Key implementation factors in telemedicine-delivered medications for opioid use disorder: a scoping review informed by normalisation process theory.

Telemedicine could improve access to medications for opioid use disorder (MOUD). Telemedicine-delivered MOUD (TMOUD) has expanded substantially in response to the restrictions imposed by the COVID-19 pandemic on in-person clinical contact, yet this expansion has not happened consistently across all health systems and countries. This Review aims to understand key factors in TMOUD implementation that might explain variations in uptake. We did a scoping review using three English language databases for articles reporting on the implementation of TMOUD services. 57 peer-reviewed articles were identified, subjected to open coding and thematic analysis, and further interpreted through normalisation process theory (NPT). NPT was originally used to evaluate telehealth innovations and has been applied extensively to describe, assess, and develop the implementation potential of a broad range of complex health-care interventions. By categorising our findings according to the four core NPT constructs of coherence, cognitive participation, collective action, and reflexive monitoring, we aim to rationalise the current evidence base to show the workability of TMOUD in practice. We find that variations in TMOUD models in practice depend on organisations' attitudes towards risk, clinicians' tensions around giving up control over standard practices, organisation-level support in overcoming operational and technological challenges, and evaluation methods that might neglect a potential widening of the digital divide.

Impact of COVID-19 lockdown on substance availability, accessibility, pricing, and quality: A multicenter study from India.

Background and Aim: Pandemic and consequent lockdowns are likely to affect the drug market by the sudden disruption of the supply chain. We explored the change in the availability, access, purity, and pricing during lockdown from respondents seeking treatment for drugs, alcohol, and tobacco dependence. Materials and Methods: A cross-sectional survey was conducted among 404 respondents from seven treatment centers across India. A structured questionnaire assessed the change in availability, access, quality, and price of substances used during the first phase (March 24-April 14) and the second phase (April 15-May 3) of lockdown. Results: A majority of the respondents in treatment used tobacco (63%) and alcohol (52%). Relatively few respondents used opioids (45%) or cannabis (5%). Heroin (44%) was the most common opioid the respondents were treated for. Seventy-five percent, 65%, and 60% of respondents treated for alcohol, tobacco, and opioid problems, respectively, reported a reduction in the availability and access during the first phase of the lockdown. In the second phase, respondents with alcohol and tobacco dependence reported greater availability than those with opioid and cannabis dependence. The reported price of all substances increased more than 50% during the first phase of lockdown and remained higher throughout the second phase. Deterioration in purity was reported by more than half of the people who used opioid. Conclusion: Lockdown could have affected both licit and illicit drug markets, albeit to a varying degree. The observed changes seemed short-lasting, as suggested by the recovering trends during the second phase of lockdown.

In silico characterization of aryl benzoyl hydrazide derivatives as potential inhibitors of RdRp enzyme of H5N1 influenza virus

RNA-dependent RNA polymerase (RdRp) is a potential therapeutic target for the discovery of novel antiviral agents for the treatment of life-threatening infections caused by newly emerged strains of the influenza virus. Being one of the most conserved enzymes among RNA viruses, RdRp and its inhibitors require further investigations to design novel antiviral agents. In this work, we systematically investigated the structural requirements for antiviral properties of some recently reported aryl benzoyl hydrazide derivatives through a range of in silico tools such as 2D-quantitative structure-activity relationship (2D-QSAR), 3D-QSAR, structure-based pharmacophore modeling, molecular docking and molecular dynamics simulations. The 2D-QSAR models developed in the current work achieved high statistical reliability and simultaneously afforded in-depth mechanistic interpretability towards structural requirements. The structure-based pharmacophore model developed with the docked conformation of one of the most potent compounds with the RdRp protein of H5N1 influenza strain was utilized for developing a 3D-QSAR model with satisfactory statistical quality validating both the docking and the pharmacophore modeling methodologies performed in this work. However, it is the atom-based alignment of the compounds that afforded the most statistically reliable 3D-QSAR model, the results of which provided mechanistic interpretations consistent with the 2D-QSAR results. Additionally, molecular dynamics simulations performed with the apoprotein as well as the docked complex of RdRp revealed the dynamic stability of the ligand at the proposed binding site of the receptor. At the same time, it also supported the mechanistic interpretations drawn from 2D-, 3D-QSAR and pharmacophore modeling. The present study, performed mostly with open-source tools and webservers, returns important guidelines for research aimed at the future design and development of novel anti-viral agents against various RNA viruses like influenza virus, human immunodeficiency virus-1, hepatitis C virus, corona virus, and so forth.

