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Table of Contents
CONCEPT ARTICLE
Year : 2019  |  Volume : 16  |  Issue : 1  |  Page : 43-48

Community-based management of opioid use disorder: Role of nursing professionals and paramedical workers


1 Senior Resident, Department of Psychiatry and NDDTC, AIIMS, New Delhi, India
2 Assistant Professor, Department of Psychiatry and NDDTC, AIIMS, New Delhi, India
3 Associate Professor, Department of Psychiatry and NDDTC, AIIMS, New Delhi, India

Date of Web Publication14-Oct-2019

Correspondence Address:
Dr. Roshan Bhad
Department of Psychiatry, NDDTC, AIIMS, New Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/IOPN.IOPN_14_19

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  Abstract 


Magnitude of the opioid use problem is high globally, as well as in the India, as has been reported in various global and national epidemiological surveys on substance use disorder. There is a marked gap between the burden of substance use problems, particularly opioid use-related problems, and treatment services. Many international organizations have recommended an integrated model of treatment to overcome this gap. Community-based treatment services help in catering to the large population of the opioid using individuals, especially the hidden, marginalized population. The newer model of low threshold approach to treatment has gained popularity among the opioid using population. Further, it plays a significant role in reducing stigma attached to opioid users and also enhances treatment seeking. Community opioid use treatment setups, being located in the community itself, are in unique position to promote community participation and integrate local resources. Such treatment centers play a crucial role in promotive, preventive, therapeutic, and rehabilitative services for individuals with opioid use problems. Paramedical staff/nursing staff play a significant role in providing opioid use treatment services such as supervised dispensing, observing signs of opioid withdrawal and also of intoxication, intervening in case of opioid overdose, and also acting as bridge between the treatment-seeking population and the specialist doctor.

Keywords: Community-based treatment, community nursing, India, opioid use disorder, paramedical staff, psychiatric nursing, substance use disorder


How to cite this article:
Dhagudu N, Gupta S, Bhad R, Rao R. Community-based management of opioid use disorder: Role of nursing professionals and paramedical workers. Indian J Psy Nsg 2019;16:43-8

How to cite this URL:
Dhagudu N, Gupta S, Bhad R, Rao R. Community-based management of opioid use disorder: Role of nursing professionals and paramedical workers. Indian J Psy Nsg [serial online] 2019 [cited 2019 Nov 22];16:43-8. Available from: http://www.ijpn.in/text.asp?2019/16/1/43/269157




  Introduction Top


The magnitude of the opioid use problem around the world can be determined by the fact that globally 34 million people are opioid users, while the figure for opiates is 19 million.[1] The latest world drug report highlights that opioids are implicated in about 76% of the drug-related mortality.[1] Similarly, in India, opioid use and dependence is a major substance-related public health problem with a national estimate of 2.3 crores (2.1% of total population) current opioid users, of which 77 lakhs (0.7%) are problem opioid users and 28 lakhs (0.26%) are dependent on opioids.[2] Further, the survey estimates the prevalence of person who injects drug to be 8.5 lakhs. Despite the huge burden of opioids and other illicit drug use in the country, there has been a significant treatment gap, as has been reported in various national epidemiological surveys.[2],[3],[4] The recent national survey observes that only in one out of four individuals who are dependent on illicit substance ever received treatment and only one in twenty dependent individuals received inpatient treatment.[2] When it comes to mental health service resources in India, the number of mental health professionals are small; for instance, there are only 0.29 psychiatrists/one lakh population against the required norm of 3/one lakh.[5] Although treatment program for substance use disorder is heavily focused on inpatient/hospitalization (in a “de-addiction center”) treatment facilities, such services are few in our country; hence, it is imperative for community-based services and integrated response mobilization to manage this public health issue.[6]

United Nation Office of Drugs and Crime has recommended a specific integrated model of treatment for opioid users or dependence patients in the community that can provide a continuum of care through outreach and low threshold services ranging from detoxification or withdrawal management and stabilization to aftercare and integrative linkage services including maintenance pharmacotherapy.[7],[8]


  Characteristics of Community-Based Treatment Top


The community-based treatment strategy is characterized by its unique model of service delivery, which can be enumerated as follows:[9]

  • Location in the community itself
  • Community empowerment – It mobilizes and empowers the community by incorporating community participation and utilizing its resources
  • Biopsychosocial approach – By utilizing the community resources, it can provide services that are holistic and biopsychosocial driven
  • Primarily outpatient setting – It primarily provides services through the outpatient setting, which are more abundant than its inpatient counterpart and utilizes referral services as and when required
  • Continuum of care model – It incorporates screening, assessment, brief intervention, rapid access to the addiction medicine/clinics, community outreach services, withdrawal management, pharmacological as well as psychosocial interventions and recovery, sustaining wellness, and ongoing care[9]
  • Integrated into community health and social services
  • Voluntarily accessible and affordable.



