Opioid substitution therapy (ost) models of programme design and implementation

Opioid substitution therapy (ost) models of programme design and implementation

1. Opioid Substitution Therapy (OST):
Models of programme design and
implementation
Dr. M. Suresh Kumar MD DPM MPH
Consultant Psychiatrist
National CME: “Opioid Substitution Therapy: Policy and Practice”
Organisedby NDDTC & AIIMS
New Delhi
April 18 2015Presented at the national CME "OST: Policy and Practice" on 18th-19th April 2015 at AIIMS, New Delhi

2. Outline of presentation
1.OST in various settings and models of OST
2.OST as drug treatment vsOST as HIV prevention
3.Integrated OST services
4.Key gaps in OST program implementation
5.SummaryPresented at the national CME "OST: Policy and Practice" on 18th-19th April 2015 at AIIMS, New Delhi

3. 1. OST IN VARIOUS SETTINGS AND
MODELS OF OSTPresented at the national CME "OST: Policy and Practice" on 18th-19th April 2015 at AIIMS, New Delhi

4. OST in various settings
OST in specialised exclusive clinics
OST in hospitals
OST in drug dependence treatment clinics
OST in primary care settings
OST in community settings
OST in custodial settingsPresented at the national CME "OST: Policy and Practice" on 18th-19th April 2015 at AIIMS, New Delhi

5. OST in various settings
OST in hospitals
Department of Psychiatry
Department of General Medicine
OST in primary care settings
OST in primary health care settings
OST delivery through Pharmacies
OST in community settings
Government sponsored OST Clinics
NGO run OST Clinics
With Outreach Programs
With Peer Support
OST in custodial settingsPresented at the national CME "OST: Policy and Practice" on 18th-19th April 2015 at AIIMS, New Delhi

6. “Everyone deserves services
no matter what”
Client centeredness
Low threshold servicesPresented at the national CME "OST: Policy and Practice" on 18th-19th April 2015 at AIIMS, New Delhi

7. Low threshold OST
Disagreement between professional groups and programs on
definition of ‘low threshold’ OST
Abstinence from opioids and other drugs is not the treatment goal
High involvement of GPs and community health providers
Prescription of buprenorphine or slow release morphine
Reduce barriers for admission
Facilitate treatment retention
Strike et al, IntJ Drug Policy 2013; 24(6):e51-6Presented at the national CME "OST: Policy and Practice" on 18th-19th April 2015 at AIIMS, New Delhi

8. Facilitators of OST
Government sponsorship
No dispensing fee
Attractive to poor opioid dependent clients
Mobile unitsPresented at the national CME "OST: Policy and Practice" on 18th-19th April 2015 at AIIMS, New Delhi

9. MMT in North AmericaPresented at the national CME "OST: Policy and Practice" on 18th-19th April 2015 at AIIMS, New Delhi

10. Methadone: IRANPresented at the national CME "OST: Policy and Practice" on 18th-19th April 2015 at AIIMS, New Delhi

11. MMT, Specialized clinic: IranPresented at the national CME "OST: Policy and Practice" on 18th-19th April 2015 at AIIMS, New Delhi

12. MMT, General hospital: Iran Presented at the national CME "OST: Policy and Practice" on 18th-19th April 2015 at AIIMS, New Delhi

13. OST Clinic: Melbourne, Australia
WHO JakartaPresented at the national CME "OST: Policy and Practice" on 18th-19th April 2015 at AIIMS, New Delhi

14. Pharmacy delivery: AustraliaPresented at the national CME "OST: Policy and Practice" on 18th-19th April 2015 at AIIMS, New Delhi

15. Community MMT Clinic: ChinaPresented at the national CME "OST: Policy and Practice" on 18th-19th April 2015 at AIIMS, New Delhi

16. MMT Clinics in ChinaPresented at the national CME "OST: Policy and Practice" on 18th-19th April 2015 at AIIMS, New Delhi

17. OST in Asia
Methadone scaling up in:
China, Malaysia, Indonesia
Methadone established in :
Hong Kong, Thailand, Myanmar, Vietnam, Cambodia
Nepal, Bangladesh, Afghanistan, Maldives
Buprenorphine substitution in :
India
Malaysia
Detoxification using buprenorphine in Indonesia, Malaysia, India,
China, MyanmarPresented at the national CME "OST: Policy and Practice" on 18th-19th April 2015 at AIIMS, New Delhi

