|DR.BUCKSHEY AWARD PAPER
|Year : 2019 | Volume
| Issue : 1 | Page : 8-14
Pathways to care and reasons for treatment-seeking behavior in patients with opioid dependence syndrome: An exploratory study
Sai Prashant Bansal, Ajeet Sidana, Shivangi Mehta
Department of Psychiatry, Government Medical College and Hospital, Chandigarh, India
|Date of Web Publication||4-Jun-2020|
Department of Psychiatry, Government Medical College and Hospital, Level-V, Block-D, Sector.32, Chandigarh - 160 030
Source of Support: None, Conflict of Interest: None
Background: Magnitude of the menace of opioid dependence syndrome (ODS) is ever escalating especially in Northern India. However, no studies have been attempted to study the pathways to care and reasons for treatment-seeking behavior in patients with ODS. Aim: This study aims to investigate the pathways to care and reasons for treatment seeking in patients with ODS attending the community outreach clinic and de-addiction outpatient department (OPD) of a tertiary care teaching hospital. Materials and Methods: In a cross-sectional, exploratory study, a total of 40 patients diagnosed with ODS as per International Classification of Diseases-10 criteria who visited the psychiatry OPD and community outreach clinic were included. In addition to the sociodemographic and clinical variables, semi-structured questionnaires were developed by the Department of Psychiatry, Government Medical College and Hospital (GMCH), Chandigarh, India, for this study. These were first used in a pilot study and then used for the assessment of reasons for seeking treatment and pathways to care from a particular setting that is either community outreach clinic or OPD. Results: Index study found out that 25% ODS patients attended OPD directly for the first time ever in their life for treatment and 55% attended community outreach clinic run by the Department of Psychiatry, GMCH, Chandigarh, India. For 30% and 35% of the individuals attending OPD and Community outreach clinic, respectively, the first point of contact ever in life since the first use of opioid was any other tertiary care center. Alternative medicine practitioners were consulted by about 20% of the patients seeking help for the first time from OPD and none amongst those attending community outreach clinic. Referral rate was also very low in OPD attending sample (20%) while absolute zero in the community sample. Whereas among reasons for seeking treatment, increasing drug cost was the most cited reason by OPD attending patients and ill-health effects by community clinic attending patients (35% each) in personal reasons, while family-related reasons were poor interpersonal relationships with family members in OPD treatment-seeking patients (45%) and family property dispute in community clinic attending patients (35%). Conclusion: It can be concluded from the study that <50% of patients with substance use disorders visit the psychiatrist for treatment on the first contact. It means that a large number of patients go to different places/people/services for advice/treatment. However, the cost of the drug was one of the main reasons for treatment-seeking behavior in this population. Community clinic attending patients are more aware about the treatment facility available in the vicinity of their dwelling place, thereby preferring a place nearby to their home for treatment.
Keywords: Community outreach, opioid dependence syndrome, pathways to care
|How to cite this article:|
Bansal SP, Sidana A, Mehta S. Pathways to care and reasons for treatment-seeking behavior in patients with opioid dependence syndrome: An exploratory study. J Mental Health Hum Behav 2019;24:8-14
|How to cite this URL:|
Bansal SP, Sidana A, Mehta S. Pathways to care and reasons for treatment-seeking behavior in patients with opioid dependence syndrome: An exploratory study. J Mental Health Hum Behav [serial online] 2019 [cited 2020 Jul 10];24:8-14. Available from: http://www.jmhhb.org/text.asp?2019/24/1/8/285990
| Introduction|| |
It is a known fact that opioids are among the world's most problematic, illegal dependence-producing substances. Medicinal use of opioids dates back to the Sumerians (3000 BCE). Poppy cultivation and the use of its extracts were transferred from the Sumerians to the people of other nations, especially the Assyrians, Babylonians, Egyptians, Greeks, Persians, and Romans. Heroin, the diacetylated form of morphine, was originally marketed as the first nonaddictive opiate to treat cough and asthma in 1898, heroin addiction has represented a major societal problem ever since. The research in the field of opioid paced upstream, and opioid receptors were identified and characterized in binding assays, and their localization examined. Opioids are the drugs which mimic endogenous opioid peptides and activate opioid receptors. Opioid use has been escalating at a fast pace. There were an estimated 3.3 crore opioid users globally in 2014. India too has huge problem of opioid use. The 2004 national survey estimates opioid use prevalence to be 0.7% in the general population which corresponds to 20 lacs current opioid users and 5 lacs opioid-dependent people. While the NMHS carried out by the Department of Psychiatry, Government Medical College and Hospital (GMCH), Chandigarh in the North Indian state of Punjab mentions, the prevalence of substance use disorder (SUD) (including opioid but other than alcohol and tobacco) to be 2.48%.
