|Year : 2018 | Volume
| Issue : 1 | Page : 43-46
KEM deaddiction center of excellence: The journey
Shilpa Amit Adarkar
Department of Psychiatry, Bombay Drug De-addiction Centre of Excellence, Seth GS Medical College and KEM Hospital, Mumbai, Maharashtra, India
|Date of Web Publication||8-May-2018|
Shilpa Amit Adarkar
B 1901, Raheja Vistas, Raheja Vihar, Chandivali, Powai, Mumbai . 400 072, Maharashtra
Source of Support: None, Conflict of Interest: None
The Department of Psychiatry at Seth GS Medical College and KEM Hospital, Mumbai has been treating substance use disorders (SUDs) at its De-addiction Center of Excellence (DAC) for more than 25 years. This DAC was established with the support of Drug De-addiction Program (DDAP) of the Ministry of Health and Family Welfare (MOH & FW). This is an overview of the services provided by the KEM DAC, with the information about the Drug Treatment Clinics (DTC) scheme of the central ministry that is implemented for the past 4 years. This provides information about the outdoor, indoor, and community services of KEM DAC along with the facilities available for the SUD patients and their relatives. The main focus of the article is the DTC scheme, its initiation, process, and the implementation. The scheme is implemented since 2014 with the support of DDAP, MOH and FW, with National Drug Dependence Treatment Center, All India Institute of Medical Sciences (AIIMS), New Delhi as the national coordinating Center and KEM DAC as the Regional Resource and Coordination Centre (RRCC) in the Western region. Besides its own DTC, KEM RRCC has established five more DTCs in the region. These are established after seeking permissions from the competent authorities and after the feasibility assessment. Thousands of patients have been taking the benefit of these DTC services and can remain drug-free. The scheme had also reduced crime and helped their families and the society at large.
Keywords: Drug Treatment Clinics scheme, KEM Deaddiction Centre of Excellence, substance use disorder
|How to cite this article:|
Adarkar SA. KEM deaddiction center of excellence: The journey. Ann Indian Psychiatry 2018;2:43-6
| Kem Deaddiction Center|| |
The Bombay Drug De-addiction Center of Excellence (DAC) was established at KEM Hospital in 1991, under the Department of Psychiatry. This was from a one-time grant given by the Drug De-addiction Program, Ministry of Health and Family Welfare (DDAP, MOH and FW). Demand reduction is a mandate of the ministry, and it established 122 DACs in India to meet this mandate with an understanding that it will be maintained by the state health departments, in KEM's case, the Municipal Corporation of Greater Mumbai (MCGM). Since the past 27 years, KEM DAC has been tirelessly providing outpatient and indoor services to substance use disorder (SUD) patients.
| Patient Services|| |
KEM DAC has been seeing >1000 outpatient department (OPD) patients every year, and they include alcohol, opioid, cannabis, nicotine… and more recently, inhalants, stimulants, benzodiazepines, rave party, and club drugs dependence. There is a 30-bedded indoor facility, and also detoxification, as well as de-addiction for relapse prevention, is provided in an individually tailored format to every patient. Family intervention in the form of group therapy has been very helpful for the relatives of patients in understanding the illness, coping with it and ensuring compliance. There is a dedicated social worker and a team of occupational therapists for our De-addiction Center.
Occupational therapy helps in giving work fitness too. Social worker and the faculty are actively involved in the rehabilitation of the patients including job placements.
The Self Help Groups, namely, Alcoholics Anonymous and Narcotics Anonymous conduct their group meetings once a week each and our patients follow their program even after discharge.
DAC faculty, being a yoga therapist, initiated a yoga group for indoor patients for their physical benefit and for changing their ways of life. The department head had started weekly talks by Brahmakumaris for our indoor patients for their spiritual healing.
The De-addiction Laboratory is a boon for urine toxicology screening and includes chemical tests, radioimmunoassays, chromatography, and rapid cassette tests for various substances used by patients. There are referrals from other hospitals too for the urine screening. Those caught under the NDPS act are also referred to our center, and they are given immunity against prosecution after a detailed assessment, periodic urine screenings, and appropriate treatment.
A separate Tobacco Cessation Clinic was established in 2002 by dedicating an OPD to it, and it is helping patients quit smoking as well as smokeless tobacco, with pharmacotherapy and psychosocial interventions.