18. Models of delivery in South Asia
Model BangladeshIndia Maldives Nepal
Drug usedMethadone
Buprenorphine
Methadone
MethadoneMethadone
BeneficiariesPWID PWID People with
Opioid
dependence
PWID
Location GO run
hospital
NGO run TIs
GO-NGO
Model
Govt Dept of
Psychiatry,
Medical
College
Urine testingNo No Random urine
screen
No
Raoet al, Bull World Health Organ 2013; 91:150-53Presented at the national CME "OST: Policy and Practice" on 18th-19th April 2015 at AIIMS, New Delhi

19. OST in Asia
Country Estimated no. of
PWID
No. of OST sites
in 2008
OST
in prison
Est. no. of PWID
covered by OST in
2008
China 1,800,000–
2,900,000
531 159,439
Indonesia 190,460– 247,80035 4 3300
India 106,518– 223,12147 1 4600
Malaysia 170,000– 240,00068 4 22000
Maldives 400–500
1 45
Myanmar 60,000–90,000
7 500
Nepal 28,000 2 192
Thailand 160,528 147 4000-5000
Viet Nam 135,305 6 1484
Adapted from: Chatterjee& Sharma / International Journal of Drug Policy 21 (2010) 134– 136Presented at the national CME "OST: Policy and Practice" on 18th-19th April 2015 at AIIMS, New Delhi

20. OST Scale-up in India (March 2014)
29
104
147
94
32
175
350
250
0
50
100
150
200
250
300
350
400
No of states
with OST
No of Districts
with OST
Services
No of OST
Centres
No of OST
centres with
Govt
Current Status
TargetsPresented at the national CME "OST: Policy and Practice" on 18th-19th April 2015 at AIIMS, New Delhi

21. Community based OST Clinic: ChennaiPresented at the national CME "OST: Policy and Practice" on 18th-19th April 2015 at AIIMS, New Delhi

22. Community based OST Clinic: Delhi,
IndiaPresented at the national CME "OST: Policy and Practice" on 18th-19th April 2015 at AIIMS, New Delhi

23. Implementation of OST within
prison
OST reduces HIV transmission within prisons
It serves as a conduit to care after release from prison
It reduces the adverse consequences of injection drug
use, including overdose both within prison and after
release
Springer, 2010. Addiction, 105, 224–225Presented at the national CME "OST: Policy and Practice" on 18th-19th April 2015 at AIIMS, New Delhi

24. MMT in Prison MalaysiaPresented at the national CME "OST: Policy and Practice" on 18th-19th April 2015 at AIIMS, New Delhi

25. OST in prisons: Malaysia
Attitudes of prisoners to MMT
Secondary HIV prevention among prisoners in Malaysia
is crucial to reduce community HIV transmission after
release
Half of the surveyed HIV+ prisoners believed that OST
would be helpful, only a third said they needed it to
prevent relapse after prison release
Those reporting the highest injection risks were more
likely to believe OST would be helpful
Bachireddyet al, Drug and Alcohol Dependence 116 (2011) 151– 157Presented at the national CME "OST: Policy and Practice" on 18th-19th April 2015 at AIIMS, New Delhi

26. 2. OST AS DRUG TREATMENT
VS
OST AS HIV PREVENTIONPresented at the national CME "OST: Policy and Practice" on 18th-19th April 2015 at AIIMS, New Delhi

27. Opioid Substitution Therapy (OST):
Triple Action
Objective Target population Responsible sectors, agencies
OST as HIV preventionIDUs Ministry of Health Prison authorities NGOs
OST toimprove treatment
adherence to ART and TB DOTS
HIV + IDUs IDUs with TB
Ministry of Health ARTCentres
Hospitals Prisons / custodial settings NGOs Private Sector
OST as drug dependence treatment
Opioid dependent persons (includes both IDUs and non-injecting drug users)
Ministry of Health Public Security Drug treatment and rehabilitation centres Prisons / custodial settings NGOs Private sectorPresented at the national CME "OST: Policy and Practice" on 18th-19th April 2015 at AIIMS, New Delhi

28. COCKRANE REVIEW: MMT
Methadoneis an effective maintenance therapy
intervention for thetreatmentof heroin dependence
It retains patients intreatmentand decreases heroin use
better than treatments that do not utilise opioid
replacementtherapy
It does not show a statistically significant superior effect
on criminal activity or mortality
Matticket al, Cochrane Database Syst Rev. 2009 Jul 8;(3)Presented at the national CME "OST: Policy and Practice" on 18th-19th April 2015 at AIIMS, New Delhi

