Methadone maintenance treatment implementation indian experience

Methadone Maintenance Treatment Implementation

- Indian Experience

Ravindra RaoNDDTC, AIIMS

New Delhi

05/05/2015 1Presented at the national CME "OST: Policy and Practice" on 18th-19th April 2015 at AIIMS, New Delhi

OST: STATUS IN INDIA

• Available since early 90s– Through some Government institutions (through DDAP

scheme)– NGOs through projects

• Part of HIV prevention programme since 2007-08

• Medications available: Buprenorphine (largely)– Coverage: ~ 20,000 / 5,00,000 opioid dependent

individuals


OST: THE PROMISE OF METHADONE

• Expanding the menu of options?

• A cheaper option?

• More effective option?

• Beneficial to those not responding to existing OST medicines (i.e. Buprenorphine)?



However…. • MMT in Indian healthcare settings?• Can our health-care staff deliver it?• What are the safe-keeping requirements?• What are the licensing requirements?• What about diversion? • Is it safe?• Does it work in India?• Is it effective?


FEASIBILITY FINDINGS: PROJECT INITIATION

• Clearances and approvals

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Drug Controller General (India)

• Use of methadone as a long term treatment for opioid dependent subjects

Indian Council of Medical Research

• Conducting research study

Health Ministry Screening Committee• Receiving Funds from

international agency (UNODC)

NACO research committee

• Conducting the research study

Ethics committees of institutes

• Ethical clearance for the research study

Punjab Government• Initiation of MMT at two

civil hospitals in Punjab.

Presented at the national CME "OST: Policy and Practice" on 18th-19th April 2015 at AIIMS, New Delhi

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NDDTC, AIIMS, Delhi

RIMS, Imphal

KEM, Mumbai

Civil Hospital, Bathinda

Civil Hospital, Kapurthala• Centres chosen after

conducting feasibility assessment

• Similarities across centres• Location in Government

De-addiction Centres• Location in cities with high

IDU population and HIV• Prior experience of treating

drug using population

• Differences• Types of drugs used• Client typology• Level of response

FEASIBILITY FINDINGS: MMT CENTRES


FEASIBILITY FINDINGS: LOCATION OF SERVICES

• Community based setting• Clinic within the premises

of a community building constructed by Delhi Govt.

• Located in an area with a high population of drug users, including IDUs

MMT clinic, Delhi

• District hospital based settings

• Clinic within the premises of De-addiction centres

• Screening in psychiatry OPD; dispensing within the DACs

MMT clinics, Punjab

• Teaching hospital based settings

• Clinic within the premises of De-addiction centres

• Screening in OPD; dispensing within the DACs

MMT clinics, Mumbai & Imphal

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• Made use of existing infrastructure• All located in Government hospitals

– Location of the methadone clinic differed between centres


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Community based MMT clinic, Delhi

MMT clinic, Manipur


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District Hospital based MMT clinic, Punjab


FEASIBILITY FINDINGS: CLINIC INFRASTRUCTURE

• Doctor’s room

• Nursing station/ Dispensing room

• Counsellor’s room

• Waiting area


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NURSING STATION


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Examination room


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COUNSELLING ROOM


05/05/2015 15WAITING AREAPresented at the national CME "OST: Policy and Practice" on 18th-19th April 2015 at AIIMS, New Delhi

FEASIBILITY FINDINGS: MMT STAFF

• One doctor (psychiatrist managing ongoing duties along with methadone clinic)

• Two nurses (part of the hospital services)

• One counsellor-cum-research assistant (provided by the project)

• Sweepers, Guards: from the hospital


FEASIBILITY FINDINGS: CAPACITY BUILDING

• One induction training of five-day duration conducted by NDDTC

• An exposure visit of two-day duration to Kathmandu, Nepal for the doctors and nurses of MMT programme

• One refresher training of three-day duration conducted by NDDTC after 6-9 months of initiation of MMT


Quota• Request for

manufacturing quantity from manufacturer to CBN

• CBN to obtain annual quota from INCB

Storage license• Application by

MMT clinic to excise department /state drug controller’s office against supply order

• Some states do not require storage license (e.g. Punjab)

Transport license• Application by

MMT clinic to excise department / state drug controller’s office

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FEASIBILITY FINDINGS: LICENSING REQUIREMENTS

• NDPS Act: Methadone classified as a ‘narcotic’


• Total turnaround time for supply of methadone: 3 – 6 months

• Lack of clarity initially on agency responsible for issuance of license

• License valid for one-year period have to reapply for license annually

• Physical inspection of storage area initially

• Physical verification of stock registers and stocks before renewal of license

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FEASIBILITY FINDINGS: PROCUREMENT PROCESS


• Methadone– Supplied as liquid 5

mg/ml– Supplied in one litre

bottle• Manual dispenser

– Bottle top dispenser– can be fitted directly on

the bottle– Calibration upto lowest

level of 12.5 mg

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FEASIBILITY FINDINGS: METHADONE DISPENSING


• Minimal training of nursing staff to calibrate and dispense liquid methadone

• Main stocks segregated from dispensing place

• Regular monitoring of stocks by doctor and nodal officer

• Regular furnishing of stock details to NDDTC by individual clinics

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FEASIBILITY FINDINGS: METHADONE DISPENSING


FEASIBILITY FINDINGS: CLINICAL SERVICES

Various strategies adopted for client recruitment

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Network with NGOs

Existing clients

Initial outreach

‘Word of mouth’ publicity

Family membersPresented at the national CME "OST: Policy and Practice" on 18th-19th April 2015 at AIIMS, New Delhi

Phases of treatment• Induction phase

– For about two weeks

• Maintenance phase– Till clients achieve their

treatment ‘goal’

• Termination phase– After the clients are ready to

lead a life without MMT support

Types of treatment• Pharmacological

– Methadone liquid– Other medicines for

associated problems

• Psychosocial – Motivation enhancement– Relapse prevention– Family intervention– Occupational rehabilitation

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• Referral for other health conditions, as required

• Methadone dispensed as a ‘Daily Observed Treatment’ medicine– Clinic open all the days in a year

• Urine screening by rapid cassette test– Mainly to assess for continued drug use and

increase methadone dose, if positivie– Not as a punitive measure


FEASIBILITY FINDINGS: QUALITY ASSURANCE MECHANISMS

QUALITY ASSURANCE

Supervisory site visits

Monthly reporting

Telephonic contacts

Record maintenance


FEASIBILITY FINDINGS: ADVOCACY EFFORTS

• Involvement of various stakeholders at different forums– Involvement of DDAP,

NACO, NCB, MSJE, Health secretaries of respective states & SACS during inaugurals

– Sharing of project updates

– Involvement of drug using community at different stages


FEASIBILITY FINDINGS: SUMMARY

• First clinic launched in February 2012– India has experience of more than two years of MMT

implementation

• MMT implemented at different Govt healthcare settings

• >700 clients initiated on methadone till-date

• Benefits of MMT: Clients, families, neighborhoods 05/05/2015 27


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Dhawan, A., Rao, R., Ambekar, A., Chopra, A., Jain, R., Yadav, D., Ray, R. (2014). Methadone Maintenance Treatment in India: A feasibility and effectiveness

Report. UNODC (ROSA) and NDDTC (AIIMS), New Delhi, India

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Methadone maintenance treatment implementation indian experience

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