abscess, active tuberculosis, etc. and any psychosocial crisis should be made such as recent homelessness, impending legal crisis, etc.
It begins once patients are taking OST medicine without intoxication or significant withdrawal symptoms. The goal is to assess and treat the target signs and symptoms by titrating the medicine to its most optimal level so as to give the desired benefits. Once withdrawal and craving are controlled, further dose increases may be done in a conservative manner.
Review of the patient by the prescribing doctor/members of the treatment team and titration of the buprenorphine dose by the reviewing doctor according to:
In our clinic we monitor the patients for stabilization for up to 6 months which involves weekly visits on Wednesday OST clinic. Patients are required to mandatorily attend group therapy sessions before review by doctor for dispensing medication. Group therapy involves participatory discussions among patients moderated by a social worker or counselor. The major themes of sessions involve psychoeducation, introduction of concept and dispelling the myths related to OST, relapse prevention and group sessions along with patient’s family members [Refer to OST group therapy manual, DDTC, PGIMER].
The maintenance phase begins with the patient achieving his stabilisation dose till the time a decision is made to stop OST for the patient.
Goals of maintenance phase are:
In our clinic we usually maintain patients on 4-8mg /day of buprenorphine as maintenance dose and allow them fortnightly visits on Tuesday OST clinic. The focus is to prevent withdrawals and craving of opioids as achieved during induction phase. Some patients may require higher maintenance doses of 10-16 mg /day. Although rare in our settings, the maximum approved daily dose of buprenorphine is 32 mg. Additional focus should be to prevent euphoria with illicit opioids consumed. If the patient used any other opioids/injections while on his current buprenorphine dose and experience euphoria in that case need to increase buprenorphine dose after been brought to the notice of a consultant and decision is to be made consensually. Generally no reduction in dose necessary is necessary in the maintenance phase and same dose as used in the induction phase should be continued unless patient complaint of side effect of buprenorphine. Patient should be referred to other services such as HIV testing & referral to ART centre (if positive) and screening for Tuberculosis, Hepatitis & referral if required. Individualized counselling and/ or group sessions would be conducted by social workers or counsellors as per requirement assessed by the senior resident in OST clinic. Psychosocial interventions with the help of PSW are conducted for re-integration and repair of ties with family and society and resume/improve occupational functioning.
The existing evidences almost unequivocally indicate that retention in treatment is directly proportional to the final recovery, in terms of complete remission, functional independence, reduction of high risk behaviour, and criminal activities. However, about one in ten patient drops out of OST within first 3 months and treatment retention is around 15% for 5 years. Moreover, when retention exceeds one year, the chances of further retention and recovery improves. The general pattern of OST treatment utilization is episodic in nature, where the patient has repeated episodes of drop out, relapse, and re-entry in to the program. This episodic pattern might indicate the relapsing-remitting nature of drug use or it could also be a reflection of treatment barriers and logistic problems.
Hence, this OST program would make an attempt to change the episodic pattern of treatment, which might be largely responsible for the ‘failure’ of OST. This could be seen as an essential adjunct for the final outcome, i.e. recovery.
Following behavioral measures might be considered for the same:
As already emphasized, evidence for a time limited OST is unequivocally ‘negative’ and more the duration of OST more likely the patient is to draw benefit from the program. Although there is no ‘standard’ minimum duration of OST, it has been seen that more than one year duration is imperative and improves the chances of further recovery.
Termination of OST would be considered in the following situations:
Termination of OST would be done over couple of months with utmost regard towards withdrawal symptoms, drug craving, and an intensive psycho-social intervention.
Evidence suggests that the possibility of relapse and overdose increase significantly after discontinuation of OST. Although the chances of such occurrences could be minimized by mutually agreed and ‘recovery oriented’ termination, the patient would still be vulnerable. Hence, a post termination medical and or psycho-social intervention is an essential component of our OST program. This intervention would at least last for 3 months (preferably 6 months) in the same clinic. Following successful completion of such intervention patient might be shifted to routine clinical care. In case of relapse, during this phase of treatment, options other than OST need to be considered first, if needed inpatient treatment might also be considered.
In the group sessions these patients could be portrayed as ‘model’ in front of others and they would be encouraged to share their experience with others in the OST. This would in a way enhance their self-efficacy and they would act as a visible example, the ‘recovery champions’.
Vomiting: Uncommon symptom with buprenorphine and present during the initial weeks of initiation of. It generally subsides on its own and if intolerable anti-emetics orally half hour before buprenorphine should be consider.
Constipation: Common side-effect of OST and occurs during maintenance phase of treatment. It could be due to co-morbid physical illness, changes in lifestyle after OST initiation or true side-effect of buprenorphine. First of all we have to rule out other causes of constipation and consideration of lifestyle modification – physical exercise, dietary changes should be made. Laxatives will be another option. Decreasing BNX dose could be considered if constipation is intractable and other possible causes are ruled out.
Missed dose: If missed for three days or more there is possibility of relapse. In that case reintroduction of OST could be considered. Proper assessment for signs of intoxication/withdrawals needs to done before recommencement of therapy.
Guidelines in our OST clinic will be:
No. of days missed | Recommended strategy |
---|---|
One day | No change in dose |
Two Days | If no intoxication, same dose |
Three-four days | Administer Half-dose |
Five days and more | Regard as new induction |
Sleep disturbances: It is a common problem encountered during the course of OST in which patient would complain of delayed initiation of sleep; frequent waking up at night etc. The reason could be protracted withdrawal symptom of opioids, cocktail injection of benzodiazepines (diazepam) along with opioids or co-occurring benzodiazepine abuse/dependence. Proper assessment is needed and treatment of benzodiazepine withdrawal, if dependent on benzodiazepines could be consider. Psychosocial in form of sleep hygiene should be given. If no improvement and symptoms persist low dose benzodiazepines / other sleep inducing medications could be given.
Sexual problems: It is common presently by patient during maintenance phase of OST and include pre-mature ejaculation (most common), erectile dysfunction and anorgasmia. It could be due to protracted withdrawals of opioids, myths/misconceptions. General assurance would be given such as improvement with passage of time. Psychoeducation regarding normal sexual process and focus on other aspects of marital life, rather than sexual alone. Some alternative methods of deriving sexual pleasure by non-penetrative measures could be made.