A multicentric survey among patients with substance use disorders during the COVID-19 lockdown in India.

Background: The unprecedented first wave of the COVID-19 pandemic severely impacted mental health services globally. However, the negative impact of such disruptions on people with substance use disorders (SUD) seeking treatment remains unclear. We aim to explore the behaviors adopted by these individuals to overcome the service disruptions. Materials and Methods: We explored the changes related to substance use behavior (quit attempts, withdrawal experienced, treatment-seeking, and risky behaviors), and behavioral changes in response to COVID-19 lockdown. A cross-sectional survey was conducted among 404 people with SUD seeking treatment from seven centers across India. They were assessed by a specially designed structured questionnaire during the first wave (June-September) of the pandemic. Results: An overwhelming majority experienced withdrawal symptoms, with close to half making quit attempts and seeking treatment during the lockdown. Three-fourth of the sample reported difficulty in accessing treatment services and medications. Patients with opioid use were significantly more likely to think about quitting (χ2 = 20.408, P = 0.000), make attempts (χ2 = 12.436, P = 0.000), seek treatment (χ 2 = 7.536, P = 0.006), and self-medicate for withdrawal symptoms (χ2 = 5.885, P = 0.015). In turn, those with alcohol use were more likely to use telepsychiatry services (χ2 = 35.143, P = 0.000) and experience stigma by family members (χ2 = 29.951, P = 0.000) and neighbors (χ2 = 17.725, P = 0.000). Among COVID-19 safety precautions, majority practised wearing masks and social distancing but not others. Conclusion: COVID-19 lockdown led a significant proportion of substance users, especially opioid users, to make quit attempts and seek help. However, these could not be sustained due to difficulty in accessing treatment services. Further, significant proportion failed to adhere to COVID-19 safety precautions.

Review of the adaptations in opioid agonist treatment during the COVID-19 pandemic: Focus on buprenorphine-based treatment.

BACKGROUND: Availability and access to opioid agonist treatment (OAT) are limited despite its evidence of effectiveness in treating opioid use disorders (OUDs). COVID-19 pandemic has inadvertently exacerbated the problems of restricted access to OAT and, at the same time, has increased odds of harm due to opioid use. OBJECTIVES: We examined (a) adaptations conceived or implemented in the buprenorphine (BPN)-based OAT service delivery at the national, regional, or local level during the COVID-19 pandemic and (b) the impact of such transformations on the quantitative and qualitative aspects of service delivery. We focused exclusively on BPN-based OAT. METHODS: We carried out a systematic electronic database search in PubMed and Google Scholar. We included all types of articles. Additionally, we looked up relevant websites of international and national government agencies working in the field of drug abuse. RESULTS: We included 21 articles from 10 countries in the review and summarized the results in a narrative format. The majority of literature was from developed countries. We observed changes in the BPN initiation, dosing, and dispensing protocols, and particular emphasis on telemedicine. There was limited literature on service provisions for the vulnerable population. The changing modes of service delivery have possibly increased the number of new patients and reduced the risk of exposure owing to limited in-person contact. CONCLUSION: Newer adaptations to meet with the challenges of COVID-19 pandemic in the BPN-based OAT delivery tend to be innovative, flexible, and patient centered. Although it is too early to comment on these newer adaptations' impact, the outcome's directions appear to be positive.

Serious health threats of novel adulterants of the street heroin: a report from India during the COVID-19 pandemic.

