|Year : 2019 | Volume
| Issue : 3 | Page : 173-178
Sociodemographic profile, pattern of opioid use, and clinical profile in patients with opioid use disorders attending the de-addiction center of a tertiary care hospital in North India
Bilal Ahmad Bhat, Shabir Ahmad Dar, Arshad Hussain
Department of Psychiatry, Government Medical College, Srinagar, Jammu and Kashmir, India
|Date of Submission||07-Aug-2018|
|Date of Decision||01-Oct-2018|
|Date of Acceptance||08-Oct-2018|
|Date of Web Publication||30-Sep-2019|
Dr. Bilal Ahmad Bhat
Department of Psychiatry, Government Medical College, Srinagar, Jammu and Kashmir
Source of Support: None, Conflict of Interest: None
Background and Objectives: Opioids are the major drugs of potential harm and health consequences with more and more people getting involved in it especially from rural areas. One of the concerns with opioids is the injecting route used for their administration. The objective of this study was to assess the sociodemographic profile, pattern of opioid use, and clinical profile in patients with opioid use disorders. Methods: This was a cross-sectional descriptive study conducted among the opioid use disorder patients ≥10 years of age, diagnosed as per the Diagnostic and statistical manual of mental disorders-5 (DSM-5), who visited the drug de-addiction center for the treatment. A semi-structured pro forma was used to record sociodemographic profile. Opioid use disorder and psychiatric comorbidity were diagnosed as per the DSM-5 after a thorough clinical assessment. Results: A total of 74 patients were included in this study. The mean age of our patients was 27.55 years (standard deviation ± 7.26) with majority of patients (83.78%) between 20 and 40 years of age. Most of the patients were males (97.5%) from nuclear families (75.68%) and from rural background (62.16%). Majority of patients (48.65%) had started using opioids in 20–29 years age group with heroin as the most common opioid used in 62.16%. Majority of our patients (43.24%) were using intravenous route. Psychiatric comorbidity was present in 41.88% with attention-deficit hyperactivity disorder (24.32%) as the most common. Conclusion: Rural areas and students are increasingly involved in opioid use disorders. Heroin use has increased significantly when compared with previous study particularly through intravenous route.
Keywords: Attention-deficit hyperactivity disorder, heroin, opioid, rural
|How to cite this article:|
Bhat BA, Dar SA, Hussain A. Sociodemographic profile, pattern of opioid use, and clinical profile in patients with opioid use disorders attending the de-addiction center of a tertiary care hospital in North India. Indian J Soc Psychiatry 2019;35:173-8
|How to cite this URL:|
Bhat BA, Dar SA, Hussain A. Sociodemographic profile, pattern of opioid use, and clinical profile in patients with opioid use disorders attending the de-addiction center of a tertiary care hospital in North India. Indian J Soc Psychiatry [serial online] 2019 [cited 2020 Feb 18];35:173-8. Available from: http://www.indjsp.org/text.asp?2019/35/3/173/268343
| Introduction|| |
Although the illicit use of opiates and prescription opioids, with an estimated 33 million illicit users, is not as widespread as the illicit use of cannabis worldwide, the opioids are the major drugs of potential harm and health consequences. One of the concerns with opioids is the injecting route used for their administration. People, who use this route for drugs, face a large number of health-related problems associated with the unsafe use of drugs including a higher chance of drug overdose and a greater risk of premature death. The overall poor health outcome in them is further worsen by poor access to services for the prevention and treatment of infectious diseases particularly human immunodeficiency virus (HIV), hepatitis B, hepatitis C, and tuberculosis. In India also, a fairly large problem of opioid use exists. The estimation on the prevalence of drug abuse in India through a national household survey has shown the prevalence of ever opium use as 0.6% and that during last 30 days as 0.4% with the prevalence of heroin use in both, ever use and last 30 days, as 0.2%. Although the prevalence of people injecting illicit drugs in India is low relative to West with an estimate between 0.18 and 1.1 million and a slowly declining trend of illicit use of opium and heroin worldwide, the injecting route of heroin and synthetic opioid analgesics in India has shown a rapid growth in the past two decades.,, This rapid growth in the population of injection drug users poses new challenges in the management and care of these patients. The characteristic injection drug user in India is typically a male, between 15 and 35 years of age, illiterate, and unemployed. During recent years, opioid dependence has become one of the most prevalent psychiatric disorders worldwide.