It is pertinent to have a look at the scenario of treatment coverage of SUDs, as per the World Mental Health Survey, 39.1% of participants with 12-month SUDs perceived a need for seeking treatment. Moreover, these levels of perceived need were higher in high-income countries (43.1%) than in upper-middle (35.6%) and low/lower-middle (31.5%) income countries. However, out of these SUDs people who perceived a need for treatment, only 61.3% had any contact with a service provider or self-help group in the previous year. Moreover, the proportions were higher in high- and upper-middle income countries (67.5% and 59.1%, respectively) as compared with low/lower-middle income countries (35.6%). In addition, people with SUDs who received any kind of treatment, 29.5% received minimally adequate treatment. Levels were lower in low/lower-middle (8.6%) and upper-middle-income countries (20.3%) than in high-income countries (35.3%).
Despite the severity of the problem, limited research has been carried out to explore pathways to care among individuals with substance use worldwide. Taking into an account, the considerably large morbidity attributable to opioid use, the study of pathways to care among its users is not even miniscule but none. We could not find any such study, the only one carried out in the region is by Pal Singh Balhara et al., mapping the pathways to care of alcohol dependence patients whose results read that in 56.9% of the individuals, first point of contact was with a tertiary care addiction psychiatrist while traditional healers were consulted by about 5.2% of the patients seeking help for the first time.
Patients with opioid dependence syndrome (ODS) and other substance use in general, feel stigmatized in seeking treatment for deaddiction. This further adds to the hindrances in the treatment of drug addiction. There have been multiple reasons for not seeking treatment, few important being, fear of treatment, time conflict, poor treatment availability, and lack of social support, privacy concerns, difficulty in getting admitted. Since the department is rendering community outreach service and tertiary care de-addiction services and there is a limited number of studies in this area to know the reasons for seeking treatment and pathways to care in patients with ODS. The current study was planned to compare the same in two different treatment settings, i.e., community and tertiary care OPD setting.
Aims and objectives
To explore the pathways to care and reasons for treatment seeking in patients with ODS attending the community outreach clinic and de-addiction OPD of tertiary care teaching hospital.
| Materials and Methods|| |
The study was conducted at the Department of Psychiatry, GMCH, Chandigarh, India, between January 2017 and April 2017. The Ethics committee of the institution approved the study. The sample consisted of 40 consecutive patients having ODS 20 each from a community outreach clinic and Psychiatry outpatient department (OPD) GMCH. Consecutive sampling technique was used in which every subject meeting the inclusion criterion was selected until the required sample size was achieved.
Male individuals in the age group of 18–60 years, who gave informed consent for the study, attended the community outreach clinic and OPD for the very first time for the treatment of ODS accompanied by family members were included.
Comorbid dependence on other substances except nicotine and caffeine, neurologically impaired and active psychotic illness, intoxicated patients and patients in acute withdrawals, not accompanied with reliable informant were excluded.
The diagnosis was made as per International Statistical Classification of Diseases and Related Health Problems, 10th revision Diagnostic criteria. Informed consent was taken, and the assessment was made on the following scales: Sociodemographic data were recorded on a semi-structured pro forma that included age, gender, education, occupation, marital status, locality, family type, and monthly family income. Clinical parameters included type of opiate, route of administration, amount of opiate, frequency of intake, age at 1st use, duration of use, duration of dependence, expenditure on drug/month, comorbid illness, and history of treatment. Further information was gathered on a questionnaire of pathways to care and reasons for seeking treatment. Usual working hours of OPD are 9 am–5 pm and community being 9 am–1 pm, with medical social worker filling up the sociodemographic details of the patient and subsequent consultation by the Psychiatry Specialist/Trainee (SR/JR) at both the setups along with standard treatment protocol being followed.
