Methadone maintenance treatment implementation indian experience

1. Methadone Maintenance Treatment
Implementation
- Indian Experience
Ravindra Rao
NDDTC, AIIMS
New Delhi
05/05/2015 1
Presented at the national CME "OST: Policy and Practice" on 18th-19th April 2015 at AIIMS, New Delhi

2. 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
05/05/2015 2
Presented at the national CME "OST: Policy and Practice" on 18th-19th April 2015 at AIIMS, New Delhi

3. 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)?
05/05/2015 3
Presented at the national CME "OST: Policy and Practice" on 18th-19th April 2015 at AIIMS, New Delhi

4. OST: THE PROMISE OF METHADONE
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?
05/05/2015 4
Presented at the national CME "OST: Policy and Practice" on 18th-19th April 2015 at AIIMS, New Delhi

5. OST: THE PROMISE OF METHADONE
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?
05/05/2015 5
Presented at the national CME "OST: Policy and Practice" on 18th-19th April 2015 at AIIMS, New Delhi

6. FEASIBILITY FINDINGS: PROJECT
INITIATION
• Clearances and approvals
05/05/2015 6
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

7. 05/05/2015 7
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
Presented at the national CME "OST: Policy and Practice" on 18th-19th April 2015 at AIIMS, New Delhi

8. 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
05/05/2015 8
• Made use of existing infrastructure
• All located in Government hospitals
– Location of the methadone clinic differed between
centres
Presented at the national CME "OST: Policy and Practice" on 18th-19th April 2015 at AIIMS, New Delhi

9. 05/05/2015 9
Community based MMT clinic, Delhi
MMT clinic, Manipur
Presented at the national CME "OST: Policy and Practice" on 18th-19th April 2015 at AIIMS, New Delhi

10. 05/05/2015 10
District Hospital based MMT clinic, Punjab
Presented at the national CME "OST: Policy and Practice" on 18th-19th April 2015 at AIIMS, New Delhi

11. FEASIBILITY FINDINGS: CLINIC
INFRASTRUCTURE
• Doctor’s room
• Nursing station/ Dispensing room
• Counsellor’s room
• Waiting area
05/05/2015 11
Presented at the national CME "OST: Policy and Practice" on 18th-19th April 2015 at AIIMS, New Delhi

12. 05/05/2015 12
NURSING
STATION
Presented at the national CME "OST: Policy and Practice" on 18th-19th April 2015 at AIIMS, New Delhi

13. 05/05/2015 13
Examination
room
Presented at the national CME "OST: Policy and Practice" on 18th-19th April 2015 at AIIMS, New Delhi

14. 05/05/2015 14
COUNSELLING
ROOM
Presented at the national CME "OST: Policy and Practice" on 18th-19th April 2015 at AIIMS, New Delhi

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

16. 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
05/05/2015 16
Presented at the national CME "OST: Policy and Practice" on 18th-19th April 2015 at AIIMS, New Delhi

17. 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
05/05/2015 17
Presented at the national CME "OST: Policy and Practice" on 18th-19th April 2015 at AIIMS, New Delhi

18. 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
05/05/2015 18
FEASIBILITY FINDINGS: LICENSING
REQUIREMENTS
• NDPS Act: Methadone classified as a ‘narcotic’
Presented at the national CME "OST: Policy and Practice" on 18th-19th April 2015 at AIIMS, New Delhi

19. • 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
05/05/2015 19
FEASIBILITY FINDINGS: PROCUREMENT
PROCESS
Presented at the national CME "OST: Policy and Practice" on 18th-19th April 2015 at AIIMS, New Delhi

20. • 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
05/05/2015 20
FEASIBILITY FINDINGS: METHADONE
DISPENSING
Presented at the national CME "OST: Policy and Practice" on 18th-19th April 2015 at AIIMS, New Delhi

21. • 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
05/05/2015 21
FEASIBILITY FINDINGS: METHADONE
DISPENSING
Presented at the national CME "OST: Policy and Practice" on 18th-19th April 2015 at AIIMS, New Delhi

22. FEASIBILITY FINDINGS: CLINICAL SERVICES
Various strategies adopted for
client recruitment
05/05/2015 22
Network with NGOs
Existing clients
Initial outreach
‘Word of mouth’ publicity
Family members
Presented at the national CME "OST: Policy and Practice" on 18th-19th April 2015 at AIIMS, New Delhi

23. 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
05/05/2015 23
FEASIBILITY FINDINGS: CLINICAL SERVICES
Presented at the national CME "OST: Policy and Practice" on 18th-19th April 2015 at AIIMS, New Delhi

24. FEASIBILITY FINDINGS: CLINICAL SERVICES
• 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
05/05/2015 24
Presented at the national CME "OST: Policy and Practice" on 18th-19th April 2015 at AIIMS, New Delhi

25. FEASIBILITY FINDINGS: QUALITY
ASSURANCE MECHANISMS
QUALITY ASSURANCE
Supervisory site visits
Monthly reporting
Telephonic contacts
Record maintenance
05/05/2015 25
Presented at the national CME "OST: Policy and Practice" on 18th-19th April 2015 at AIIMS, New Delhi

26. 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
05/05/2015 26
Presented at the national CME "OST: Policy and Practice" on 18th-19th April 2015 at AIIMS, New Delhi

27. 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
Presented at the national CME "OST: Policy and Practice" on 18th-19th April 2015 at AIIMS, New Delhi

28. 05/05/2015 28
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
THANK YOU
Presented at the national CME "OST: Policy and Practice" on 18th-19th April 2015 at AIIMS, New Delhi