In our state of Jammu and Kashmir, the geographical location makes an easy transit possible for drugs across the whole state. Moreover, besides the phenomenal increase in other psychiatric disorders, the prevailing socio-political upheaval has worsened the drug abuse scenario in Kashmir. The hospital prevalence of use of opiate-based preparations increased from 9.5% in 1980 to 73% in 2002 and has worsen now. With the scarcity of literature about the profiles of opioid-dependent patients from this part of the world, we aimed to assess the sociodemographic profile, the pattern of opioid use, and clinical profile in patients with opioid use disorders attending the de-addiction center of the Department of Psychiatry of a tertiary care hospital.
| Methods|| |
This was a hospital-based cross-sectional descriptive study conducted among the opioid use disorder patients who visited the drug de-addiction center of the Department of Psychiatry, Government Medical College, Srinagar, from March 2018 to June 2018. All the patients with a diagnosis of opioid use disorder made as per the Diagnostic and statistical manual of mental disorders-5 (DSM-5) diagnostic guidelines and treated on both inpatient and outpatient basis were considered. The study was approved by the Institute's Ethical Committee. Written informed consent was taken from the patients when >18 years old and from the parents when ≤18 years old. Patients, who fulfilled the criteria for opioid use disorder as per the DSM-5 and who were willing to participate in the study, were taken. Those patients, who were currently fulfilling the criteria for other substance use disorders (except tobacco and caffeine use disorders) and who refused to give consent, were excluded from the study. A thorough clinical assessment was done to diagnose opioid use disorder at first encounter with the patient, and the second assessment for psychiatric comorbidity was also done in the study population using DSM-5 diagnostic guidelines after detoxification. Both diagnosis, opioid use disorder and psychiatric disorder (if present) were confirmed by consultant psychiatrist. A semi-structured pro forma was used to assess the sociodemographic status and pattern of opioid use among the patients included in the study. The semi-structured pro forma for sociodemographic variables covered details regarding the age group, sex, residence, family type, education, occupation, socioeconomic status, and path of referral. The socioeconomic status of patients was evaluated using modified Kuppuswamy's socioeconomic status scale, revised for 2016. The pro forma for the pattern of opioid use in patients covered the details regarding the prior course of drug use, age of initiating opioid use, route of opioid use, and type of opioid used.
The data about various parameters were entered into Microsoft Excel. Descriptive analysis was carried out with the Statistical Package for the Social Sciences version-21 software. The information thus generated was presented in tables as frequencies and percentages.
| Results|| |
Over 4 months (March 2018–June 2018), a total of 74 patients with opioid use disorder were included in the study. The mean age of our patients was 27.55 years (standard deviation ± 7.26) with the majority of patients (83.78%) between 20 and 40 years of age. Most of the patients were males (97.5%) and from nuclear families (75.68%). About 62.16% of patients were from rural background. In occupation, most of the patients were either businessmen (37.84%) or students (29.73%). Most of the patients belonged to either lower middle class (48.65%) or upper middle class (37.84%). Most of the patients were accompanied by their family members (33.78%) or referred by friends (31.08%) whereas 32.43% of patients reported on their own. The sociodemographic profile is summarized in [Table 1].
Over three-quarter of patients (89.19%) had started substances of abuse (before opioids) in the age group of 10–19 years. Maximum number of patients (48.65%) started using opioids in 20–29 years age group. Heroin was the most common opioid used in 62.16%. Majority of our patients were using intravenous route either alone (18.92%) or in combination (24.32%). About one-third of the patients (32.43%) had experienced an overdose of opioids. The pattern of opioid use is summarized in [Table 2].
