experiential account experience as a private practitioner

Experiential account: experience as a private

practitionerDr. Ashwin Mohan

M.D. Psychiatry (PGI)Chandigarh

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

The Facts Completed MD in 2000 Practice since 2001 OPD set up mainly; Attachment to Multi specialty

hospitals for admission


Senior Residency in DDTC, PGI for one yearMultiple relapses and admissions of patientsProblems in controlling withdrawalPoor follow up and compliance to naltrexoneExtremely frustrating for the treatment provider, patient and the familymember and very limited options available

First exposure to OST in PGI Chandigarh underguidance of Dr. D. Basu

Patient was heroin user for 18 years including IV use and was admitted for third time in DDTC, PGI and was put on OST even after discharge. He continues to be relapse

free till date


The Beginning: First 4 years – only 3 patients on OST; good follow up

and no relapse Around 2005: scaling up started after multiple failures

using traditional treatment methods, both OPD and inpatient.

In this initial period: used for detoxification and short term maintenance – few weeks to about three months

Selectively in patients of IV use and multiple relapses


The Journey:

Relapse rates were still high with short term use With more experience: After evaluation and clinical

need, increase in doses and duration of treatment-initially used 2-8 mg/d for detoxification and tapered off on follow up after a few months

Mainly used plain BPN and not FDC of BPN/NLX


The Journey: Encouraging results and positive feedback.

.. “to hell and back” is how most patients describe their journey

Shifted from detoxification and short term maintenance to long term maintenance therapy while monitoring the patients functioning and drug history

Patients were educated beforehand about the rationale for the therapy as well as need of the longer term therapy


The journey: Progressive increase in number of patients as word

spread- availability of treatment without need for admission, smooth withdrawal, improved functionality, less relapse rates and less legal problems

Since last 10 years – treated approx. many thousands of patients, both with short term and maintenance treatment using BPN

High patient numbers - a reflection of the high degree and decades of drug abuse in the catchment region


The logistics Private Clinic- limited space and infrastructure and

resources Initially dispensed on my own but kept additional staff

later on as number increased Consultation : specified number of tablets and written

(and later stamped) on prescription; patient would enter his name, address and

phone number and sign in the designated register No reports of abuse or diversion, esp. in the initial

years and no reports of patients injecting sublingual BPN after crushing.


Patient Profile: Majority (75%)- poppy husk, opium and heroin

Remainder (25%)- CCCS, dextropropoxyphene, diphenoxylate and IV Buprenorphine and pentazocine

Most from Punjab; followed by Haryana and Rajasthan. Lesser number of patients from Delhi, Himachal, Gujarat and Maharashtra

Mostly males, age range from 18-90 years. Duration of use ranged from few months to 70 years of use Both rural and urban background


Starting treatment: Opioid dependent patients suffer from multiple

misconceptions and fears re using, treatment and withdrawal- need to allay fears

Prevention of precipitated withdrawal –key to treatment success

Logistical issues- difficult to start treatment under observation; problem overcome by ensuring adequate time gap

Developed my own method- instructed patients to stop using all opioids by 4 pm and start treatment next morning- a gap of about 12-16 hours


Starting treatment: Time gap - strict rule to be followed; most adhered except

heroin users Day 1 of treatment - start low dose as withdrawals start and

increase, as instructed, within a few hours Most experienced smooth and painless withdrawal Those with more severe withdrawal – managed with

reassurance and dose titration, depending on symptoms Was accessible and available. Most settled within 6-8 hours Less than 1% admitted; most treated on OPD basis No major complications; no fatalities


The doses and duration:DOSE Initiation phase: 2 mg/d to 24 mg/d, rarely upto 30 mg/d Stabilization phase: 2 mg/d to 16 mg/d Maintenance phase: 0.4 to 12 mg/d

DURATION A few weeks to many years Functionality, and control of craving were key

“ how well the patient was doing” Decision collaborative and not unilateral- to increase

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

Termination or …… People often ask – “do you ever stop Buprenorphine”

The answer is YES.Substance Dependence is a chronic, relapsing medical

illness. Maintenance treatments are used for a large number of medical and psychiatric disorders- Do we Question them so vehemently.

Can categorize the patients in the following :• The most important- majority follow up and reduce the

dose of medication under medical supervision and eventually stop and many remain relapse free.

