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 Table of Contents  
Year : 2021  |  Volume : 37  |  Issue : 1  |  Page : 117-118

Opioid use disorder and COVID-19 in India: Waiting for an epidemic within the pandemic?

1 Department of Psychiatry, School of Medicine, Patan Academy of Health Sciences, Lalitpur, Nepal
2 Beacon Centre, Edgware Community Hospital, Barnet, Enfield and Haringey Mental Health NHS Trust, London, UK
3 Department of Psychiatry, Himalayan Institute of Medical Sciences, Swami Rama Himalayan University, Dehradun, Uttarakhand, India
4 Department of Psychiatry, All India Institute of Medical Sciences, Bhubaneswar, India

Date of Submission19-Jun-2020
Date of Acceptance29-Jun-2020
Date of Web Publication31-Mar-2021

Correspondence Address:
Dr. Pawan Sharma
Department of Psychiatry, School of Medicine, Patan Academy of Health Sciences, Lalitpur
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijsp.ijsp_169_20

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How to cite this article:
Sharma P, Gupta P, Pal A, Parmar A. Opioid use disorder and COVID-19 in India: Waiting for an epidemic within the pandemic?. Indian J Soc Psychiatry 2021;37:117-8

How to cite this URL:
Sharma P, Gupta P, Pal A, Parmar A. Opioid use disorder and COVID-19 in India: Waiting for an epidemic within the pandemic?. Indian J Soc Psychiatry [serial online] 2021 [cited 2022 Oct 3];37:117-8. Available from: https://www.indjsp.org/text.asp?2021/37/1/117/312861


We are going through uncertain times which the world has rarely ever witnessed before. The current COVID-19 pandemic is adversely affecting almost the entire world's population. History has shown that during such large-scale disasters, marginalized groups within the population tend to be impacted the worst. People who suffer from opioid use disorders and injection drug use constitute one such vulnerable group. According to a recent national-level survey, around 2.3 crore people in India use opioids, out of whom 77 lakh are problem users and 28 lakh are dependent users.[1] Further, there are around 8.5 lakh people who inject drugs, predominantly opioids.[1] These data sufficiently underscore the magnitude of opioid use disorders in the country. Through this letter, we aim to highlight the difficulties faced by this population in times of the current pandemic and the need for attention from the public health system of the country.

  1. Behaviors associated with drug use: Quite often, opioid drugs are used in peer groups, often in public places such as parks or public toilets, referred to as “hot spots.” Often, within these peer groups, materials such as cigarettes, bidis, chillums, needles, syringes, and bottles for diluents are shared. Staying in groups and sharing paraphernalia may increase the risk of COVID-19 spread in the current times. This has huge public health implications as these behaviors pose a risk of converting opioid drug hot spots into COVID-19 hot spots.

  2. Further, it is common to see opioids being shared between the drug-using peers in usual circumstances. However, presently, in areas where a strict lockdown and social isolation has been enforced, opioid users run the risk of consuming a larger dose alone which was earlier meant for the entire group because loss of control over drug use is a common phenomenon among those having substance dependence. This may increase the chances of fatal opioid overdoses, which is one of the leading causes of mortality in this group.

  3. Medical comorbidities: Studies have shown a high prevalence of respiratory ailments such as chronic obstructive pulmonary disease and asthma among those who suffer from opioid use disorders,[2] owing to the use of opioids through inhalational route or comorbid smoking of tobacco and other substances. Recent literature on COVID-19 suggests disproportionately high mortality among those suffering from respiratory disorders.[3] Moreover, higher prevalence of immunosuppressive conditions such as HIV and malnutrition, and serious chronic comorbidities such as hepatitis B and C in this population, especially the injection drug users, predispose them to acquire infectious diseases which, intuitively, may include COVID-19.
  4. Social inequalities: Poverty and homelessness are quite rampant among opioid drug users in India. A substantial number of opioid drug users live in shared homes or public shelters (such as rain basera) or are rough sleepers on streets. In addition, the vast majority of those who do live with families, have to dwell in overcrowded accommodations. This potentially makes social isolation and self-quarantine, which are the basic pillars of the containment strategy against the virus, more of a luxury in this group. Low levels of education and poor percolation of factual scientific information among these groups further complicate the situation.
  5. Restricted access to health care and opioid substitution therapy (OST): The service delivery models for the treatment of opioid use disorders are often in direct contradiction to the principle of lockdown and social distancing required during COVID-19, for example, most of the OST centers in India follow a strategy of supervised agonist maintenance treatment which require frequent, if not daily visits to the treatment centers. This is to minimize the risk of overdose and illegal diversion. However, in the current state of lockdown, daily visits to OST centers are not feasible logistically, and may even be detrimental to the social-distancing measures. Moreover, many de-addiction clinics and centers, self-help groups, therapeutic communities, syringe-needle exchange, etc., are either under pressure to curtail their services or have already closed down, which leaves this population without access to de-addiction treatments. To add to this, the current lockdown seems to have disrupted the supply chain of illicit opioid drugs, which might have otherwise be a boon for the society, but in the current scenario, it adds to the number of people who might seek treatment for withdrawals from a health-care system which has already been stretched thin, or it may drive people to quench the withdrawals and craving with other more easily accessible substances such as cannabis, alcohol, and benzodiazepines, thus adding to the burden of morbidities associated with these substances.

An even more deleterious effect may be seen due to reduced access to Directly Observed Treatment Short-course for Tuberculosis[4] or anti-retroviral treatment for HIV/AIDS,[5] as tuberculosis and HIV are common comorbidities in this population. It is highly foreseeable for an overburdened and panic-stricken health-care system to ignore drug use-related ailments and emergencies in favor of other medical conditions.

Due to stigma around opioid use disorders, this population tends to be heavily marginalized and largely ignored by health-care services. However, as the current pandemic has shown us in real time, the health of our population is only as good as its weakest member. Hence, it is of urgent importance that the public health system of India gives due attention to this population, otherwise we are just waiting for the outburst of an epidemic within this pandemic. So far, agencies such as the National AIDS Control Organization and institutes such as the National Drug Treatment Centre and National Institute of Mental Health and Neuro-Sciences have taken the lead in the continuation of OST service and provision of tele-consultations for drug use disorders. However, given the magnitude of the problem in India, the current efforts are less than likely to be sufficient. Hence, it is important to upscale the effort on a bigger level. Moreover, there is a need for state- or national-level policies or guidelines for the provision of OST and other health-care services to this population during the current COVID-19 pandemic.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Ambekar A, Agrawal A, Rao R, Mishra AK, Khandelwal SK, Chadda RK. Magnitude of Substance Use in India. New Delhi: Ministry of Social Justice and Empowerment, Government of India; 2019.  Back to cited text no. 1
Palmer F, Jaffray M, Moffat MA, Matheson C, McLernon DJ, Coutts A, et al. Prevalence of common chronic respiratory diseases in drug misusers: A cohort study. Prim Care Respir J 2012;21:377-83.  Back to cited text no. 2
Zhao Q, Meng M, Kumar R, Wu Y, Huang J, Lian N, et al. The impact of COPD and smoking history on the severity of COVID-19: A systemic review and meta-analysis. J Med Virol 2020;92:1915-21.  Back to cited text no. 3
Banerji A. Over 100 DOTS Providers not Paid, TB Programme Takes a Hit: The Tribune India; 2020.  Back to cited text no. 4
Chattopadhyay S. India's COVID-19 lockdown hits HIV+ and chronic patients hard | India News; Al Jazeera; 2020.  Back to cited text no. 5


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