Psychiatric comorbidity was currently present in 41.88% with attention-deficit hyperactivity disorder (ADHD) in 24.32%, major depressive disorder in 10.81%, panic disorder in 04.05%, obsessive-compulsive disorder in 1.35%, and personality disorders in 1.35%. Psychiatric comorbidity is summarized in [Table 3].
| Discussion|| |
It has been found that opioid use disorders have higher prevalence in young adulthood (22–28 years). A study by Farhat et al., from the same center, also found most of their patients in 20–40 years age group. With regard to age, similar findings have been shown by previous studies from India.,, The predominance of males in our study is consistent with other studies from India, which have found males predominantly visiting the de-addiction centers.,, Although the opioid use disorders affect many age groups, the involvement of young working-age population has a bad impact on the economy of these individuals. Little is known about the economic impact of opioid use in these patients from this part of the world. Besides having a direct impact, there are indirect costs such as those due to disability and absenteeism from the workplace. Therefore, widespread public attention is of utmost importance.
Similar to our study, the previous studies on substance use disorders from our state have also found the predominance of nuclear families; however, a study on opioid use by Mohanty et al. found equal distribution of joint and nuclear families in their de-addiction center.,,
Although, in our study, we found a rural predominance in our individuals, the previous studies from our state as well as from outside have either found urban or a slight rural predominance.,,, Whether the opioid use has increased in rural areas or more patients have turned for de-addiction from rural areas cannot be comprehended in the absence of prevalence studies from our state. Further, it is traditionally accepted that the illicit use of drugs is a problem with urban areas, however, an increase in substance use disorders in rural areas in past decade has been recognized globally, both in developing and industrialized countries.
Most of our patients were either students or businessmen. These results are in contradiction to the previous study from our de-addiction center in which 64% of individuals were in employment, and 36% were unemployed, and from a study from Ranchi, in which 50% of individuals were employed, 28% were unemployed, and 2% were students., This is a matter of great concern that students are increasingly involved in substance use disorders, and it requires a particular attention with prompt and immediate intervention.
Majority of our patients belonged either to lower middle class or upper middle class. Giri et al., in their study, also found most of their patients from the upper and lower middle classes.
Regarding the referrals, a study on substance abusers by Rather et al. in our center showed about 68% of visitors were referred by family and friends, a finding consistent with our results. A good social support from family and friends has been shown to delay/prevent relapse in substance users and improve their quality of life. Our results on the initiation of opioids are in consistent with other studies globally. Mohanty et al., in their study, found that the age of the initiation was 10–19 years in 32% of patients and 20–29 years in about 50% of patients. A study from the West on patients receiving methadone replacement therapy also found results consistent with our study on the age of the initiation of opioids. Heroin was the most often used drug of our patients. Our results are in contradiction with the study of Farhat et al. who found only 13% of patients with heroin and combination of many drugs in 53% of patients. Mohanty et al. also found different results with 33.8% of patients using heroin and 47.6% using a combination of drugs. Majority of our patients were intravenous drug users using this route either only intravenous or combination of intravenous route with oral and/or inhalation route. The major route of drug administration in the previous study by Farhat et al. from our center was oral. They justified it because, in their study, the diverted pharmaceutical products were used by their patients which are mainly available in oral preparations. People, who share needles and syringes, are at higher risk of infection with HIV and hepatitis B/C viruses. These infectious diseases further decrease the quality of life and increase morbidity and mortality in this group.
In our patients, about one-third reported experiencing of drug overdose in the form of slow, difficult breathing and extreme drowsiness. Mohanty et al., in their study, found similar results with overdose history in 27.5% of their individuals. Overdose of opioids has led to increased deaths in recent years, and this epidemic of opioid use and overuse is less recognized globally. Although there is a risk of chronic infection and sudden death due to opioid overdose, there are effective treatments as well that substantially reduce these risks. However, it has been found worldwide that only a small proportion of patients with opioid use disorder receives effective treatment.
Psychiatric comorbidity was present in a little less than half of our study participants. Other Indian studies have found a higher comorbidity of psychiatric disorders in opioid use disorders., Varying but higher rate of psychiatric comorbidity has been found in studies outside India as well., Most of these studies found personality disorders as comorbid to a varying extent. Variation in comorbidity of other psychiatric disorders could be understandable because of the widely different diagnostic criteria used, the different populations studied, and different settings. In this study, ADHD was the most frequent disorder present as comorbidity. A recent retrospective chart-based review of 11 years by Basu et al. in addiction patients reported that mood disorders were the most common comorbid disorders with personality disorders reported less frequently. A prospective study on the association of childhood ADHD and substance use disorders showed that ADHD children are more likely to have ever used nicotine and other illicit substances other than alcohol and are also more likely to develop substance use disorders. Furthermore, in a recent survey on 1057 heroin-dependent patients who were on opioid substitution treatment, 19.4% of the patients screened positive for concurrent adult ADHD symptoms. Carpentier et al. found a substantial number of patients on methadone maintenance treatment having adult ADHD. In addition, the studies on adult ADHD have shown that the patients with both ADHD and substance use disorder are at an increased risk of other psychiatric disorders than either disorder alone., The presence of ADHD in a substantial minority of opioid use disorder patients and its role as a risk factor for other substances and psychiatric disorders accentuates the need for its early detection and treatment.