Furthermore, a pilot study with five patients each from OPD and Community was carried out to tap responses on pathways to care in opioid-dependent patients as well as reasons for seeking treatment from the respective treatment facility and in general. The findings were incorporated in the questionnaires used specifically in the study.
Using the questionnaires prepared on the basis of the pilot study, pathways to care taken before reaching the current treatment facility were explored, and reasons for seeking treatment from the current treatment-seeking facility were also enquired along with sociodemographic and clinical profiling.
All analyses were conducted using SPSS for Windows (Version 16.0; SPSS Inc., Chicago, IL, USA). Discrete categorical data were presented as n (%); continuous data are given as mean. Normality of quantitative data was checked by measures of Kolmogorov–Smirnov tests of normality. Forskewed data, Kruskal–Wallis test was used. For normally distributed data, one-way ANOVA was applied. For categorical data, comparisons were made by Pearson Chi-square test. All statistical tests performed at a significance level of α =0.05.
| Results|| |
A total of 40 patients, fulfilling the inclusion and exclusion criteria were inducted in the study, 20 attending the OPD of Psychiatry and 20 attending the community outreach clinic under the Department of Psychiatry, GMCH, Chandigarh, India. The two groups were comparable on sociodemographic variables with statistically significant results in occupation and family income per month.
Sociodemographic details of the participants [Table 1] showed that the mean age of ODS patients seeking treatment from OPD was 28.95 ± 8.95 years while those from community outreach clinic was 32.95% ± 7.63. 50% of the patients seeking treatment from OPD were married and 70% of those at community clinic. ODS patients attending OPD were higher educated (70% above matriculation) while community outreach clinic patients were less (60% under matriculation). As far as, occupation is concerned OPD attending ODS patients were businessmen (40%) while farmer/driver was in majority (60%) among those attending community outreach clinic and the difference was statistically significant (P = 0.002). 65% of the ODS patients presenting to OPD had >25,000 (INR) income while 85% had <25,000 (INR) presenting to community outreach clinic and the difference was statistically significant (P = 0.018). Majority of ODS patients attending the OPD were Sikh religious background (70%), rural joint families of Punjab, whereas those attending community outreach clinic were Sikh background urban joint families of Chandigarh.
|Table 1: Depicts the sociodemographic profile of the outpatient department and community outreach clinic attending patients|
Click here to view
[Table 2] shows the clinical profile of ODS patients, 70% attending OPD were using semi-synthetic opiate, while 60% were using natural opiate in community outreach clinic attending the patient. Intravenous drug (40%) use is the route of opioid (heroin) administration opted by OPD patients, while community outreach clinic patients preferred oral route, majority of OPD attending patients used <1 g quantity (70%), while community outreach clinic patients used >10 g opiate/day. Moreover, the age of first ever use of opiate was <25 years in 90% of OPD attending patients while less (65%) in community outreach clinic patients.
|Table 2: Depicts the clinical profile of outpatient department and community outreach clinic patients|
Click here to view
As per [Table 3] which depicts pathway to care, majority (30%) of the patients attending OPD had earlier sought treatment from the other tertiary care clinic or de-addiction center/camp, while majority of those coming to the community outreach clinic attended the clinic directly for the first time (55%) in their life. However, only 20% of the patients sought treatment from alternative medicine in those attending OPD setup while those from community outreach clinic were only 10%. Not surprisingly, no ODS patient sought treatment from religious faith healer, unlike patients with psychotic mental illness [Bar Graph 1].
|Table 3: Depicts the pathways to care in outpatient department and community outreach clinic patients|
Click here to view
Among the reasons for attending the OPD setup as per [Table 4] – reputed services of the OPD of tertiary care hospital was the most significant reason for attending the same (70%) while ODS patients attended community clinic due to proximity to their home (85%).
|Table 4: Depicts the reasons for attending the particular setup, i.e., either outpatient department or community outreach clinic|
Click here to view
Few other reasons for attending OPD were the availability of inpatient facility (10%) and referred by other departments (20%), for attending community clinic was less time consuming due to all facilities available in one room (20%). The difference in the reasons for attending the particular setup by OPD and community sample was statistically significant (P = 0.005).
