It is 12:45 pm on a weekday and 42-year-old Mangal Singh has taken his place in a queue outside a small room at the Community Health Centre (CHC) in Kot Ise Khan town, just like he has done for the past three months. When Singh’s turn comes, a staffer enters his name in a register, crushes a few tablets in a steel container, and asks Singh to place the powder under his tongue. Singh, a drug addict for seven years, will return the next day for another dose of this medicine, Buprenorphine. This opioid substitute, combined with another drug called Naloxone, is the government’s big health plan against drug addiction. The idea is to taper the drug off over one year, alongside providing pyschiatric support and post-treatment monitoring. This plan is still a work in progress. At the moment, it is in three districts as a pilot programme launched in October 2017 called Outpatient Opioid Assisted Treatment (OOAT) – Moga, Tarn Taran and Amritsar.
“I have been taking different kinds of drugs in the past seven years. I used would spend thousands of rupees every week to get drugs from a dealer in my village. I realised it was wastage of money. I want to shun drugs now,” says Singh, a welder by profession. “I came to know about this programme three months ago from a neighbour. Since then I am taking this medicine on a daily basis. I hope this addiction will go from my life.” Singh is among the 3,000 patients in the state who have been registered in the pilot programme, where psychiatrists first assess the patient to determine the daily dose, and also offer supportive counselling. As many as 1,950 addicts have registered for the programme in Moga across six centres, 562 in and 491 in Tarn Taran. The patient retention rate, according to health officials is 83.33 per cent. The expectation is that as police crack down on drug supplies, the number of registrations at the centres will increase.
At the OAAT centre in village Janer in Moga, the staff says the number of registrations is increasing daily. All are male, and mostly in their 30’s. There are some middle-aged and older people, too. A patient from the nearby village of Janer, who did not wish to be identified, said drugs were still available in the market but he had stopped buying them.
“I deleted the number of the supplier from my phone. I come daily here to get my medicine and it is helping me,” he says. In Bhagupur in district Tarn Taran, a 27-year-old patient from Bhagupur village enrolled for the OOAT programme, said: “I was taking tablets and spending Rs 100 daily. But now I am coming to this centre. My body doesn’t break down after taking this dose and it may also help me in quiting drugs.” A CHC staffer at Janer villager in Moga said addicts who come daily had started showing improvement, as doctors gradually reduce the dosage of the medicine administered to them
Dr. P D Garg, head of the project in Amritsar district, said of 500 patients registered at the Amritsar OOAT, around 250 had been coming regularly. “I will say enrolling 500 patients in Amritsar is a success. Such programmes take time. People slowly come to know about these efforts. For now I am satisfied with numbers and will call it success,” he said.
However, OOAT is not without its critics, who raise concerns about the potential for abuse of Buprenorphine, which can be habit forming on its own. The previous government had clamped down on the drug after complaints of its illegal retailing. “Several Opioid Substitute Therapy centres are already in operation in the state under the National Aids Control Organisation (NACO), where injecting drug addicts are given OPD treatment on daily basis. The treatment is continuous. But there is hardly any addict who has recovered from the problem,” said one psychiatrist. “We have to be extremely careful about misuse.”
The central government-run NACO-OST centres treat patients with the same drug, but without a time-frame. In Tarn Taran district, more than 900 patients are enrolled at the Patti OST, but only 250 are regulars. Around 1,600 patients are enrolled at the Tarn Taran OST but only 500 are regular patients. Similarly only 150 patients come every day against 700 enrolled at Sur Singh OST center. “The high dropout rate at OST centres indicates that these patients have been getting drugs from open market. Otherwise they should come to us. OOAT centres will face the same challenge,” said an official, working at one of the centres.
Doctors at the Post Graduate Institute of Medical Education and Research in Chandigarh, the region’s premier health facility, expressed other concerns about OOAT. “No one can doubt that opioid substitution is the most evidence-based therapy for people with severe opioid dependence. but it should be recovery-oriented rather than just mindlessly administered,” Dr D Basu, a professor with the PGI psychiatry department (Drug De-addiction and Treatment Centre) told The Indian Express. “We have to be careful about selecting the right patients, doing it the right way, monitoring them closely, focusing on the progress of the person in terms of full recovery rather than simply repeating the prescription, and maintain complete records in terms of procurement, storage, and dispensing of the opioid medication.”
As of now, the state government does not have adequate staff to follow up with patients, but Dr Ranbir Singh Rana who is in charge of government’s drug de-addiction centre in Tarn Taran and is involved in OAAT programme said the plan is to appoint Drug Abuse Prevention Officers soon. “Their job would be creating awareness among the people against addiction, and to ensure that patients go for treatment. DAPOs will also monitor all recovering patients,” he said. The DAPOs would be appointed at the block level. “We are proceeding in a structured way, with minimal chances of diversion (of the medicine). There is a foolproof plan to run this programme and we don’t see any chance of misuse anywhere,” said Dr Rana.
A health department official said, “We have put the infrastructure in place. Now it is the duty of the police that it should stop the sale of drugs so that more and more patients should turn to these centres. Only then can we motivate addicts to quit drugs,” Said an official. Punjab’s Haelth Minister Brahm Mohindra told The Indian Express that the “the feedback so far is good and now we are going to extend the programme to other districts of the state,” he said. It would also be provided in eight jails in Punjab, he added.