  Objectives of Community-Based Treatment Top


The community-based treatment approach has the following objectives:

  • To develop the skills to manage the opioid use problems like early identification and assessment of the severity of opioid use disorder and treat the opioid withdrawals with effective evidence medicines and possible maintenance options
  • To stop or reduce the use of opioid drugs
  • To reduce the harms by harm prevention services such as needle syringe programs and linkage services with the nearby local health system
  • Respond to needs of the opioid users and ensure the best possible outcomes
  • Active engagement with local organizations or existing nongovernment organizations (NGOs) in the community thereby empowering them
  • To reduce the demand or need for residential or custodial services
  • Mobile methadone services in a specified location in the community to provide medicines to the registered/stabilized patients (in their vicinity) and thus overcome the peer influence and other logistic barriers.



  Benefits of Community-Based Treatment Top


The community-based treatment strategy has multiple benefits:

  • It facilitates access to treatment
  • Affordable to patients, families, and to the community as a whole
  • Appealing to patients
  • Fosters patient independence
  • Flexible as compared to other treatment modalities
  • Focus on family or social integration right from the beginning of the treatment
  • Less intrusive approach
  • Facilitates the reduction of stigma not only at an individual level but also at the macro level, thereby promoting community expectation of positive outcomes.



  Principles of Community-Based Management of Opioid Use Disorders Top


The community-based treatment programme is governed by the following principles:[10]

  1. Availability and accessibility of evidence-based medicine for opioid use disorders such as buprenorphine and/or buprenorphine and naloxone combinations and/or methadone along with other essential medicines to manage the individuals with opioid use problems in the outpatient settings
  2. Capacity building to provide screening, assessment, diagnosis, and long-term treatment plan
  3. Evidence-based promotive, preventive, and treatment services
  4. Ensuring rights-based services and fostering the dignity of the patients with opioid use disorder by taking appropriate measures
  5. Targeting special population – like providing harm reduction services to Injecting Drug Users (IDUs) or gender-sensitive services for females and gay lesbian bisexual and transgender (LGBT) population
  6. Involvement of and integrating criminal justice system
  7. Promoting community funding through orienting the patients and community and thus increasing their participation
  8. Clinical governance of treatment services – Policies framing, setting up of rules and protocols, formulating sensitive definitions, and last but not the least strengthening financial reasoning
  9. Treatment systems – Strategic planning to reach up to the needy population of the community by utilizing the services of peer educator, outreach workers, NGOs; coordinating among those services and thus develop the treatment policies.



  Strategies to Provide Community-Based Treatment Services for Opioid Use Disorders Top


A. Following strategies are useful when providing community-based treatment of opioid use disorders[11]

  1. Identify the concerns of the heterogeneous opioid using population ranging from opioid users to injecting drug users (IDUs), the hidden marginalized population
  2. Identifying resources – Including funding, place of dispensing, utilizing existing health system, soliciting the support of local leaders and local police people to ease up the administrative issues
  3. Problem-solving – Stepwise prior establishment and also to ongoing measures to tackle upcoming problems
  4. Referral system establishment – to linkage services with tertiary care or specialist services when it required
  5. Expert support.


B. The setting of treatment

Community clinics cater to the need of the individuals with opioid use problems who belong to a nearby geographic area, with an intention to provide evidence-based medicines like Buprenorphine and Methadone to opioid use disorder population. The prerequisite to receive treatment services from these centres usually follow a low threshold model, coupled with harm reduction services to reduce immediate risk in lives of the service users and provide a pathway into drug stabilization, reduction or further treatment for substance use.[11] Additionally, these services have better acceptance among the problem opioid users, leading to greater attraction towards availing such services and eventually helping in reducing stigma in seeking treatment.[12] The community drug treatment services are at a better position to utilize services of the NGOs and also integrate with other specialty treatments whenever required for a person by referring to nearby specialty hospitals as well as to primary health care centres. Further, community clinics also serve as a relay centre for opioid use disorder patients who have serious issues or require inpatient stabilization. They refer and engage with specialized centres and once the acute care in specialty addiction treatment centres is over, the individuals can re-enter into the community clinics and continue their recovery interventions with full potential.

