|Year : 2016 | Volume
| Issue : 2 | Page : 154-157
Characteristics of opioid drug users in an Urban Community Clinic
Sonali Jhanjee, Hem Sethi
National Drug Dependence Treatment Centre, All India Institute of Medical Sciences, New Delhi, India
|Date of Web Publication||25-Apr-2016|
Dr. Sonali Jhanjee
E-24, West Ansari Nagar, AIIMS Residential Campus, New Delhi - 110 029
Source of Support: None, Conflict of Interest: None
Background: Community-based treatment program is an approach for the treatment of opioid users that aims to engage, retain, and provide treatment to some of the most marginalized and hardest to reach populations in order to reduce the harms of continued opioid use. Aims: To describe the demographic and clinical characteristics of opioid drug users from a community clinic for opioid drug users in a metropolitan city of India. Methods: Oral substitution treatment with buprenorphine for opioid-dependent drug users was being carried out through a community clinic located in an urban resettlement colony in Delhi. The information on 104 opioid users attending the clinic was gathered by self-report on the drug abuse monitoring system questionnaire and a brief semi-structured proforma. Results: Majority of opioid-dependent (mainly heroin) drug users were male (97.1%) and most were married (58.7%). Around 33% were illiterate, and a large number (42%) were presently unemployed. Heroin was the primary drug of abuse in majority of the patients (97%). The mean age of initiation of opioid use was 20.3 ± 7.3 years and mean duration of opioid use 10.8 ± 8.9 years. Around 67.3% had a history of injecting drug use, while 49% were still injecting drug in the last 1 month. The highest rates of injecting drug use were among those who were between the ages of 18 and 25 years, unmarried, having some education, employed, and living in nuclear families. The significant risk factors for injection drug user (IDU) were being unmarried (odds ratio [OR] = 3.6, confidence interval [CI] = 1.2–10.9) and having sex with sex workers (OR = 2.9, CI = 1.4–7.7). A highly significant linear relationship was found between the number of risk factors and IDU. Conclusions: Studying the characteristics of opioid drug users and injectable drug use among people who use opioids will help to define treatment and preventive interventions.
Keywords: Community clinic, demographic correlates, injection drug use, opioid use
|How to cite this article:|
Jhanjee S, Sethi H. Characteristics of opioid drug users in an Urban Community Clinic. Indian J Soc Psychiatry 2016;32:154-7
| Introduction|| |
Illicit drug users are a marginalized and hard-to-reach population, and as their behavior is illegal, they carry on their activities in a covert fashion and frequently avoid using available treatment facilities. One of the greatest challenges in the HIV prevention efforts for high-risk drug users is effectively reaching this population with services. Opioid drug users, including those who use by injecting route, are a subgroup of drug users who could benefit most from drug dependence treatment and HIV/AIDS prevention services but are often the least likely to use these services. Hence, it is imperative to make efforts to reach out to them to study their characteristics and engage them in treatment.
Community-based treatment programs have emerged as an important way to reach various vulnerable groups and in this approach, treatment is made available to alcohol/drug affected individuals and afflicted families closer to their homes. This approach may have several unique advantages including increased access to care, affordability, flexibility, and reduced stigma and is well-designed to access hidden, marginalized populations. Community-based programs are designed specifically to engage and retain drug users and to reduce harm while not requiring individuals to completely abstain from illicit drug use.
As a part of its community-based treatment program and an attempt to develop a low-cost intervention program for high-risk substance users, National Drug Dependence Treatment Centre, AIIMS initiated community clinic services for drug users at Sunder Nagari, in Delhi. The aim of the present study is to describe the demographic and clinical characteristics of opioid drug users attending this clinic.
| Methods|| |
The community sample was recruited from Sunder Nagari, East Delhi, which is an urban resettlement colony plus jhuggi cluster (shanty dwelling) with a permanent population of around 60,000 and a migratory population of 15–20,000. This area has a high prevalence of opioid drug users and is inhabited largely by people from the lower socioeconomic strata. This activity was done in collaboration with a nongovernmental organization (NGO) (St. Stephens Hospital), which was providing community services in this area for the last 20 years.
Provision of treatment was started at the Community Center of St. Stephen's, which was located in the heart of the community. Both pharmacological and psychosocial modalities of intervention were provided. Buprenorphine was provided as maintenance treatment for opioid-dependent drug users and was dispensed in a daily supervised manner. Buprenorphine-naloxone combination was provided on holidays to reduce the risk of misuse of medication. Psychosocial and educational intervention comprised of low-intensity group and individual intervention as well as the distribution of information and education material. HIV risk reduction counseling was provided to all drug users. Referral was done to other medical facilities located in the vicinity, if required. This included directly observed treatment clinic for antitubercular treatment, screening for HIV (voluntary counseling and testing center) and antiretroviral treatment, and treatment for comorbid medical disorders.
