Indian Journal of Social Psychiatry

INVITED PERSPECTIVE/VIEWPOINT
Year
: 2021  |  Volume : 37  |  Issue : 4  |  Page : 360--365

Community management of substance use disorders: Past, present, and future


Kshitiz Sharma, Tathagata Mahintamani, BN Subodh, Debasish Basu 
 Department of Psychiatry, Drug De-addiction and Treatment Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, India

Correspondence Address:
Dr. Debasish Basu
Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh
India

Abstract

Substance use disorder (SUD) is a common entity in the Indian population, with a huge treatment gap of around 90%. Poor availability, accessibility and acceptability due to various reasons contribute to the treatment gap. The management of SUD at the community level can reduce this gap. Various private, government, and nongovernmental organizations (NGOs) are the leading agencies to provide pharmacological and nonpharmacological treatment at the community level in India. Historically, addiction treatment “camps” were efficient, cost-effective, and resource-saving community treatment approaches. Conventionally, there has been an attempt to integrate SUD treatment in primary healthcare, but this requires training and resource development at the community level. Outreach clinics, organized by tertiary care hospitals, help in training and research, besides catering to the community need for treatment. NGOs also help in the provision of treatment, awareness generation and capacity building at the community level. Currently, integration of screening and brief intervention with primary care is being tried in various community setups. This approach would be more effective with an efficient referral system. Telemedicine emerged as a new tool during the Coronavirus disease-19 pandemic. Telemedicine has been efficiently incorporated in the hub and spoke model and has been found to enhance the community treatment of difficult to reach patients with SUD. Various modifications in telemedicine help in more efficient diagnosis, decision-making, and treatment. Proper integration of multiple approaches can help in effective service delivery in a resource-limited setup in the community.



How to cite this article:
Sharma K, Mahintamani T, Subodh B N, Basu D. Community management of substance use disorders: Past, present, and future.Indian J Soc Psychiatry 2021;37:360-365


How to cite this URL:
Sharma K, Mahintamani T, Subodh B N, Basu D. Community management of substance use disorders: Past, present, and future. Indian J Soc Psychiatry [serial online] 2021 [cited 2022 Jan 23 ];37:360-365
Available from: https://www.indjsp.org/text.asp?2021/37/4/360/331126


Full Text



 Substance use Disorder in the Community



Substance use disorder (SUD) is a common entity in the community. Globally, alcohol use disorder was the most prevalent among SUDs, with an estimated prevalence of around 1.3% in the community. Cannabis was the most commonly used illicit substance worldwide. The estimated prevalence of cannabis use disorder was around 0.29% worldwide.[1] A nationwide survey in India has revealed that around 2.7% of the Indian population is dependent on alcohol, whereas approximately 0.25% of the population is dependent on cannabis and opioids, respectively.[2] Tobacco use (both in chewable and smoked forms) is highly prevalent in India, with a population prevalence of around 21.4% as estimated in 2016–2017.[3] The trend has been gradually reducing in the last couple of years. However, unlike other substances, a large proportion of the female population uses tobacco, especially in chewable forms. In the last decade, tobacco use is also declining among the youths, although 8.5% of the population aged between 13 and 15 years consumes tobacco currently.[4]

 Why is Community Approach to the Management of Substance Use Disorder Needed?



The treatment of SUD was traditionally fraught with various issues including poor standard of care and limited availability, accessibility, and acceptability.

Various surveys show a rising trend of SUDs (such as alcohol and opioids) in India, whereas the treatment gap remains wide across various substance use and sociodemographic variables. The treatment gap of alcohol use disorder in Indian adults was around 86.3% as per the National Mental Health Survey (NMHS).[5] The treatment-seeking is low in the alcohol and psychotropic substance-using population. The recent magnitude of SUD in India study revealed that only about one-fourth of patients who tried quitting alcohol and psychoactive substances could access any form of treatment. When we see the proportion concerning the total substance-using population, it is found that around 2.6% of alcohol-dependent patients and 12% of SUDs can access any form of treatment.[2] The scenario is similar in the younger patients also. It is found that around 25%–30% of patients initiated their substance use during their adolescence, whereas among the treatment seekers, the adolescent population comprised <5%.[6] This indicates an interplay of multiple factors related to treatment service, service provider and utilizers, as well as various socioeconomic and political factors.

