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Operational Research Understanding the Contexts and Response Related to Overdose Among Injecting Drug Users

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Operational Research Understanding the Contexts and Response Related to Overdose Among Injecting Drug Users Understanding the contexts and response related to overdose among Injecting Drug Users Project HIFAZAT: Strengthen the capacity, reach and quality of IDU harm reduction services OPERATIONAL RESEARCH Year of Publication: 2012 Published by: United Nations Office on Drugs and Crime, Regional Office for South Asia Authors: Dr. M. Suresh Kumar All rights reserved The text of this publication may be freely quoted or reprinted with proper acknowledgement. Disclaimer The opinions expressed in this document do not necessarily represent the official policy of the United Nations Office on Drugs and Crime (UNODC). The designations used do not imply the expression of any opinion whatsoever on the United Nations concerning the legal status of any country, territory or area of its authorities, frontiers and boundaries. Designed & Printed by: Mensa Design Pvt. Ltd., New Delhi. E-mail: [email protected] Operational research understanding the contexts and response related to overdose among Injecting Drug Users “Currently ‘Injecting Drug Users’ (IDUs) are referred to as ‘People Who Inject Drugs’ (PWID). However, the term ‘Injecting Drug Users’ (IDUs), has been used in this document to maintain consistency with the term used presently in National AIDS Control Program”. Supported by The Global Fund to Fight AIDS, Tuberculosis and Malaria- Round-9 India HIV-IDU Grant No. IDA-910-G21-H with Emmanuel Hospital Association as Principal Recipient Preface In India, Targeted Interventions (TIs), under the National AIDS Control Programme (NACP) framework, is one of the core strategies for HIV prevention amongst injecting drug users (IDUs). Apart from providing primary health services that include health education, abscess management, treatment referrals, etc., the TIs have also designated centres for providing harm reduction services such as Needle Syringe Exchange Program (NSEP) and Opioid Substitution Therapy (OST). The services under the TIs are executed through a peer based outreach as well as a static premise based approach, i.e., through Drop-In Centres (DIC) which in turn serve as the nodal hubs for the above activities to be executed. To further strengthen these established mechanisms under the NACP and to further expand the reach to vulnerable IDUs, The United Nations Office on Drugs and Crime (UNODC) in India provides technical assistance to the National AIDS Control Organisation (NACO) through the Global Fund Round 9 Project (i.e., Project Hifazat), amongst others. In doing so, UNODC supports NACO through technical assistance to undertake the following: 1. Conduct Operational Research 2. Develop Quality assurance SOPs 3. Develop Capacity Building/ Training materials 4. Training of Master Trainers It is in this context, that a study, “Operational Research on Understanding the Contexts and Response Related to Overdose among Injecting Drug Users” has been conducted. The study aims analyze the contextual factors associated with overdose among IDUs, and document the existing mechanisms to respond to the overdose among IDUs. In the context of India, the pattern of drug use, especially via injecting route, and its correlation with overdose among IDUs is not well studied even though injecting drug use as a problem is well established. While heroin and brown sugar injecting is predominant in the north eastern region as well as the metropolitan cities, injection of pharmaceutical opioids (in combination with other depressants) is found in other parts of the country. The pharmacological differences of the different types of opioids being injected may play an important role in determining the extent to which overdose occurs. Some of the very well-known risks of overdose include factors such as mixing different depressants together, or resuming previous doses of drugs after a period of abstinence (especially among those who have recently released from drug treatment centres or prisons). Apart from these factors, the existing structural responses for management of overdose, the capacity of the staff to manage overdose and the overall legal and policy environment are important in determining the occurrence and outcome of overdose. This study therefore, has been conducted with a vision to serve as an invaluable tool to provide decision makers and programme implementers the necessary basis in the form of scientific information to establish the local context of the overdose problem especially amongst IDUs. It is also expected that the study would help evolve strategies and introduce actions aimed at overdose prevention and management among injecting drug users in India. This study was possible, thanks to the