Inclusion criteria were patients of either sex with current opiate dependence who were above the age of 18 years, from a defined catchment area in Sunder Nagari and patients currently not in substance abuse treatment for last 1 month. Patients with associated current psychiatric co-morbidity and those with severe physical complications were excluded from the study.
The sociodemographic and drug use history of opioid drug users were recorded on drug abuse monitoring system  questionnaire and a brief semi-structured proforma. This included information about demographics, drug use history, high-risk behaviors, history of medical complications and treatment history, and details of current treatment provided. The total number of subjects recruited over 12 months period was 104.
| Results|| |
Around 21% of these patients were recruited through street outreach, especially in the initial stages. The drug users were recruited from sites they used to congregate in such as isolated shanties or public toilets. Further recruitment occurred through snowballing.
Majority of opioid-dependent (mainly heroin) drug users (n = 104) were male (97.1%). Around 40.4% of the sample was young drug users belonging to the 18–25 years age group. Most were married (58.7%) and belonged to a nuclear family (48%), 33% were illiterate, and a large number (42%) were presently unemployed.
Drug use characteristics
Heroin was the primary drug of abuse in majority of the patients (97%). Most of the subjects were polydrug users with concomitant use of cannabis (50%), alcohol (28%), and tobacco (91%). Heroin was used both by chasing and injectable route. The mean age of initiation of opioid use (in years) was 20.3 ± 7.3, and mean duration of opioid use was 10.8 ± 8.9 years.
Injectable drug use
Among the opioid-dependent males attending the clinic, around 67.3% had a history of injecting drug use while 49% were current (last 1 month) injecting drug users. The mean age of initiation of injectable drug use was 24.4 ± 9.0 years, and mean duration of injectable drug use was 3.2 ± 2.3 years [Table 1]. The predominant opioid that was injected was heroin. A total of 78% reported sharing of syringe and needles. The highest rates of injecting drug use were among those who were between the age of 18 and 25 years, unmarried, having some education, employed, and living in nuclear families. In the total sample of opioid drug users, 32% reported having sex with sex workers whereas a higher percentage of injection drug users (IDUs) (45%) reported such behavior. The significant risk factors for IDU were being unmarried (odds ratio [OR] = 3.6, confidence interval [CI] = 1.2–10.9) and having sex with sex workers (OR = 2.9, CI = 1.4–7.7). A highly significant linear relationship was found between the number of risk factors and IDU [Table 2].
| Discussion|| |
Opioid-dependent patients seeking treatment in community clinic, Sunder Nagari, were mostly males with 63% belonging to the 18–35 years age group, a sizeable proportion were illiterate (33%) and unemployed (42%) and most were married. Most were chronic opioid users with the mean duration of opioid use of around 11 years. Heroin was the primary opioid used in this community and was used both by chasing and injecting routes. Initiation of opioid use was at a young age with a mean of 20 years. In another study  from a community clinic, (which targeted all drugs of abuse) located in an urban resettlement colony, in East Delhi, among a total of 754 patients registered at the clinic during the 1-year (2005–2006) period; heroin was the primary drug of use for 63% of the patients. Patients in this community were comparable in their marital status (63%) and rates of illiteracy (35.5%), chronicity of use (mean duration of 10.7 years [standard deviation = 8]) but had a greater proportion of patients (77.8%) who were employed. However, the proportion of users who were injecting drug users (17.47%) was lower than what was found in this study.
Almost half of the opioid users registered in our clinic were current injecting drug users. The highest rate of injecting was seen in the younger age range of 18–25 years and most IDU were single. Initiation of injecting drug use was later than that of chasing at around 25 years, and mean duration of injectable drug use was 3.2 ± 2.3 years suggesting that most were recent injectors. Heroin was mostly mixed with pheniramine for injecting. Majority (78%) reported sharing syringes and needles. The significant risk factors for IDU were being unmarried and having sex with sex workers.