| Conclusion|| |
Opioid use disorders have shown a significant rising trend as compared to the previous study from the same center in the form of more patients representing the rural population as compared to the urban population, involvement of students in opioid dependence as compared to more employed people, increase in use of heroin as compared to pharmaceutical agents, and increase in use of intravenous route as compared to oral. Further, psychiatric comorbidity is common in this group of patients which need a concomitant treatment.
Despite the limitation of being a cross-sectional hospital-based study and not representative of the community, this study provides us glimpse of opioid dependence in Kashmir. The increasing use of heroin and intravenous route suggests us a trend in opioid dependence which was seen in the West. Although the Department of Psychiatry has started this only hospital-based de-addiction center of Kashmir valley, from where this study was conducted, it is very unfortunate that to tackle the problem of substance use disorders in general and opioid use disorders in particular in this center, there is poor infrastructure and lack of specialized staff. Both the government and policymakers should make efforts to improve this center at an earliest to combat the increasing drug menace in our valley.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Mathers BM, Degenhardt L, Bucello C, Lemon J, Wiessing L, Hickman M, et al.
Mortality among people who inject drugs: A systematic review and meta-analysis. Bull World Health Organ 2013;91:102-23.
Srivastava A, Pal HR, Dwivedi SN, Pandey A, Nath J. Prevalence of drug abuse in India through a national household survey. Int J Curr Sci 2015;15:103-3.
Aceijas C, Friedman SR, Cooper HL, Wiessing L, Stimson GV, Hickman M, et al.
Estimates of injecting drug users at the national and local level in developing and transitional countries, and gender and age distribution. Sex Transm Infect 2006;82 Suppl 3:iii10-7.
Medhi GK, Mahanta J, Adhikary R, Akoijam BS, Liegise B, Sarathy K, et al.
Spatial distribution and characteristics of injecting drug users (IDU) in five Northeastern States of India. BMC Public Health 2011;11:64.
McLellan AT, Lewis DC, O'Brien CP, Kleber HD. Drug dependence, a chronic medical illness: Implications for treatment, insurance, and outcomes evaluation. JAMA 2000;284:1689-95.
Margoob MA, Dutta KS. Drug abuse in Kashmir – Experience from a psychiatric diseases hospital. Indian J Psychiatry 1993;35:163-5.
] [Full text]
Margoob MA. The Menace of Drug Abuse in Kashmir. Trend, Tradition or Trauma. Srinagar: Valley Book House; 2008. p. 6-8.
DSM-5 American Psychiatric Association. Diagnostic and statistical manual of mental disorders. Arlington: American Psychiatric Publishing. 2013.
Shaikh Z, Pathak R. Revised Kuppuswamy and BG Prasad socio-economic scales for 2016. Int J Community Med Public Health 2017;4:997-9.
Vasilenko SA, Evans-Polce RJ, Lanza ST. Age trends in rates of substance use disorders across ages 18-90: Differences by gender and race/ethnicity. Drug Alcohol Depend 2017;180:260-4.
Farhat S, Hussain SS, Rather YH, Hussain SK. Sociodemographic profile and pattern of opioid abuse among patients presenting to a de-addiction centre in tertiary care hospital of Kashmir. J Basic Clin Pharm 2015;6:94-7.
Nigam AK, Ray R, Tripathi BM. Buprenorphine in opiate withdrawal: A comparison with clonidine. J Subst Abuse Treat 1993;10:391-4.
Kalra I, Bansal PD. Sociodemographic profile and pattern of drug abuse among patients presenting to a de-addiction centre in rural area of Punjab. Age 2012;19:38-66.