Community-based services can also integrate with the existing primary health care system by providing training to primary health care staff about the intricacies of opioid use disorder management like identification of intoxication and withdrawals, establishing the referral system and building competency in delivering brief interventions and Screening Brief Intervention and Referral to Treatment (SBIRT) services. Office-based opioid treatment services which have the option of take-home medication to overcome the barriers in clinic-based treatment still needs to be operationalized all over the country because of policy related constraints, as a result, this public health issue limits the availability of health facility.

C. Steps in Providing Community Opioid Use Treatment Services

This includes[11]

  1. Screening for problematic opioid use and intervene early and refer for proper assessment
  2. Assessment – To assess in details those who found positive in the screening tools
  3. Detoxification or opioid withdrawal management
  4. Medication (medication-assisted treatment)


    1. Long term maintenance – Antagonist (naltrexone) and Opioid Substitution Therapy (OST) (buprenorphine and methadone)
    2. Overdose management
    3. Innovative strategies for treatment
    4. Innovative strategies for prevention of diversion like a buprenorphine–naloxone combination.


  5. Counseling
  6. Family interventions
  7. Nonpharmacological/psychological interventions
  8. Vocational training
  9. Income generation
  10. Mutual support
  11. Aftercare services.


Opioid Substitution Therapy (OST) in India

In India, buprenorphine (tablet formulation) and methadone (syrup form) are prescribed as a form of OST. Similar to many other countries, trained nursing professionals usually perform supervised dispensing of OST in India. Their basic training includes knowledge about dispensing, monitoring signs and symptoms of opioid withdrawal and opioid intoxication and intervening appropriately. Hence, in community opioid use treatment setting, with minimum training, nursing professionals /para-medical workers can dispense medicines with a specialist doctor/medical officer supervising their work on a weekly/ twice weekly basis. A number of studies have shown that supervised dispensing of OST (particularly Buprenorphine) results in better outcome and reduced risk of diversion.[13] Buprenorphine use as OST started in India since 1989. A nongovernment organization (NGO) in New Delhi also started OST (Buprenorphine) in community settings in 1993. Initially available as 0.2 mg tablet, currently 0.4 mg and 2 mg tablets with and without combination of 0.5 mg naloxone is available for treatment in India.[14]

Whereas, Methadone was only introduced in year 2012. Methadone as OST is available in syrup form (5mg/ml). Treatment induction is done in starting dosage of 15-20 mg, and dosage can be optimize every 4th day depending of improvement in craving and withdrawal symptoms. Most patients with opioid use disorders maintained well on 40-120 mg of Methadone. Nursing professionals needs additional training in dispensing Methadone, due to associated side effects including overdose related deaths with this medication. Although Methadone is less safer than Buprenorphine, it is one of the most commonly used form of OST in the world. As it manages craving for opioids effectively and there is less risk of diversion. Nausea, vomiting and sedation are commonest side effects reported with Methadone and many times dosage adjustments are required during dispensing. Due to its lethal side effect of overdose, reinduction on initial dosage is must be done whenever patient is absent for 5 or more days from treatment, demanding increased need for supervision and expertise in opioid overdose identification and management by nursing professionals dispensing the Methadone.[15]


  Opioid Overdose Identification and Management in Community Setting Top


Opioid overdose characterized by the “triad” of (1) reduction of respiratory rate (below 12 breaths/min), (2) unconscious spell, and (3) pinpoint (small) pupil. Clinically, these can be identified early by looking for signs such as over sedation with nodding (closes the eyes with forwarding bending of the neck), bluish lips and peripheries, slurring speech, incoordination of movements, itching, and vomiting. Such potentially fatal complications can be identified and managed by adequate training to community clinic staff and paramedical workers.

Such cases should be managed as per the following guidelines:[16],[17],[18]