The COVID-19 pandemic and a consequent nationwide lockdown in India for several weeks had restricted the access to street heroin and treatment for substance abuse. Use of cutting agents to increase the volume or psychoactive effect has been widely practised under such circumstances. Our patient with opioid use disorder chased heroin with an unknown cutting agent to enhance psychoactive effect from the limited quantities of heroin. He suffered from an abrupt onset sedation, weakness, postural imbalance, slurred speech, cognitive dysfunctions and disinhibited behaviour. Symptoms rapidly reversed following abstinence and initiation of buprenorphine-naloxone. Gas chromatography-mass spectrometric analysis of the adulterant revealed high concentrations of benzodiazepines and barbiturates, alongside the usual cutting agents-caffeine and acetaminophen. Abrupt reduction in availability of 'street drugs' in conjunction with poor healthcare access can lead to the use of novel adulterants with potentially serious clinical and public health implications.

Telemedicine-assisted stepwise approach of service delivery for substance use disorders in India.

Restricted access to healthcare during COVID-19 pandemic warranted an urgent adaptation of telemedicine practice. We describe a synchronous, stepwise (telephonic, video, and in-person consultation) direct-care model. From 18th May to 31st August 2020, 128 new and 198 follow-up patients received consultation. Eighty-nine percent of new patients required video-consultation. Sixty-eight percent of follow-up cases were managed by telephonic consultation. A third of new and a fifth of the follow-up patients had to be called for physical consultation. Limited access to and understanding of the technologies, potential breach in privacy, and restrictions imposed on online prescription of medications posed significant challenges.

Screening and brief intervention for substance use disorders in times of COVID-19: potential opportunities, adaptations, and challenges.

The ongoing pandemic has led to a sudden disruption of routine treatment services. Consequently, the already existing treatment gap for substance use disorders is likely to widen. There is an opportunity to expand the scope of Screening and Brief Intervention (SBI) to meet this unprecedented challenge. Its brevity, flexibility, and generalizability have positioned SBI to deal with additional systemic, structural, and attitudinal barriers that pertain to the pandemic. The standard content of SBI could be modified to adapt to the current context. SBI could also be used as a vehicle to render strategies for infection risk minimization. In this Perspective, we anticipate the challenges of expanding and implementing SBI in the present circumstances and present potential solutions. SBI, with adaptations, could bridge the augmented treatment gap for substance use disorders during COVID-19.

Access to Healthcare and Harm Reduction Services During the COVID-19 Pandemic for People Who Use Drugs.

: Globally, there are concerns about access to healthcare and harm reduction services for people who use drugs (PWUD) during the coronavirus disease 2019 (COVID-19) pandemic. Members from the Network of Early Career Professionals working in Addiction Medicine shared their experiences of providing treatment to PWUD during the COVID-19 pandemic. Drawing on these qualitative reports, we highlight the similarities and discrepancies in access to services for PWUD in 16 countries under COVID-10 restrictions. In most countries reported here, efforts have been made to ensure continued access to services, such as mobilising opioid agonist maintenance treatment and other essential medicines to patients. However, due to travel restrictions and limited telemedicine services, several Network of Early Career Professionals working in Addiction Medicine members from lower-resourced countries experienced challenges with providing care to their patients during periods of COVID-19 lock-down. The insights provided in this commentary illustrate how the COVID-19 lock-down restrictions have impacted access to services for PWUD.

Disulfiram Ethanol Reaction with Alcohol-Based Hand Sanitizer: An Exploratory Study.

AIMS: We conducted a cross-sectional survey to estimate the prevalence and clinical manifestation of disulfiram ethanol reaction (DER) and isopropanol toxicity (IT) in patients with alcohol use disorders, on disulfiram. Alcohol-based hand rub contains either ethanol or isopropanol or both. COVID-19 pandemic has led to wide scale usage of sanitizers. Patients with alcohol use disorders, on disulfiram, might experience disulfiram ethanol like reactions with alcohol-based sanitizers. METHODS: We telephonically contacted 339 patients, prescribed disulfiram between January 2014 and March 2020. The assessment pertained to the last 3 months (i.e. third week of March to third week of June 2020). RESULT: The sample consisted of middle-aged men with a mean 16 years of alcohol dependence. Among the 82 (24%) patients adherent to disulfiram, 42 (12.3%) were using alcohol-based hand rubs. Out of these, a total of eight patients (19%; 95% CI 9-33) had features suggestive of DER; four of whom also had features indicative of IT. Five patients (62.5%) had mild and self-limiting symptoms. Severe systemic reactions were experienced by three (37.5%). Severe reactions were observed with exposure to sanitizers in greater amounts, on moist skin or through inhalation. CONCLUSION: Patients on disulfiram should be advised to use alternate methods of hand hygiene.