From [Table 5], depicting the reasons for seeking treatment, it was found that financial constraints due to up-surged prices of the drug were the most cited reason for treatment seeking in OPD attending patients (35%) while health-related issues were the primary reason among patients coming to community outreach clinic for treatment (35%) among the personal reasons. However, in family-related reasons, poor IPR accounted by 45% OPD patients and financial disputes with family members were reported by 35% of community clinic attending patients.
|Table 5: Depicts the reasons for seeking treatment in outpatient department and community outreach clinic patients|
Click here to view
| Discussion|| |
Index study has been attempted to investigate the pathways to care and reasons for seeking treatment in opioid-dependent patients seeking treatment from OPD and community outreach clinic.
Although plenty of research has been carried out on the treatment of ODS, there is wee bit of research on reasons for seeking the treatment and literally no information on pathways to care in ODS per se. Despite opinion of the research experts on need for pathway to care study for individuals with mental disorders, none been conducted among Opioid-dependent patients. To the best of our knowledge, this is the first study that directly maps the pathways to care in ODS patients. Majority of the patients in this study were young, and they were accompanied by family members, mostly parents, and friends.
No previous studies from India have explored pathways to care exclusively among individuals with opioid use disorders; there is one study that has focused on alcohol-dependent patients only.
Strong possibility of pathways to care differences based on the psychiatric diagnosis has been expressed earlier. A North Indian study reported that the psychiatrist is the first doctor to be consulted by 58% of the patients of mental illness and SUDs. In addition, 33% of them sought help from faith healers at first contact. Majority of the sample in the study constituted of psychotic and affective disorders explaining the nature of help-seeking. It is indeed a point of debate that the difference in psychiatric diagnoses across these studies could explain the difference in the preferred first point of contact in help-seeking pathway. Hence, it is important to study pathway to care separately for individuals diagnosed with different psychiatric disorders including SUDs.
In the index study, 25% of the OPD sample and 55% of the community sample had consulted a Psychiatry specialist at tertiary level hospital and community camp/center directly for the first time at GMCH, Chandigarh, India. For 30% and 35% of the individuals attending OPD and community outreach clinic, respectively, the first point of contact ever in life since the first use of opioid was any other tertiary care Psychiatrist. It can be inferred that large number of patients of SUDs prefer to visit other general practitioners, traditional healers and pharmacists, and other treatment facilities. These findings are contrary to the finding of the Pal Singh Balhara et al.
Furthermore, majority of the patients attending the OPD were using semi-synthetic (70%) opiate as compared with community sample, where majority was using natural (60%) opiate, which could mean that heroin, i.e., semi-synthetic type of opiate user preferred to seek treatment from the OPD while bhukki/afeem/doda, i.e., natural type opiate opioid-dependent patients preferred seeking treatment from the community clinics, the finding is consistent with other studies in the area.
Significant observations across past studies from our country have shown a high rate of help-seeking from faith healers and religious healers. Lahariya et al. reported that two-third of the study cases first consulted faith healers. Balhara et al. also observed that there was a very high rate of help-seeking from faith healers, traditional medicine practitioners, and quacks for mental disorders other than SUDs. However, these studies did not include patients with SUDs. Direct help-seeking from faith healer in the current study was absolute zero. This could be because of the awareness in the community about the need and utility of treatment of patients of alcohol and drug abuse since the Department of Psychiatry, GMCH, Chandigarh, India, is providing the community outreach services in the villages of Chandigarh for more than two decades now. Interestingly, Pal Singh Balhara et al. accounts a parsimonious result of 5.2% treatment by alcohol-dependent patients from traditional healers.
About 20% of the OPD sample went to alternative medicine as against 10% in the community sample. However, Pal Singh Balhara et al. reported that 5.1% of patients of AUD go to Alternative Medicine Specialist. Hence, it can be inferred from the study that the patient in the community preferred to take help from the qualified psychiatrist more often than the OPD sample. In addition, there is a need to strengthen the Alternative System of Medicine.
A very small number of patients (20%) were referred from other departments for the treatment of opioid dependence. Despite, noteworthy comorbidity of SUD with medical/surgical illnesses the referral rate is low. It means that professionals from other departments need training in the areas of identification of SUD in patients with medical/surgical illnesses.
Abysmally small proportion of individuals (5%) utilized additional sources of quitting the drug that is alternative modes in the current study. It seems that most of the patients with psychiatric disorders (including SUDs) do not seek treatment from alternate systems of medicine in these regions of the country. This observation has important policy implication as over the past few years, there has been a growing emphasis on promotion of alternate systems of medicine across the country, as has been reiterated by Pal Singh Balhara et al.
