How India Introduced Methadone Take-Homes in the Pandemic

    Dear Helen, You will be pleased to know that during the COVID-19 pandemic and lockdown we in India have also started the practice of take-home methadone.”

    It was one of the most welcome emails I’ve received recently. It came from Dr. Atul Ambekara professor and researcher at the National Drug Dependence Treatment Centre, and at the Department of Psychiatry of the All India Institute of Medical Sciences in New Delhi.

    Dr. Ambekar is also a member of the Expert Advisory Panel on Drug Dependence at the World Health Organization, and of the Strategic Advisory Group on Injecting Drug Use at the United Nations. His published articles address an eclectic range of subjects, from retention in drug treatment to Bollywood portrayals of alcohol.

    “It must be noted that overdose will be a big deal in India.”

    I previously interviewed Dr. Ambekar in my documentary, Liquid Handcuffs: A Documentary to Free Methadone. For that project, he secured permission for me to interview and film patients and staff in Delhi’s Sunder Nagri clinic. So I know him as a warm and gracious man, and a rare psychiatrist who “gets” the core of harm reduction: dignity and respect for people who use drugs. He is committed to ending the stigmatization and suffering of people who use opioids.

    Dr. Atul Ambekar. 

    Dr. Ambekar has been instrumental in making methadone available in India, and I asked him to tell me about the situation there. Our interview has been lightly edited for length and clarity.

     

    Helen Redmond: How many people are on methadone in India? 

    Dr. Atul Ambekar: About 3,000 patients are getting methadone in India for the treatment of opioid dependence. More than 90 percent of these are men, mostly in their 20s and 30s.

     

    How does a person who wants to take methadone get it?

    The process is fairly simple and straightforward. A person with opioid dependence residing in the vicinity of a methadone clinic may come to know about the medication from a variety of sources: Peers, health providers, outreach workers, or family. The person presents at the clinic and gets registered. On the day of the visit itself, the person undergoes an assessment by a counselor and a physician. It takes about an hour. If everything is fine, meaning the patient is willing and provides consent and doctor deems the patient fit to receive methadone, the treatment begins. There is no waiting list and methadone treatment is totally free of cost to patients.

     

    Are there mandatory urine screens for people on methadone? 

    Urine screens are seen as “good to have” but are not mandatory and patients can refuse. 

    Urine screens are not mandatory for the obvious reasonsthey are a hindrance in the therapeutic relationship and endorse the misconception that self reports from patients are not trustworthy. Additionally, a negative or positive test result informs little about the overall status of the patient in terms of their productivity, employment, or their quality of life in general. 

    Guidelines prohibit the provider from penalizing the patients on the basis of a positive urine report.

    It doesn’t mean they are useless though. As a doctor, a positive result for illicit opioids tells me that perhaps the dose of methadone may be inadequate and perhaps there are other factors which need to be addressed. The treatment guidelines specifically prohibit the provider from penalizing the patients in the form of denial of methadone on the basis of a positive urine report. But in my experience, many patients are more than willing to have their urine screened. 

     

    Who works in methadone clinics? 

    Every methadone clinic has the following essential staff: Doctor (need not be a specialist but need to be trained in opioid dependence treatment); counselor with a psychology or social work background; and a nurse for dispensing the medications. Usually all of these professionals work under the overall administrative supervision of a psychiatrist.

     

    What do you say to people who believe methadone is just substituting one addiction for another? 

    That remains an ongoing battle in every part of the world, particularly when this form of treatment is newly started. Fortunately, long before methadone which began in 2011, we had had a long experience with buprenorphine maintenance in India. So, every now and then a policy maker, a politician, a law enforcement officer, a family member of a patient or sometimes patients themselves need to be told why methadone or buprenorphine are a form of treatment and are not substituting one addiction for another. 

    Among various arguments that we use in India, an allegory of opioid dependence as any other chronic disease works well. People often need lifelong medications for a variety of health conditions–diabetes, hypertension, epilepsy, hypothyroidism, depression and so on. So what’s wrong in being on methadone?  

     

    Prior to COVID-19, were people ever allowed take-home doses? 

    Prior to COVID-19, take-home methadone was an absolute No. There were concerns about diversion and more importantly, overdose. 

    Compared to Western developed countries, the use of opioids among Indians is lower. Heroin in India is quite impure and the majority of users smoke it. Among those who inject opioids, just about half inject heroin while the remaining half inject another pharmaceutical opioid, largely buprenorphine. So the tolerance to opioids is generally low and hence there were justifiable concerns with risk of overdose on methadone if it were provided as take-homes in large amounts.

    For people like me who develop treatment guidelines and standard operating procedures—besides the actual risk of something going wrong—there was also the concern about the negative publicity any such incident would attract. Bad publicity due to overdose with take-home doses could jeopardize the entire treatment approach which is just beginning to be scaled up in India. 

    It must be noted that overdose will be a big deal in India. 

    By and large our patients managed daily visits to clinics prior to COVID-19 since they live in the vicinity of the clinic.

     

    How did the pandemic lead to people being able to get take-home doses of methadone, and how does the new system work?

    India instituted the lockdown as a response to COVID-19 in the very early days of the pandemic. It doesn’t appear that the infection rate of the coronavirus among drug users is high, but the epidemic is still rising and it remains to be seen.

    These are early days, but so far, the system seems to be working smoothly.

    There were concerns about the need to minimize the crowds at the clinics and to minimize the requirement for patients to commute every day. We made the decision to allow up to one week’s take-home doses. They are being provided only to those who are deemed “stable,” to those who have been on treatment for more than three months and their doses are not likely to be adjusted frequently. 

    In people where there may be safety concerns, for example mental health issues, we recommend caution and to avoid take-home methadone to the extent possible. On their scheduled day, patients visit the clinic, go to the dispensing counter, sign the registers, carry their own empty bottles (one bottle for each daily dose) which are then filled-up by the dispensing staff. These are early days, but so far, the system seems to be working smoothly. We have not noted any instance of diversion or overdose from any of the clinics and we continue to monitor the situation. 

     

    Would you like this change to be permanent?  

    Too early to say. What I would like is to review, monitor and evaluate the impact of take-home doses and then come to a decision. Advantages of take-homes are obvious for both service providers and patients. A clear assessment of risks and benefits is needed post-COVID-19.


     

    Photo of patients and staff at the Sunder Nagri clinic in New Delhi by Helen Redmond.

    Photo of Dr. Ambekar via the All India Institute of Medical Sciences.

    • Helen Redmond

      Helen is the senior editor of Filter. She has written about nicotine, mental health and drug policy for publications including Al Jazeera, AlterNet, Harper’s and The Influence. As an LCSW, she works with drug users in medical and community mental health settings. An expert on tobacco harm reduction, she provides training and consultation on mental health, nicotine use and THR, and in 2016 organized the first Tobacco Harm Reduction Conference in the US. Helen is also a documentary filmmaker.

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