Methadone maintenance treatment has been implemented in India since 2012 across several government healthcare settings with over 700 clients enrolled. The document discusses the feasibility findings of setting up methadone clinics in India, including obtaining necessary approvals, selecting clinic locations, infrastructure requirements, staffing, licensing, procurement, dispensing, clinical services, quality assurance, and advocacy efforts. Overall, the experience so far demonstrates that methadone maintenance treatment can be successfully implemented in India to benefit opioid dependent clients and communities.

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