The index study findings imply that direct reporting to community outreach setup shortens the pathway to care in opioid-dependent patients. And hence, there is a strong need for further strengthening of community outreach services. Low referral rate from other medical professionals calls for need of training of other health professionals in the area of SUDs.
Limitations and future directions: Index study reports the findings from exclusive male sample that too very small and also did not explore the comorbid psychiatric illnesses (except active psychotic illness) hence before the results are generalized, study with larger sample size and inclusive of fairer sex as well with and without comorbid psychiatric illnesses needs to be carried out. A comparative study with other SUDs would further throw light in this area.
| Conclusion|| |
It can be concluded from the current study that still a small numbers of patients of opioid use disorders directly visit the tertiary care Psychiatry OPD in comparison to community de-addiction clinic, which reflects the awareness and utility of community de-addiction services. In addition, <50% of the patients in both the settings sought help from the psychiatrist since the beginning of the illness, which reflects that still large number of patients seek help from other nonmental health professionals/nonprofessionals, etc., and which ultimately add up to chronicity and delay in contact with the psychiatrist. A substantial number of patients cited increased cost of the drug as a reason for seeking treatment along with other personal, family, and social reasons.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Brownstein MJ. A brief history of opiates, opioid peptides, and opioid receptors. Proc Natl Acad Sci U S A 1993;90:5391-3.
Norn S, Kruse PR, Kruse E. History of opium poppy and morphine. Dan Medicinhist Arbog 2005;33:171-84.
Booth M. Opium: A History. New York: St. Martin's Press; 1986.
Degenhardt L, Charlson F, Mathers B, Hall WD, Flaxman AD, Johns N, et al.
The global epidemiology and burden of opioid dependence: Results from the global burden of disease 2010 study. Addiction 2014;109:1320-33.
United Nations Office on Drugs and Crime. World Drug Report 2016. Vienna: United Nations Pubns Publisher; 2016.
Ray R. The Extent, Pattern and Trends of Drug Abuse in India: National Survey. Ministry of Social Justice and Empowerment, Government of India and United Nations Office on Drugs and Crime, Regional Office for South Asia; 2004.
Chavan BS, Das S, Garg R, Puri S, Banavaram AA. Prevalence of mental disorders in Punjab: Findings from national mental health survey. Indian J Psychiatry 2018;60:121-6.
] [Full text]
Degenhardt L, Glantz M, Evans-Lacko S, Sadikova E, Sampson N, Thornicroft G, et al.
Estimating treatment coverage for people with substance use disorders: An analysis of data from the world mental health surveys. World Psychiatry 2017;16:299-307.
Kline A. Pathways into drug user treatment: The influence of gender and racial/ethnic identity. Subst Use Misuse 1996;31:323-42.
Pal Singh Balhara Y, Prakash S, Gupta R. Pathways to care of alcohol -dependent patients: An exploratory study from a tertiary care substance use disorder treatment center. Int J High Risk Behav Addict 2016;5:e30342.
Rapp RC, Xu J, Carr CA, Lane DT, Wang J, Carlson R. Treatment barriers identified by substance abusers assessed at a centralized intake unit. J Subst Abuse Treat 2006;30:227-35.
World Health Organization. The ICD-10 Classification of Mental and Behavioural Disorders: Clinical Descriptions and Diagnostic Guidelines. Geneva: World Health Organization; 1992.
IBM Corp. Released 2011. IBM SPSS Statistics for Windows, Version 20.0. Armonk, NY: IBM Corp; 2011.
Trivedi JK, Jilani AQ. Pathway of psychiatric care. Indian J Psychiatry 2011;53:97-8.
] [Full text]
Chadda RK, Agarwal V, Singh MC, Raheja D. Help seeking behaviour of psychiatric patients before seeking care at a mental hospital. Int J Soc Psychiatry 2001;47:71-8.
Patra S, Chavan BS, Gupta N, Sidana A. Clinical profile of patients seeking services at urban community psychiatric services in Chandigarh. Indian J Psychiatry 2016;58:410-6.
] [Full text]
Lahariya C, Singhal S, Gupta S, Mishra A. Pathway of care among psychiatric patients attending a mental health institution in central India. Indian J Psychiatry 2010;52:333-8.
] [Full text]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]