These findings were somewhat similar to a previous NGO-based study of IDUs in Delhi and Imphal. In Delhi arm, the majority of male IDUs were single, in unstable and multiple sexual relationships, and engaged in commercial sex with both male and female partners and had a similar age of onset of injecting drug use (26 years). However, IDUs in this study reported greater use of semisynthetic opioids such as buprenorphine. The findings among IDUs in Imphal were different in that patients were mostly married and lived with their families but had higher levels of unsafe injecting practices. In addition, IDUs in Imphal were not recent injectors but rather had been injecting for longer periods of time and had established injecting practices. Another study from the North-East where initiation into injection drug use was seen at an earlier age, majority did not report sharing and different compounds, such as spasmoproxyvon, were injected. The sociodemographic profile of IDUs in a size estimation of IDU study carried out in Punjab, Haryana, and the Union Territory of Chandigarh was similar to what was found in this study. The findings revealed that most IDUs across different sites belonged to the age group of 18–30 years and large proportion had started injecting only recently (i.e., 3–7 years) and a large number – ranging from 34% to as high as 94% – reported having shared their injecting equipment. However, the compounds injected were different and included subjects who mostly injected pharmaceutical preparations such as buprenorphine, pentazocine, and a variety of sedatives (for example, diazepam, promethazine, and pheniramine).
Hence, across India and even within the same region considerable heterogeneity is seen in the profile of IDUs. It is important to study and document this heterogeneity, especially in the context of India being home to about 177,000 IDUs with an estimated HIV prevalence of 7.1% nationally, and this is the highest among high-risk groups. Delhi has the second highest HIV prevalence among injecting drug users in India at 18.3% and an estimated IDU population of approximately 17,000. Different prevention strategies and treatment approaches may need to be employed according to the risk profile seen such as young and unmarried IDUs in this study. For example, different behavior change strategies may be required for recent injectors, as seen in Delhi, as compared to long-term injectors with established behaviors, as seen in Imphal and, therefore, require need-based tailored prevention interventions. A lot is being done in this direction with NACO providing HIV prevention services to high-risk groups, including IDUs, through targeted interventions (TIs) delivered by NGOs. Despite the government's TI efforts, significant gaps in coverage exist. Multiple strategies are needed to cover these gaps such as outreach-based interventions, peer-driven interventions, and community-based treatment programs. Expansion of community-based treatment programs is required to engage, define their profile, and retain high-risk injection users and ensure accessibility to those who are in dire need for these services. This is essential to reducing transmission and acquisition of blood-borne infections among IDUs.
| Conclusions|| |
There is a need to understand the unique characteristics of high-risk groups so that efficient ways are devised to reach IDUs with prevention interventions. Taking treatment and preventive facilities to their doorstep through expansion of community-based treatment and preventive strategies may be important to engage and retain opioid drug users in treatment.
This is a study done in a clinic setting among treatment-seeking opioid-dependent individuals. The findings of this study are not generalizable to other communities or urban resettlement colonies.
The study underscores the need to study the characteristics of opioid and injecting drug users in a particular community as there may be considerable heterogeneity in their profile across communities and regions. Community-based preventive and treatment interventions may be targeted according to the needs identified in a particular community.
Dr. Amod Kumar, Professor and Head, Department of Community Medicine, St. Stephen's Hospital, Delhi.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Sharma HK. Community-based treatment of substance use disorder. In: Lal R, editors. Substance Use Disorder: Manual for Physicians. 1st
ed. New Delhi: National Drug Dependence Treatment Centre, AIIMS; 2005. p. 1-8.
Ray R. The Extent, Pattern and Trends of Drug Abuse in India: National Survey. Ministry of Social Justice and Empowerment and United Nations Office on Drugs and Crime; 2004.
Balhara YP, Ranjan R, Dhawan A, Yadav D. Experiences from a community based substance use treatment centre in an urban resettlement colony in India. J Addict 2014;2014:982028.
Sarna A, Tun W, Bhattacharya A, Lewis D, Singh YS, Apicella L. Assessment of unsafe injection practices and sexual behaviors among male injecting drug users in two urban cities of India using respondent driven sampling. Southeast Asian J Trop Med Public Health 2012;43:652-67.
Kermode M, Longleng V, Singh BC, Hocking J, Langkham B, Crofts N. My first time: Initiation into injecting drug use in Manipur and Nagaland, North-East India. Harm Reduct J 2007;4:19.
Ambekar A, Tripathi BM. Size Estimation of Injecting Drug Use in Punjab and Haryana. New Delhi: SPYM and UNAIDS; 2008.
National AIDS Control Organization (NACO). Ministry of Health and Family Welfare, Government of India: Annual Report 2011-2012. New Delhi; 2012.
National AIDS Control Organization (NACO). Government of India: National AIDS Control Programme, Phase III, State Fact Sheets. New Delhi; 2012.
Tun W, Sebastian MP, Sharma V, Madan I, Souidi S, Lewis D, et al.
Strategies for recruiting injection drug users for HIV prevention services in Delhi, India. Harm Reduct J 2013;10:16.
[Table 1], [Table 2]