Opioid Substitution Therapy

(OST)

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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…

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

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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)

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Philosophy of OST

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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

OST Under NACP IIIIs 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 NGOs6

Benefits of OST

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Injecting vs. OST

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contd…

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 drugs9 Contd

…

Why OST?

10 Contd…

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…

Why OST?

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Process to Start Client on OST

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OST: Basic Facts OST is given ONLY to those who use opioids and

are dependent on themThose 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

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Criteria for OSTInclusion 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

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

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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 counsellor17

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

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Termination of TreatmentTreatment 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

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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.

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Myths About Substitution Treatment

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Myth #1: Patients are Still AddictedFact: 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

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Myth #2: Buprenorphine is Simply a Substitute for Illegal DrugsFact: 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 normally23

Myth #3: Providing Medication Alone is Sufficient for Opioid AddictionFact: 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

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Role of Project Manager

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Key Areas of WorkRole 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

26Contd…

Key Areas of WorkRole 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

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ConclusionOST: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

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