KEM DAC has been active in the community as well. The faculty, residents and social workers conduct awareness programs in the form of lectures, street plays, and camps too. Every year, on World No Tobacco Day (31st May), World De-addiction Day (26th June), and during Mental Health Week (4th to 10th Oct), awareness talks are organized in the areas around KEM Hospital. The residents and nursing students perform street plays. Last few years, KEM DAC has been collaborating with Anti Narcotic Cell of Mumbai Police and conducts lectures in schools and colleges about how to say no to drugs. There is collaborative work with various nongovernment organizations also, such as those working with street children for their rehabilitation. The center has also collaborated with National Legal Services Authority of India for awareness talks in the community on SUDs.
| Research Work|| |
Plenty of research work has been done at the DAC on a variety of topics such as Alcohol, Opioid, Cannabis Dependence, Wives of Alcoholics, Adolescent drug users, Stimulant Use, Street children, and many more. Our FDG PET studies on Alcohol and Cannabis use disorders have won the prestigious Dr. AV Shah award in the West Zone and the Dr. Marfatia award at Annual National Conference of Indian Psychiatric Society.
Maharashtra University of Health Sciences (MUHS) has approved a Fellowship Course in De-addiction in 2014 with an intake of three students per year and students have been completing this 1 year specialized course to add to their resumes.
| Projects|| |
Besides its services to the patients, KEM DAC has been coordinating many Central Government projects in collaboration with National Drug Dependence Treatment Centre, All India Institute of Medical Sciences, New Delhi (NDDTC, AIIMS).
KEM DAC has been a Resource Centre (Western Region) for training programs for General Duty Medical Officers under the NFCDA (Department of Revenue, Ministry of Finance) funded scheme. These training programs have been helpful for the medicos in treating SUDs locally at Primary Health Centre/district levels.
KEM DAC was a Regional Technical Training Centre– West, under the project Hifazat (funded by GFATM round 9 grant) for the training of staff working under National AIDS Control Program (NACO). Sixteen training programs were conducted in 4 years for doctors and nurses working with Injective Drug Users 
KEM DAC was one of the five centers in India for Methadone Maintenance Treatment Project (MMT project, the first ever in India) funded by the UNODC and coordinated by NDDTC, AIIMS. After completing the project, Methadone treatment has continued at our center as a part of the current DTC scheme.
At present, KEM DAC is one of the Regional Technical Agencies for National Household Survey on Substance Use. KEM faculty and staff under the project are training and monitoring the survey in the Western Region.
| Dtc Scheme|| |
Background: Although 122 DACs were established by DDAP, MOHFW initially, the evaluation exercises conducted by NDDTC in 2002 and in 2006–2007 showed that only one-third of these were functioning adequately. This was mostly due to lack of awareness about substance use being a medical illness, and hence, it was not given a priority. This had led to nonavailability of medications, lack of dedicated staff, DACs being shut down, space used for other purpose and the aim of treating SUDs not being achieved adequately.
Hence, to enhance the functioning of DACs, a Drug Treatment Clinics (DTC) scheme was proposed under DDAP, MOHFW to be implemented by NDDTC, AIIMS.
Under the scheme, NDDTC, AIIMS functions as a National coordinating Centre which identified health facilities treating SUD patients and having an existing infrastructure to run as DTCs. NDDTC is also responsible for curriculum development, training, funds management, and overall coordination with the support and supervision of DDAP, MOH & FW.
Thus, in 2014, KEM DAC was selected, and the feasibility assessment was done by the faculty of NDDTC, AIIMS. The head of the department is the Nodal Officer of the DTC. The Nodal Officer and the department faculty attended the training at Delhi. After seeking permissions from the authorities at MCGM, a letter of agreement was signed by the nodal officer with NDDTC, AIIMS, and a separate bank account was opened. Under the scheme, each DTC gets:
- 3 personnel - Medical officer, Counselor, Nurse
- Refurbishment funds (rooms for staff, waiting area, dispensing area, furniture)
- Free medications for the treatment of SUD.
The free medications include-
- T. Diazepam
- T. Lorazepam
- Injection Thiamine
- T. disulfiram
- T. Naltrexone
- T. Buprenorphine (0.4 and 2mg), Buprenorphine–Naloxone combination (2+0.5) and Syrup Methadone: Specialized services in the form of Opioid Substitution Therapy (OST).
Thus, the recruitment process was started along with refurbishment. Some changes had to be made in the existing De-addiction OPD for the staff as well as for safe dispensing of medications. The KEM DTC was started in 2014. The 5-day induction training of the newly appointed staff of all centers was conducted by NDDTC, AIIMS. The funds, as well as medications, were received, and our center started enhanced services for our SUD patients and their families.
| Regional Centre|| |
Under the DTC Scheme, it was decided to establish two Regional Centers which would, in turn, establish more DTCs in their regions and be responsible for their training and supervision. The regional centers were expected to provide mentoring and monitoring to all the DTCs in their respective regions.
