I found our earlier discussions with YRG Care staff in Chennai around the provision of opioid substitution therapy (OST) for people who inject drugs (PWID) really interesting, since that problem and that population consume a considerable amount of my clinical time back in the US. Frankly, I thought that between stigma and cost, this would largely be an issue that was not addressed in South Asia – and I was impressed to see what has been started here! Some background on OST on a global scale can be found in this WHO brief; the one-clause summary would be that access is poor in lower- and middle-income countries, both due to financial constraints as well persistent concerns that this is not truly the optimal therapy for opioid use disorder.
This speech reviews some of the history of opioid substitution in India, a truly fascinating topic. The ending discussion of the legalities of prescribing OST is a useful reminder on how complicated these medications are from a social perspective; the initial mention of the British government’s chronic opium user registry is a captivating bit of historical trivia. Present challenges seem to be around 1) need for increasing overall access, 2) ensuring adequate doses are used to prevent relapse, and 3) consideration of expansion to all patients with opioid use disorders rather than solely those who are PWID.
Meanwhile, recent news reports echo what our colleagues at YRG found in their studies of PWID in India, that cocktails of various pharmaceuticals have replaced heroin as the IV drugs of choice, especially in areas further away from heroin production. It also documents well that OST is by no means widely available for patients with addiction, a point echoed in this paper reviewing OST access throughout South and Southeast Asia.