Service provision related factors

The drug de-Addiction program of the Ministry of Health and Family Welfare, Government of India, established around 122 addiction treatment centers across the country, but on repeated assessment, it was found that the capacity building, community involvement, and record-keeping were inadequate in most of the centers. The meager numbers of new patients, as well as poor treatment retention rate, further highlight the issues. The Drug Treatment Clinic scheme is emerging and being closely monitored. It is still now in the phase of expansion. Despite this, accessibility is a big issue in the Indian population.[7]

Service utilizer related factors

These are further complicated by the poor treatment-seeking from the patients due to inadequate knowledge, poor motivation and fear of stigma or other social and legal consequences. Unfortunately, the major barriers remained similar across the past few decades, and besides accessibility and affordability issues, treatment cost, embarrassment, inability to share the problem, stigma have been major limiting factors for treatment initiation in SUD.[8],[9] In India, the time conflict also poses a major limiting factor.[10]

Service provider related factors

The service providers (like doctors and nurses) often bear a negative outlook towards various components of addiction treatment. In most cases, the “addicts” are seen in a negative light and considered to lie, prone to crime and or aggressive behavior, which often leads to undue penalization and delay or sometimes denial of treatment.[11] It is also found that with training and understanding, the negative attitude improves to a significant extent.[12]

Other factors

Some other factors impairing treatment seeking are the long-distance of the center, long waiting period, etcetera.[10] There is also a negative perception regarding some treatment approaches in different stakeholders. For example, in India, opioid substitution treatment is often seen in a negative way by the family members as well as some of the policymakers.[13]

The limited availability of treatment for SUD and the other service provision-related issues indicate that community provision of treatment for SUD is a pressing need at present.

The community approach for the management of SUD inherently includes preventive, therapeutic and rehabilitative aspects. For the scope of this article, we would like to focus on the treatment-related aspects only. The preventive and rehabilitative aspects in the community are extremely important but are beyond the scope of this focused commentary.

Service Pathways at the Community Level

The medical and rehabilitative treatment for SUDs at the community level is provided mostly by the various private, government, and NGOs. Different self-help groups (i.e., Alcoholics Anonymous, Narcotics Anonymous, etc.) and religious groups also provide valuable support for SUD treatment. Usually, the private setups provide service in exchange for fees from the patients, whereas the government bears a large part of the government setup expenses. The NGOs often get initial and recurrent grants from the Ministry of Social Justice and Empowerment to run addiction treatment services. Although the sources of service providers appear to be discreet, the service users often shuffle from one service pathway to the other depending on the availability, access, and acceptability. Usually, the service pathways provide complementary and concurrent services at the community level.[14]

 Approaches in the Past



Various community-based treatment approaches were taken for the treatment of SUDs in the past. Camp, community clinic, and NGO run approaches are predominantly tried in India.

Camp approach

The camp approach is considered to be a cost-effective way for treating SUDs.[15] It has an added advantage of direct involvement of the community. The camp organization is a planned activity with regular coordination with the community leaders, announcement, communication through various means, etc. Camps can be arranged for a couple of days for detoxification, or it can be a single-day camp to provide initial care. The resources are usually mobilized from a higher center, and patients are referred to the nearest outreach clinic after the camp is over.[16] There is an encouraging response to the camp approach in various parts of India. It has been seen that in some settings, the camp approach can have better treatment retention and better recovery rates. Some proposed mechanisms are easy to access to treatment and involvement of the family members, along with the easy accessibility to acute care and follow up treatment.[17]