Can google trends search inform us about the population response and public health impact of abrupt change in alcohol policy? A case study from India during the covid-19 pandemic.

BACKGROUND: Sudden alcohol prohibition in India during the COVID-19 pandemic presented an opportunity to test whether Google Trends data could indicate population responses and the public health impact of alcohol policy. We hypothesized, following prohibition: there would be a significant change in the relative search volumes (RSV) of alcohol-related queries; that temporal analysis of the trends would reflect a public response to policy changes; and that geospatial analysis of RSV would correlate with the prevalence of alcohol use. METHODS: Three different search periods were used to test the hypotheses. The search inputs were based on potential public response to alcohol prohibition, as evidenced by the literature, newspaper articles, and consensus. We used RSV as the unit of analysis. Mean RSV of search queries, pre-post implementation of prohibition, were compared. Smoothing of scatter plots examined the temporal association of trends with policy measures. Multiple linear regression tested the relationship of state-wise RSV and alcohol use prevalence. RESULTS: Post-implementation of prohibition, a significant increase in the RSV was observed for searches related to alcohol withdrawal (p<0.001), how to extract alcohol from sanitizer (p = 0.002), alcohol home delivery online (p<0.001), alcohol home delivery (p<0.001), and sleeping pills (p = 0.006). The trends suggested a decrease in general interest in alcohol but increased demand, and a possible connection with changes in policy measures. State-level RSV and alcohol use prevalence did not reveal a significant relationship. CONCLUSION: Google trend is a potential source of rapid feedback to policymakers about population responses to an abrupt change in alcohol policies.

The Changing Landscape of Alcohol Use and Alcohol Use Disorder During the COVID-19 Pandemic - Perspectives of Early Career Professionals in 16 Countries.

: Alcohol use is a major risk factor for infectious disease and reduction of harms associated with alcohol consumption are essential during times of humanitarian crises, such as the COVID-19 pandemic. As a network of early career professionals working in the area of addiction medicine, we provide our views with regards to national actions related to reducing alcohol-related harm and providing care for people with alcohol use disorder during COVID-19. We believe that COVID-19 related measures have affected alcohol consumption in the majority of countries represented in this commentary. Examples of these changes include changes in alcohol consumption patterns, increases in cases of alcohol withdrawal syndrome, disruptions in access to medical care for alcohol use disorder and increases in illegal production of alcohol. Our members urge that treatment for acute and severe conditions due to substance use should be considered as essential services in times of humanitarian crises like COVID-19.

Extended lockdown and India's alcohol policy: a qualitative analysis of newspaper articles.

OBJECTIVES: Since 25th March 2020 India went into a complete and extended lockdown. Alcohol production, sales, and purchase were barred with this overnight prohibition order. We conducted a qualitative analysis of the media reports published within the first month of the nationwide lockdown with the objectives (a) using the media reports as indications of possible public health impact and population response of a sudden alcohol prohibition in India, (b) suggesting areas for future research. METHODS: We performed thematic and content analysis of 350 articles published online in national newspapers between the 26th March, 2020 and 25th April, 2020. Initial inductive, followed by deductive coding was done in this exploratory thematic analysis. RESULTS: The thematic analysis revealed four main themes: the beneficial aspects of the policy, the harmful aspects of the policy, non-compliance and attempts to change and / or subvert the policy, popularity and level of public buy-in of the policy. We generated relevant sub-themes under main themes. Two additional themes, not directly related to the sudden prohibition, were use of stigmatizing language and ethical concerns. The content analysis showed the frequency of the appearance of the main themes and proportions of sub-themes and codes under those main themes. CONCLUSION: The harms, perceived from the media reports, should be balanced against the potential benefits. Absence of a national-level alcohol policy was made apparent by the reflexive, disconnected, and conflictual measures. Future research could systematically examine the potential ramifications of alcohol prohibition on public health, social, and economic aspects.