Rather YH, Bashir W, Sheikh AA, Amin M, Zahgeer YA. Socio-demographic and clinical profile of substance abusers attending a regional drug de-addiction centre in chronic conflict area: Kashmir, India. Malays J Med Sci 2013;20:31-8.
Mohanty R, Senjam G, Singh NH. Psychiatric comorbidities among opioid-dependent patients attending department of psychiatry, Regional Institute of Medical Sciences Hospital, Manipur. Indian J Soc Psychiatry 2018;34:132. [Full text]
Rice JB, Kirson NY, Shei A, Cummings AK, Bodnar K, Birnbaum HG, et al.
Estimating the costs of opioid abuse and dependence from an employer perspective: A retrospective analysis using administrative claims data. Appl Health Econ Health Policy 2014;12:435-46.
Bashir N, Sheikh AA, Bilques S, Firdosi MM. Socio-demographic correlates of substance use disorder patients seeking de-addiction services in Kashmir India – A cross sectional study. Br J Med Pract 2015;8:9-13.
Margoob M, Majid A, Dhuha M, Murtaza I, Abbas Z, Tanveer M, et al
. Thin layer chromatography (TLC) in detection of current nature of drug abuse in Kashmir. JK Pract 2004;11:257-62.
Giri OP, Srivastava M, Shankar R. Quality of life and health of opioid-dependent subjects in India. J Neurosci Rural Pract 2014;5:363-8.
] [Full text]
Naji L, Dennis BB, Bawor M, Varenbut M, Daiter J, Plater C, et al.
The association between age of onset of opioid use and comorbidity among opioid dependent patients receiving methadone maintenance therapy. Addict Sci Clin Pract 2017;12:9.
Humphreys K, Caulkins JP, Felbab-Brown V. Opioids of the masses: Stopping an American epidemic from going global. Foreign Aff 2018;97:118.
Schottenfeld RS, O'Malley SS. Meeting the growing need for heroin addiction treatment. JAMA Psychiatry 2016;73:437-8.
Vivek K, Dalal P, Trivedi J, Pankaj K. A study of psychiatric comorbidity in opioid dependence. Delhi Psychiatry J 2010;13:86.
Brooner RK, King VL, Kidorf M, Schmidt CW Jr., Bigelow GE. Psychiatric and substance use comorbidity among treatment-seeking opioid abusers. Arch Gen Psychiatry 1997;54:71-80.
Borgohain L, Phookun HR. Psychiatric comorbidity with substance abuse: A clinical study. Dysphrenia 2013;4:59-70.
Basu D, Sarkar S, Mattoo SK. Psychiatric comorbidity in patients with substance use disorders attending an addiction treatment center in India over 11 years: Case for a specialized “dual diagnosis clinic”. J Dual Diagn 2013;9:23-9.
Lee SS, Humphreys KL, Flory K, Liu R, Glass K. Prospective association of childhood attention-deficit/hyperactivity disorder (ADHD) and substance use and abuse/dependence: A meta-analytic review. Clin Psychol Rev 2011;31:328-41.
Lugoboni F, Levin FR, Pieri MC, Manfredini M, Zamboni L, Somaini L, et al.
Co-occurring attention deficit hyperactivity disorder symptoms in adults affected by heroin dependence: Patients characteristics and treatment needs. Psychiatry Res 2017;250:210-6.
Carpentier PJ, van Gogh MT, Knapen LJ, Buitelaar JK, De Jong CA. Influence of attention deficit hyperactivity disorder and conduct disorder on opioid dependence severity and psychiatric comorbidity in chronic methadone-maintained patients. Eur Addict Res 2011;17:10-20.
Sobanski E. Psychiatric comorbidity in adults with attention-deficit/hyperactivity disorder (ADHD). Eur Arch Psychiatry Clin Neurosci 2006; 256 Suppl 1:i26-31.
Wilens TE, Kwon A, Tanguay S, Chase R, Moore H, Faraone SV, et al.
Characteristics of adults with attention deficit hyperactivity disorder plus substance use disorder: The role of psychiatric comorbidity. Am J Addict 2005;14:319-27.
[Table 1], [Table 2], [Table 3]