29. Impact of MMT Program, China
In 2008 and 2009, respectively, an
estimated 2969 and 3919 new HIV
infections (excluding secondary
transmission) were prevented
Consumption of heroin was
reduced by 17.0 tons -22.4 tons
$US939 million -US$1.24 billion in
heroin trade were avoided
MMT program is supported
legislatively and financially by the
central government with multi-
sector cooperation
Incorporation of MMT clinics into
existing medical infrastructure,
which has facilitated delivery of
services
Yin et al, International Journal of Epidemiology 2010;39:ii29–ii37Presented at the national CME "OST: Policy and Practice" on 18th-19th April 2015 at AIIMS, New Delhi

30. MMT Program, China
(128 clinics, 2-year follow -up)
Yin & Wu, 2008:
Presented at 19th International Conference on Harm Reduction,
11-15 May 2008, Barcelona, SpainPresented at the national CME "OST: Policy and Practice" on 18th-19th April 2015 at AIIMS, New Delhi

31. Components of effective methadone
treatment
Flexible but adequate dose of methadone after
stabilisation (usual range 50– 150 mg)
Adequate duration of treatment
Goal of maintenance
Rapid and client-centred assessment and induction
Ward et al, 1999. THE LANCET, Vol 353Presented at the national CME "OST: Policy and Practice" on 18th-19th April 2015 at AIIMS, New Delhi

32. Components of effective methadone
treatment
Psychosocial services to deal with social disadvantage
and psychiatric comorbidity
Trained staff with positive attitudes towards MMT and
opioid dependent patients
Affordable -cost of treatment should not exceed ability
to pay
Engagement with clients rather than punishment of
continuing illicit drug use
Ward et al, 1999. THE LANCET, Vol 353Presented at the national CME "OST: Policy and Practice" on 18th-19th April 2015 at AIIMS, New Delhi

33. Buprenorphine and illicit drug
use
Fiellinet al, J Acquir Immune DeficSyndr2011;56:S33–S38Presented at the national CME "OST: Policy and Practice" on 18th-19th April 2015 at AIIMS, New Delhi

34. OST in HIV settings:
OST as HIV prevention
Injecting frequency
Injecting risks
Sex risksHIV infectivity
HIV incidence
OST
↓↓x --↓
Adapted from: Degenhardtet al, Lancet 2010; 376: 285– 301Presented at the national CME "OST: Policy and Practice" on 18th-19th April 2015 at AIIMS, New Delhi

35. Evidence for MMT as HIV
prevention
Metzeret al, J Acquir Immune DeficSyndr. 1993 Sep;6(9):1049-56Presented at the national CME "OST: Policy and Practice" on 18th-19th April 2015 at AIIMS, New Delhi

36. Effectiveness of MMT
MMT is associated with a significant decrease in
injecting drug use and sharing of injecting equipment
MMT is associated with a lower incidence of multiple sex
partners or exchanges of sex for drugs or money, but no
change, or only small decreases, in unprotected sex
Studies of seroconversion, suggest actual reductions in
cases of HIV infection
Farrell et al, International Journal of Drug Policy 16S (2005) S67–S75Presented at the national CME "OST: Policy and Practice" on 18th-19th April 2015 at AIIMS, New Delhi

37. Evidence for OST:
Other benefits in HIV integrated care
BHIVES Collaborative findings
•Established in 10 sites as integrated models of HIV primary care and
substance abuse treatment
•OST with buprenorphine/naloxonepotentially effective in improving
health related QOL for HIV-infected patients with concurrent opioid
dependence
•Integration of buprenorphine/naloxoneinto HIV clinics increases
receipt of high-quality HIV care
•Buprenorphine/naloxoneprovided in HIV treatment settings also
decreases opioid use
J Acquir Immune DeficSyndr2011;56Presented at the national CME "OST: Policy and Practice" on 18th-19th April 2015 at AIIMS, New Delhi

38. Evidence for OST as HIV prevention:
Buprenorphine in reducing HIV related
risk behaviours
Sullivan et al, J Subst Abuse Treat. 2008; 35(1): 87– 92Presented at the national CME "OST: Policy and Practice" on 18th-19th April 2015 at AIIMS, New Delhi