collective efforts of a number of experts, agencies and members from the drug using community. Contributions from the Technical Working Group of Project Hifazat, which included representatives from NACO, Project Management Unit (PMU) of Project Hifazat, SHARAN, Indian Harm Reduction Network and Emmanuel Hospital Association was critical towards articulating and consolidating the study. iii Acknowledgement The UN office on Drugs and Crime, Regional Office for South Asia (UNODC ROSA) in partnership with national government counterparts from the drugs and HIV sectors and with leading non-governmental organizations in the countries of South Asia is implementing a project titled “Prevention of transmission of HIV among drug users in SAARC countries” (RAS/H13). As part of this regional initiative UNODC is also engaged in the implementation of the Global Fund Round 9 IDU-HIV Project (i.e., HIFAZAT). Project HIFAZAT aims to strengthen the capacities, reach and quality of harm reduction among IDUs in India. It involves providing support for scaling up of services for IDUs through the National AIDS Control Programme. We would like to acknowledge the invaluable feedback and support received from various stakeholders, who include NACO, Project Management Unit (PMU) of Project HIFAZAT, Emmanuel Hospital Association (the Principal Recipient of the grant “Global Fund to Fight AIDS, Tuberculosis and Malaria- India HIV-IDU Grant No. IDA-910-G21-H”), SHARAN, Indian Harm Reduction Network and individual experts who have contributed significantly in the development of this document. We would also like to thank co-lead consultants Mr. C. Bangkim, Mr. Brijesh Dash, Mr. Richard Francis, Ms. Kanudeep Kaur and Mr. Shiva kumar, as well as to all the NGOs from where the data was collected. Special thanks are due to the UNODC Project H13 team for its persistent and meticulous efforts in conceptualizing and consolidating this document. iv Abbreviations AIDS Acquired Immuno Deficiency Syndrome ART Anti-Retroviral Therapy BCC Behaviour Change Communication CPR Cardio Pulmonary Resuscitation DIC Drop-In Centre DOTS Directly Observed Treatment Short Course FGD Focus Group Discussion FIDU Female Injecting Drug User HBV Hepatitis B Virus HCV Hepatitis C Virus HIV Human Immunodeficiency Virus HR Harm Reduction ICTC Integrated Counselling and Testing Centre IDI In-Depth Interview IDU Injecting Drug User IDU-TIs Injecting Drug User Targeted Interventions IEC Information Education and Communication MOH&FW Ministry of Health and Family Welfare MMT Methadone Maintenance Treatment MSJ&E Ministry of Social Justice and Empowerment MSM Men who have Sex with Men NACO National AIDS Control Organisation NACP National AIDS Control Programme NGO Non-Governmental Organisation NSEP Needle Syringe Exchange Program OD Overdose v OST Opioid Substitution Treatment PE Peer Educator PLWA People Living with AIDS PUD People who Use Drugs SP Spasmoproxyvon TB Tuberculosis TI Targeted Intervention UNODC United Nations Office on Drugs and Crime UNODC-ROSA United Nations Office on Drugs and Crime–Regional Office for South Asia VCT Voluntary Counselling and Testing VCCT Voluntary Confidential Counselling and Testing vi Contents Preface iii Acknowledgement iv Abbreviations v Executive Summary ix 1 Background 01 2 Aim and Objectives 03 3 Methodology 05 4 Findings 09 4.1 Calicut, Kerala 9 4.2 Cochin, Kerala 12 4.3 Delhi 14 4.4A Dimapur, Nagaland: Male Injecting Drug User Targeted Intervention 17 4.4B Dimapur, Nagaland: Female Injecting Drug Users Targeted Intervention 21 4.5 Haryana 25 4.6 Hyderabad 27 4.7A Imphal, Manipur: Male Targeted Intervention 29 4.7B Imphal, Manipur: Female Targeted Intervention 32 4.8 Mizoram 36 4.9 Narsinghpur, Madhya Pradesh 39 4.10 Bhubaneswar, Odisha 41 4.11 Patna, Bihar 44 4.12 Pune, Maharashtra 47 4.13 Amritsar, Punjab 50 4.14 Taran Tarn, Punjab 53 4.15 Lucknow, Uttar Pradesh 56 4.16 Kolkata, West Bengal 59 vii 5 Summary of Key Findings 63 6 Recommendations 65 7 Conclusions 69 8 References 71 Appendix: Tools used in Operational Research 73 A. Interview Guide for Interview with IDU TI Staff 75 B. Focus Group Topic Guide for IDU Clients on Risk of Overdose 81 C. IDI with IDU Clients for Witnessed Overdose 84 D. Interview Topic Guide for IDI with IDU Clients for Experienced Overdose 90 viii Executive Summary Operational Research: Understanding the Contexts and Response Related to Overdose among Injecting Drug Users Objectives A qualitative study, it explored the contextual factors in overdose risk that are relevant to the development of appropriate prevention and management interventions. To describe the various contexts in which overdose occurs among injecting drug users (IDUs) To analyze the contexts and document some common factors associated with overdose among IDUs To document and analyze the existing mechanisms and processes for management of overdose in the context of targeted
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