Integration of service with community care center

Another approach was to integrate addiction treatment services with the community treatment center. This approach was initiated in the 1970s. Sakalwara and Raipur Rani Projects were two major projects to test the feasibility of this approach. In both the projects, the psychiatry team trained the primary health workers regarding the identification and care of various mental illnesses. Although it was found that the primary care health workers were enthusiastic regarding the training to diagnose psychiatric illness, their role in imparting curative care was somehow inconsistent across the studies.[18] Besides this, SUD was not the main focus in both the projects. In the Sakalwara project, it was seen that a more detailed evaluation helps in diagnosing substance-related problems in a better way.[19] On the other hand, the Raipur Rani project algorithm showed that the presence of SUD and mental illness warranted referral at a higher center.[20]

The “Punjab model” of addiction treatment also proposes an integrated treatment model with a broad community base comprising general healthcare providers, including health workers (i.e., Accredited Social Health Activists and Multipurpose Health Workers). The general duty medical officer is expected to identify the SUD, document, provide initial management and, if necessary, refer to the higher center (i.e., district hospital). The district hospitals and the psychiatrist posted there are expected to be the most important resource person in the model. For effective implementation, there should be necessary training, provision of medications, and other resources as well as a cross-referral system, including the option of vertical and lateral entries [Figure 1].[21]{Figure 1}

Community outreach clinic

Although prior to the above-mentioned community care integration initiatives, there were some standalone community outreach clinics, these experimental projects had a widespread effect on community psychiatry in India. On one hand, these paved the way to formulate the National Mental Health Programme, which later on led to the initiation of the District Mental Health Programme in India. On the other hand, it had set a clear direction toward establishing community outreach clinics to provide psychiatric outreach clinics in difficult to reach areas. The community outreach clinics were mostly oriented to service provision and source of referral rather than training and capacity building. One study in an urban setup shows that regular follow-up through a community clinic leads to significant improvement in the number of nondrinking days longitudinally after discharge from an inpatient facility.[22] The data from these clinics also give much-needed insight into the magnitude of substance-related problems and the treatment needs of the community. In one such study from Chandigarh, it was found that the preferred nature of opioids in the addiction treatment outreach clinics, catering for the general population, was different from those catering the population associated with transport business.[23]

Role of nongovernmental organizations

Various NGOs assume a significant role in the prevention and treatment of SUDs. The NGO and government organizations interact to (i) exchange information, (ii) pilot-testing of government initiatives, and (iii) large scale replication of innovations achieved by NGOs. Currently, there are more than 400 NGO-run addiction treatment centers.[14]

NGOs are supported by the Central Sector Scheme to prevent and treat alcohol and SUD s. NGOs provide important support in all three demand reduction approaches under Narcotic Drugs and Psychotropic Substance Policy 2012.

Dealing with the patients with SUD through program of motivational counseling, treatment, follow-up, and social reintegration are conducted through the Integrated Rehabilitation Centre for Addicts (IRCA)Through Regional Resource Training Centres (RRTC), large NGOs help to impart drug abuse prevention/rehabilitation training to volunteersBoth the IRCAs and RRTCs help in building awareness and educating people about the ill effects of drug.

 Approaches at Present



Integration of screening and brief intervention in primary care

The integration of full-scale SUD treatment facilities in primary healthcare is difficult to achieve due to budgetary constraints and less manpower. An alternative approach will be to incorporate screening and brief intervention (SBI) with the primary care or emergency setting, and facilitating referral to specialist care if there is a felt need. There is some experimentation in the Indian context, and in two instances, SBI was provided from the primary care service. The interventions are linked to the Alcohol use disorder Identification Test or Alcohol Smoking and Substance Involvement Screening Test score screening and are brief lasting for 30–45 min. The number of sessions varied from a single session up to four brief sessions. The interventions were mostly directed to alcohol use and the result was encouraging in terms of reduced alcohol consumption and improved quality of life on follow up assessments.[24],[25] Another study assessed the efficacy of nurse-delivered SBI among college students in an urban setting. Although the study was conducted in a tertiary care setting, the nature of service provision (single session BI delivered by nurse) and the service users show that this kind of service can aptly be provided in primary care set up. There was a significant reduction in alcohol consumption in the BI group on three months follow up.[26] Although integration is not widely practiced in the primary care set up, a recent review suggests that integration is a feasible and effective approach to treat alcohol use disorder in the community.[27]