39. OST medications: Is there a
choice?
Methadone Buprenorphine
Most researched and proven effectiveness as HIV prevention and dependence treatment
Relatively less researched; evidence for HIV prevention and dependence treatment exists
Cheaper; cost effective optionExpensive
Overdose not uncommon ‘Ceiling effect’ – Safety of the drug
Drug interactions with ARVs –need to
adjustdoses
No clinically significant drug interactions with ARVsPresented at the national CME "OST: Policy and Practice" on 18th-19th April 2015 at AIIMS, New Delhi

40. Key findings from WHO
collaborative study on OST and HIV
OST can achieve similar outcomes consistently in a culturally
diverse range of settings in low-and middle- income countries to
those reported widely in high- income countries
It is associated with a substantial reduction in HIV exposure risk
associated with IDU across nearly all the countries
Results support the expansion of opioid substitution treatment
Lawrinsonet al, 2008; Addiction, 103, 1484– 1492Presented at the national CME "OST: Policy and Practice" on 18th-19th April 2015 at AIIMS, New Delhi

41. Methadone vs Buprenorphine
Methadone clients have more severe substance abuse and
psychiatric and physical problems compared to buprenorphine
clients
Clients on methadone are more likely to remain in treatment
However, those retained on buprenorphine are more likely to
suppress illicit opiate use and achieve detoxification
Buprenorphine may also recruit more individuals such as those
who do not want methadone to treatment
Pinto et al, J SubstAbuse Treat.2010;39(4):340- 52.
The SUMMIT TrialPresented at the national CME "OST: Policy and Practice" on 18th-19th April 2015 at AIIMS, New Delhi

42. Effectiveness of OST with
methadone or buprenorphine
There is strong evidence that OST with methadone or
buprenorphine suppresses illicit opioid use
Both access to and effectiveness of OST contribute to
sustaining adherence to HAART in HIV-infected IDUs
There is also evidence that OST for HIV-positive IDUs is
associated with improved health outcomes
Farrell et al, International Journal of Drug Policy 16S (2005) S67–S75
Roux et al, 2008; Addiction, 103, 1828– 1836Presented at the national CME "OST: Policy and Practice" on 18th-19th April 2015 at AIIMS, New Delhi

43. Effectiveness of OST with
methadone or buprenorphine
Buprenorphine is an effective medication in the
maintenancetreatmentof heroin dependence, retaining
people in treatmentat any dose above 2 mg
Compared tomethadone, buprenorphine retains fewer
people when doses are flexibly delivered and at low
fixed doses.
If high doses are used, buprenorphine
andmethadoneappear no different in effectiveness
care.
Methadoneis superior to buprenorphine in retaining
people in treatment
Matticket al, Cochrane Database SystRev.2014 Feb 6;2Presented at the national CME "OST: Policy and Practice" on 18th-19th April 2015 at AIIMS, New Delhi

44. 3. INTEGRATED OST SERVICESPresented at the national CME "OST: Policy and Practice" on 18th-19th April 2015 at AIIMS, New Delhi

45. Integrated Services
Different models of integration
Co-located services
Case management
Referral networks
Role of medical providers in screening and
interventionPresented at the national CME "OST: Policy and Practice" on 18th-19th April 2015 at AIIMS, New Delhi

46. Integrated Services
Different models of integration
Clinic site level integration
Same physician delivering addiction and
medical services
Two physicians working together at the
same clinicPresented at the national CME "OST: Policy and Practice" on 18th-19th April 2015 at AIIMS, New Delhi

47. Integrated Services
Psychosocial services
Mental Health Services
Pregnancy and reproductive health services
Infectious diseases care services –HIV, HCV,
TBPresented at the national CME "OST: Policy and Practice" on 18th-19th April 2015 at AIIMS, New Delhi

48. Integrated Services
Potential benefits of providing integrated
substance use and medical care services
Increase drug treatment capacity
Reduce health and administrative costs
Diminish duplication of services
Improve health and drug treatment outcomesPresented at the national CME "OST: Policy and Practice" on 18th-19th April 2015 at AIIMS, New Delhi

49. New Initiatives at Integrated
Services
Integrating the Substance use and HIV
services
Buprenorphine HIV Evaluation and Support
Services (BHIVES)
Integration into community and hospital based
clinics
Weiss et al, J Acquir Immune DeficSyndrVolume 56, Supp 1, March 2011
BHIVES CollaborativePresented at the national CME "OST: Policy and Practice" on 18th-19th April 2015 at AIIMS, New Delhi

50. Evidence for OST:
Positive HIV treatment outcomes
Alticeet al, J Acquir Immune DeficSyndrVolume 56, Supp 1, March 2011
BHIVES CollaborativePresented at the national CME "OST: Policy and Practice" on 18th-19th April 2015 at AIIMS, New Delhi