  • Should be seen as an emergency and call for help
  • Basic life supports need to be ensured to restore the vitals
  • Stimulate the patient so as to increase his/her wakefulness/consciousness
  • Keep the person in the recovery position
  • Ensure that the airways and the oral cavity are clean for any obstructions or objects or remnants of drugs
  • Naloxone (opioid antagonist) is a life-saving antidote for the management of opioid overdose
  • Naloxone (0.4 mg) should be given parenterally (intravenous or intramuscular), preferably at the gluteal region, upper arm or anterior part of the thigh.
  • Wait for 2–3 min for reversal of overdose symptoms like an increase in pupil size or increase the respiratory rate or gaining or rise in the consciousness level
  • If not, keep repeating the same dose till maximum dosage of 10 mg
  • Keep observing for the reappearance of overdose symptoms because of recirculating of absorbed opioid inside the body
  • Keep emergency naloxone tool kit ready, along with other emergency medicines such as pheniramine maleate, ondansetron, diclofenac, and others for supportive management purpose
  • Educate the patient about the seriousness of the condition and its recurrence chance in future after the recovery
  • Family members also need to be counseled
  • Peer-based interventions are needed as the bystander intervention could prove lifesaving
  • Education and promotion of knowledge regarding chance and outcomes of opioid overdose and its remedy available in the form of antidote, naloxone
  • Naloxone is available at the pharmacy as a prescription medicine in India.



  Role of Peer Networks in the Prevention of Opioid Overdose and Management of Opioid Use Disorder Top


Peer tutoring where individuals from similar networks can assist each other on how to tackle medical emergency needs like overdose management in their community is cost-effective strategy.[11] These peer networks can work in tandem with paramedical workers and nursing professionals for prevention of opioid overdose and management of opioid use disorder.


  Role of Nursing Professionals in Community-Based Management of Opioid Use Disorder Top


Nursing professionals can play a vital role in the community-based management of opioid use disorders. It includes promotive, preventive and therapeutic services for individuals with opioid use disorder, both at the rural and urban settings. They, being in the regular touch with the substance using populations, act as a link between the substance users and the substance use treatment specialist. They can also play a crucial role in the psycho-social rehabilitative services.[19] In some countries including India (recently started) provide opioid substitution treatment services through a unique model (methadone mobile dispensing clinic). Such services are primarily managed by the trained nursing professionals. They maintain records of patients, dispense medicines, refer to speciality care as and when required, and intervene in case of opioid overdose.[20]

Opioid Addiction Treatment Options available for Nursing Professionals Working at PHC/CHC

Supportive treatment options for opioid withdrawals and detoxification like NSAIDS, Diazepam etc., can be utilized in outpatient settings of PHC (Primary Health Care). Whereas at CHCs (Community Health Centres), opioid analgesics e.g. Tramadol is also available in addition to aforementioned medications as per essential drug list.[21] There is scope of provision of primary treatment in terms of opioid withdrawal and detoxification in patients with low level of opioid addiction. However, training in management of opioid withdrawal/detoxification and development of treatment protocols for PHC/CHC setting is must for optimum utilization of health care workers including nursing professionals. These services not only improve coverage of essential care but will also full fill the gap in treatment of opioid use disorder in the country.

Relevance of the Opioid Management by Nursing Professionals post-NMC Act, 2019

Nursing practitioners identified as mid-level medical practitioners in National Medical Council Act (NMC Act), 2019 along with pharmacists, physician assistants and optometrists.[22] Nursing professionals were already playing important active role in service delivery in various settings for opioid use disorders management. Additionally NMC Act 2019 allows limited license to prescribe specified medicines in primary and preventive healthcare settings and in other settings under the supervision of a medical doctor in government sector. Which means at Community health Centre (CHC) nursing professionals will be able prescribe essential drugs (Tramadol/NSAIDS/Diazepam etc.) which in turn will ensure pragmatic and symptom based management of opioid withdrawals treatment and relapse prevention management after requisite training and certification.. Similarly at PHC level symptomatic management for mild level opioid use disorders, early identification, assessment and referral services for moderate to severe opioid use disorders can be provided by nursing professionals with adequate training.


  Conclusions Top


A country like India needs to integrate speciality services with existing primary health care services in the community and involve other community based organizations like NGOs, peer networks and peer educators, civil society advocacy groups for enhancing access to evidence-based treatment like OST (Buprenorphine and Methadone) for patients suffering from opioid use disorder. Community based treatment of opioid use disorder through low threshold treatment model is cost effective, reduces stigma and improves access to the treatment. Further, it also improves coverage of with opioid use disorder treatment especially the marginalized groups like IDUs, women and LGBT population. Role of nursing professionals/ paramedical workers is of paramount importance as they form the backbone of community based opioid use disorder treatment services. In Low- and Middle-Income countries like India, where there is a significant gap between the burden of substance use problems and trained specialist nursing professionals by virtue of their skills and position health care system can act as a bridge between the patients suffering from substance use disorders and specialist doctor, and could be important resource personnel for providing substance use treatment services. Recent developments like limited prescription rights, professional development for mid-level practioners and separate professional registry will open new era of nursing practice for public health problems like opioid use disorder treatment in India.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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