Able to manage without any sort of treatment later


The other categories Those who use it to facilitate treatment for short term

withdrawal and then stop using Bpn Those using it for longer periods of time for months and then

gradually taper off on their own and don’t follow up Those who continue to use relatively higher doses and maintain

well on that so as to control craving Those tapering it off to as low as 0.4 mg and continue using it as

a form of psychological support in order not to get back to using. Those using Bpn intermittently and shift from using to

abstinence Those using bpn on an sos basis Those who start but don’t find complete benefit so they seesaw

between treatments Those who take higher doses and want to reduce but are unable

to do so despite multiple attempts as withdrawal is painful for them – least common

Categories not mutually exclusivePresented at the national CME "OST: Policy and Practice" on 18th-19th April 2015 at AIIMS, New Delhi

The crisis: March 2014, before General Elections - Tightened controls,

forces deployed, trans border and cross border vigilance increased

Politics to the fore with blame games, accusations and counter accusations

Sudden crackdown without adequate treatment infrastructure in place - Gross underestimation of the problem by authorities

A massive tsunami of patients …thousands suddenly deprived of their fix, supply lines cut

Huge numbers registered in both govt. and private set ups LOGISTICAL NIGHTMARE Extraordinary problems with no clear solution


The crisis: Unparalled environment of FEAR, PERSECUTION and

PROSECUTION prevailed Cases registered against patients; threats and coercion;

people forced to go for treatment Chemists raided….medication availability virtually

stopped in some districts Psychiatrists were overwhelmed, both govt. and

private sectors…most places were not equipped to deal with the situation


Psychiatry’s dilemma Harm reduction: deeply polarizing issue - No consensus,

Emotive issue, Sharp divisions. Fraternity itself plays negative role in damning and demeaning Harm Reduction.

Issues of Diversion and Abuse cropped up and selective feeding by enforcement agencies fuelled this issue; blown out of proportion relative to benefits of the medication

Also provided a welcome distraction from the “real issue” at hand- decades of facilitation and poor enforcement and narco-money used for funding political ambitions

Psychiatrists inspected, persecuted and prosecuted to no end; Blamed for the whole situation as if they were the ones responsible for its creation


The crisis: Diversion occurred during this period : reason was

huge Demand – Supply gap between number of patients and treatment services, and irrational restriction of medication availability

More a case of ‘para-prescribing and ‘unobserved treatment’ and hoarding by panic stricken patients

Vicious media campaign started against OST modality and psychiatrists practicing it


The crisis: Psychiatrists esp. private sector equated to drug

peddlers and blamed for diversion Govt. supply reduced further and even govt.

psychiatrists threatened..restricted to inpatient use Apart from BPN, even tramadol use was severely

restricted Convoluted, irrational and unscientific cobweb of

rules, policies and laws invoked to prosecute psychiatrists


The result:“BUPRENORPHINE BECAME A GREAT MEDICATION WITH A BAD PRESS”

Psychiatrists stopped using BPN in many centres Those using it, reduced dispensing doses and duration

such that it was inadequate to control withdrawal/ craving No medication was available for treatment. In some

districts, even benzodiazepines were stopped There was an aversion towards treatment of opioid

dependence by doctors. Many did not want to treat themPresented at the national CME "OST: Policy and Practice" on 18th-19th April 2015 at AIIMS, New Delhi

The result Illicit drugs still available- cost increased to 2-4 times. Treatment avenues and modalities reduced. No medications to address the crucial issue of craving No maintenance treatments, naltrexone a failure. The number of addicts registering at centres show a dramatic

fall. This statistic has been used to “show success” of the campaign

Many patients either relapsed or flocked to Haryana and Rajasthan where treatment is still available

Newer Epidemics- IV heroin use increased dramatically; Tramadol and Tapentadol Dependence have emerged as the newer drugs of abuse


My opinion- the way forward OST is a wonderful treatment - one of the best tools Use can reduce the demand for illicit drugs significantly The principle of harm reduction needs better

understanding, publicity and coverage. This is where we have failed miserably.

All psychiatrists by way of their qualification need to be allowed to use BPN and other treatments irrespective of the setting in which they practice- Govt. Hospital, Community health centres, Nursing homes or clinics. The setting should not matter

Checks and balances can be made - All psychiatrists desirous of using OST can be registered, if required, rather than persecuted.


My opinion- the way forward Other treatment modalities like methadone should

also be widely available Urgent scaling up of services is the need of the hour There may also a case for opening up of low strength

poppy husk vends which can be taxed, with direct supply from Govt. factories and fixed quotas

Will take care of diversion to a large extent


Conclusion Roller coaster ride with a current low as far as OST is

concerned Substance Dependence is treated with disdain and

repugnance; Need to change fraternity’s own approach to dependence

More patient friendly policies required All stakeholders need to be taken into confidence and

knee jerk reactions avoidedThough my experience can be described as

BITTER- SWEET, I continue to have faith in OST and remain a firm advocate of the same


experiential account experience as a private practitioner

Health & Medicine

national cme ost

new delhi

number of patients

short term maintenance

ost good follow

maintenance treatment

thousands of patients

short term use