51. Reasons for poor adherence to
OST and ART
Perception of adverse effects
Alcohol consumption
Depression
Roux et al, 2008; Addiction, 103, 1828– 1836Presented at the national CME "OST: Policy and Practice" on 18th-19th April 2015 at AIIMS, New Delhi

52. Integration with mental health
services
High prevalence of personality disorders
Depression
Co-morbid substance use disorders
Integrated servicesPresented at the national CME "OST: Policy and Practice" on 18th-19th April 2015 at AIIMS, New Delhi

53. OST, Pregnancy and
Neonatal abstinence syndrome
Methadone has been the recommended standard of care for
opioid- dependent pregnant women
Buprenorphine is an alternative to methadone for the treatment
of opioid dependency during pregnancy
The benefits of buprenorphine in reducing the severity of NAS
among neonates with this complication suggest that it should
be considered a first-line treatment option in pregnancy
Jones et al, N Engl J Med 2010; 363:2320-31Presented at the national CME "OST: Policy and Practice" on 18th-19th April 2015 at AIIMS, New Delhi

54. How to improve and ensure effective
linkages?
Co-location of services
Collaboration between various departments
Cross training of health professionals
Treatment literacy for IDUs
Other supportive services
mental health, psychosocial support, nutritionPresented at the national CME "OST: Policy and Practice" on 18th-19th April 2015 at AIIMS, New Delhi

55. 4. KEY GAPS IN OST PROGRAM IMPLEMENTATIONPresented at the national CME "OST: Policy and Practice" on 18th-19th April 2015 at AIIMS, New Delhi

56. OST adoption
Despite evidence, detoxification is preferred than opioid
substitution therapy by several addiction programs
Leadership qualities critical to OST adoption
Leaders’ training treatment orientation, tenure determine
OST adoption
Leaders less ideologically grounded in abstinence only
approaches
Friedmannet al, J Behav Heal ServRes 2010, 37(3):322-37Presented at the national CME "OST: Policy and Practice" on 18th-19th April 2015 at AIIMS, New Delhi

57. OST: Key challenges for the
resource poor settings
What is the most effective model for implementing
OST?
How can OST become a fundamental component of
integrated HIV prevention?
How can the quality of the OST programmes be
ensured and evaluated?
Kermode, Crofts, Kumar & Dorabjee , Bull World Health Organ 2011;89:243 Presented at the national CME "OST: Policy and Practice" on 18th-19th April 2015 at AIIMS, New Delhi

58. Efficient ways of delivering opioid
substitution medication
Prescription by general practitioners
Community pharmacies
Community based approach to OST
Integration into primary carePresented at the national CME "OST: Policy and Practice" on 18th-19th April 2015 at AIIMS, New Delhi

59. Key obstacles to safe and effective
delivery of opioid substitution medication
Restricted Government funding and support for
OST
Limited patient capacity to pay for OST
Prejudices against OST
A balance between overregulation and laissez -
faireprovisionPresented at the national CME "OST: Policy and Practice" on 18th-19th April 2015 at AIIMS, New Delhi

60. Advocacy in Islamic Republic of IranPresented at the national CME "OST: Policy and Practice" on 18th-19th April 2015 at AIIMS, New Delhi

61. Islamic Republic of IRAN
This order is to remind judges at all courts of justice and
prosecutors’ offices throughout the country that, since a major
element of criminal action is verifiable malicious intent, the
aforementioned interventions are clearly void of such intent and,
instead, are motivated by the will to protect society from the
spread of deadly contagious diseases, such as AIDS and hepatitis.
Therefore all judicial authorities must consider the lack of
malicious intent in the interventions of the Ministry of Health and
Medical Education as well as those of other centres and
organizations that are active in this field. They must not accuse
service providers of assisting in the criminal abuse of narcotics
and must not impede the implementation of such needed and
beneficial programmes.
Seyed Mahmood Hashemi Sharoudi
Head of the Judiciary
24 January 2005Presented at the national CME "OST: Policy and Practice" on 18th-19th April 2015 at AIIMS, New Delhi

62. Policy and OST
Policy shifts increase coverage of OST
In Vietnam, Malaysia and China, shift from punitive
law enforcement to evidence based treatment has
increased coverage
Policy shift in Ukraine increased OST coverage
Russia’s stand against OST and closing down
access to information on methadone
Degenhartet al, IntJ Drug Policy 2014; 25(1):53-60Presented at the national CME "OST: Policy and Practice" on 18th-19th April 2015 at AIIMS, New Delhi