Emergence of teleconsultation

From the last decade of the 21st century, teleconsultation started emerging as a new approach to reach the unreached. Fully automated, internet-based, computerized, clinical decision support system was formulated at our institute. It helped the general physician reach a diagnosis and recommend necessary pharmacological and nonpharmacological treatment. It was found to be a highly reliable and feasible intervention, with sufficient sensitivity and specificity.[28]

The effect of coronavirus disease-19

The community approach to the treatment of SUD suffered heavily during the Coronavirus disease-19 pandemic. As there was nationwide lockdown and restriction to movement, the community outreach clinics suffered. The plight of the service users with SUD aggravated manifold, as there was a sudden stoppage of the sell of alcohol and tobacco products due to lockdown. This led to a sudden rise of complicated alcohol withdrawal,[29] consumption of adulterated and nonconsumable alcohol, criminal activities to access alcohol, and attempted or completed acts of suicide. Although some discreet attempts were there to use this abrupt and forced cessation as an opportunity to treat alcohol use disorder, there was almost no coordinated attempts from the states in this regard.[30] Regarding medication-assisted treatment for opioid use disorder, the National AIDS Control Organization and Outpatient Opioid Assisted Treatment Clinic systems were operational. There was a difficulty as patients were unable to attend the clinic. To address this, various adoptive measures such as providing take-home medication (where daily attendance was mandatory) or increasing the duration of take-home medications were initiated. Besides this some systems started providing medication by proxy, especially for the patients who are quarantined or living in a containment zone.[31]

Hub and spoke model in teleconsultation

The teleconsultation approach emerged as an alternative to provide treatment during the difficult time. The telemedicine practice guideline was shortly followed by the telepsychiatry guideline from the National Institute of Mental Health and Allied Sciences, Bengaluru, (NIMHANS).[32] In NIMHANS, a teleconsultation based hub and spoke model was used to provide training and treatment for SUD in the community. Initial assessment showed an encouraging result in terms of participation in the training.[33] During the pandemic, this system was further expanded, and the e-consult service was initiated where the trained personnel could interact with the team in the hub through teleconsultation (smartphone or e-mail-based synchronous or asynchronous communication). The involvement was encouraging as there were more than 1800 views within 2 weeks of the inception of lockdown, and more than 100 healthcare providers took the help of e-consult during that period.[34]

 Future Approaches



Telemedicine-scope of improvement

Telemedicine appears to be one of the suitable options to provide treatment of SUD at the community level. This saves time and expenses, but at the same time, this approach is fraught with some drawbacks. One major drawback is the inability to perform a detailed physical examination. During video consultation, the inspection is possible, and to address this drawback, virtual physical examination “on rest” and “on instruction” is proposed.[35] Besides this, a unique limitation of teleconsultation in psychiatric disorders and especially SUD is the difficulty to pick up various nonverbal cues during virtual consultation. This problem is likely to accentuate in India due to the frequent lack of a stable and high-quality internet connection. There are some other concerns for the effective implementation of telemedicine in the treatments of SUDs. The use of benzodiazepines (except clonazepam) in teleconsultation is banned as per the currently existing telepsychiatry guidelines. On the other hand, there is clear-cut barrier in providing partial agonist and complete agonists through teleconsultation.[36] Apparently, the “abuse potential” of benzodiazepines and opioid agonists are a major concern, but that cannot explain the exemption of clonazepam.

Early diagnosis and referral

The future approach to the community treatment of SUD should focus more on early detection of the problem at the community level. This warrants more extensive training regarding SUDs among medical and nursing students. The incorporation of psychiatry training in the MBBS curriculum would help reduce the huge treatment gap and expedite the referral process,[37] which would save both money and resources.

 Conclusion



The community management of SUD is an undeniably important need at present. At the same time, there are multiple limitations in the effective implementation of the service. The community outreach or teleconsultation approach from the tertiary care centers is likely to have limited effect unless there is an effective integration of service at the community level. There is a necessity of awareness and empathetic understanding among general healthcare providers to achieve this target. This would further facilitate early detection of the problem and prompt treatment.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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