63. Workforce and Training
Limited training and teaching in addiction
medicine during MBBS
Possibility for one day training course for
prescribing buprenorphine
Training of nurses, pharmacists and other
healthcare workersPresented at the national CME "OST: Policy and Practice" on 18th-19th April 2015 at AIIMS, New Delhi

64. MMT in China: Barriers and
facilitators
Barriersto MMT for
clients
Requirement for registration in the police department Perceived societal stigma; Logistic difficulties; Side effects; Inappropriate perception of methadone; Fear of being addicted to another drug; Lack of additional services; Economic burden
Barriers for Service Providersin MMT
Financial difficulties; Lack of professional training Difficulties in pursuit of career; Lack of institutional support Concern for personal safety; Low income Large work load; Misunderstanding by society
Factors associated with successful MMT
MMT clinics affiliated with local CDCs have more clients, higher retention rates Longer operating hours Incentives for compliant clients
Lin et al, J SubstAbuse Treat. 2010; 38(2): 119 .
Lin et al, IntJ Drug Policy. 2010; 21(3): 173–178
Lin, 2009. Dissertations & Theses, UCLAPresented at the national CME "OST: Policy and Practice" on 18th-19th April 2015 at AIIMS, New Delhi

65. Factors that maximise
participation inOSTprograms
Client related Ease of access
Extended opening hours at clinics
Sufficiently high doses
Service Providers
related
Non-judgemental clinicians
Professionally & technically competent to deal with
addiction related issues
High staff morale
Access to allied medical, psychological and welfare
services
Supportrelated Significant peer support
Family support
Support groupsPresented at the national CME "OST: Policy and Practice" on 18th-19th April 2015 at AIIMS, New Delhi

66. OST: Key gaps identified
•OST is available for a limited number of IDUs at present in
most countries of South Asia
•Lack of exclusive OST centres for women injecting drug
users
•Effective linkages with other services such as ICTC, ART,
TB DOTS, Drug dependence treatment is a significant
challenge
•Pharmacological options for OST need to be expanded
–Methadone; Buprenorphine; Buprenorphine-Naloxone; Oral morphine Presented at the national CME "OST: Policy and Practice" on 18th-19th April 2015 at AIIMS, New Delhi

67. Evidence for OST as HIV prevention:
Coverage is critical
Country IDU
prevalence
(%)
OST
availability
HIV
incidence
among
IDUs, 2005
HIV
incidence
among
IDUs, 2006
Russian
Federation
Current IDU
1.78
OST not available72/million 79/million
Ukraine Current IDU
1.16 (1.00, 1.31)
OST mostly
unavailable (~1%)
134/million 153/million
USA Current IDU
0.96 (0.67, 1.34)
OST available
(1998– 2004:
15%–25%)
18/million NA
Canada Lifetime IDU
1.3 (1.0, 1.7)
OST available
(2003: ~26%)
7.2/million 7.3/million
EU (27 countries)Current IDU
0.19 (0.16–0.21)
OST available
(2004: ~33%)
6.4/million 5.9/million
Australia Current IDU
1.09 (0.65–1.50)
OST available
(2006: ~50%)
1.6/million 1.4/million
Weissinget al, Am J Public Health 2009; 99:1049– 1052.Presented at the national CME "OST: Policy and Practice" on 18th-19th April 2015 at AIIMS, New Delhi

68. Why OST is needed for non-injecting
opioid dependent users?
Strathdeeet al, Lancet 2010; 376: 268– 84Presented at the national CME "OST: Policy and Practice" on 18th-19th April 2015 at AIIMS, New Delhi

69. 5. CONCLUSIONPresented at the national CME "OST: Policy and Practice" on 18th-19th April 2015 at AIIMS, New Delhi

70. Conclusion
•OST is an effective evidence based drug use treatment for injecting
as well as non-injecting opioid dependent individuals
•OST is evidence based opioid use disorder treatment
•OST in HIV settings is primarily to prevent HIV and improve ART
adherence; often benefits go beyond HIV related issues
•Integrated OST services are essential
•The identified gaps in OST in Asia can be effectively addressed in
future through scaled-up efforts (in community & custodial settings)
and multi-sectoral collaborationPresented at the national CME "OST: Policy and Practice" on 18th-19th April 2015 at AIIMS, New Delhi