The two academic institutes were chosen to be the Regional Resource and Coordination Centers (RRCC), one at RIMS, Imphal and the other at KEM Hospital, Mumbai. These centers were chosen as they had already been running their DTCs and also had the experience in training as regional centers on other projects earlier. The RRCCs were provided with the additional staff of a DTC Coordinator, a Training Coordinator, and an Accountant. A meeting was conducted at NDDTC with the RRCC Nodal Officers and faculty to discuss the strategies and the future expansion plan of the scheme. KEM DAC started functioning as RRCC from July 2015.
The RRCC identified institutes/hospitals already having patients with SUD and some de-addiction facilities. In the initial phase, three institutes were selected, namely, Bhardawadi De-addiction Centre at Andheri Mumbai, Department of Psychiatry at Rajawadi Hospital, Ghatkopar, Mumbai and Civil Hospital, Osmanabad, Maharashtra.
Bhardawadi De-addiction Centre is located in Western suburbs of Mumbai and is under the Public Health Department of MCGM. It has outdoor and indoor services. Rajawadi Hospital is one of the peripheral Hospitals of MCGM and is in an Eastern suburb of Mumbai. They see SUD patients in Psychiatry OPD and have a ward also. Civil Hospital, Osmanabad is in Marathwada region of Maharashtra. It has a Psychiatry OPD and a full-time Psychiatrist under District Mental Health Program.
Permissions had to be sought from the competent authorities namely, MCGM and Directorate of Health Services (DHS) for these selected sites.
The Nodal officer, a faculty and the DTC coordinator from KEM traveled to these sites and conducted feasibility assessments at the three sites. The Nodal officers were identified, and their willingness and the support of their authorities were assessed. The existing infrastructure and the space needed to run a DTC was evaluated, and refurbishment suggestions were given. The report was sent to NDDTC, AIIMs. After their visit to these sites and the approval, a letter of agreement was signed by the Nodal Officers with the RRCC.
In June 2016, the first 5 days Induction training was conducted by RRCC, KEM, for all the newly recruited staff of the three DTCs. The agenda included lectures, demonstrations, and discussions and were conducted by KEM faculty. A faculty from NDDTC served as a Technical Resource person. A Nodal Officers' meeting was held on the last day, and other operational issues were discussed.
Since then, all these DTCs have been catering to the needs of SUD patients with the help of pharmacotherapy and psychosocial interventions. KEM DTC's patient load has increased manifold. Bhardawadi DTC has become a popular treatment centre, and hundreds of patients from western suburbs are benefitting from its OST medications of Buprenorphine. As the word has spread around, Rajawadi DTC has got an increased number of alcohol use patients and their OST services of Syp. Methadone are being utilized by opioid dependence patients, especially injective drug users. Osmanabad DTC has been seeing increased number of SUDs. As there are no opioid dependent patients there, they have been provided with all medications except OST.
In the next phase, KEM RRCC planned the expansion in the Western region beyond Maharashtra and has established two more DTCs in Gujarat and Goa. Similar processes were followed for them as well. One is located at Civil Hospital, Surat and the other is at North Goa District Hospital, Mapusa. Both the sites have a NACO OST program running for a few years. Their services are enhanced by the DTC scheme as it has dedicated staff, free medications, and a refurbished place.
Another 5 day induction training programme was held in January 2018 for the newly recruited staff at these centers in collaboration with NDDTC and refresher training for the earlier DTC staff.
Continuous monitoring, evaluation, and mentoring are being done by RRCC, KEM. Online reporting has started under the DTC scheme, and all DTCs send their monthly reports to RRCC which then compiles and forward them to NDDTC. An exclusive website has been initiated under the scheme and is being updated and maintained by a dedicated staff at NDDTC, AIIMS.
The DTC Scheme was lauded for its efforts internationally in South Asia by prestigious “British Medical Journal South Asia Award 2016” in the category noncommunicable disease initiative of the year.
As a benefit of this scheme, thousands of patients of SUD are treated with medications and can remain drug-free. Psychosocial interventions are helping them cope with life better and can get the support of their families. Some broken families have been united too. As their status has changed from addicts/druggies to patients, their social image has been uplifted. Patients can find steady jobs and are away from criminal and other antisocial activities.
The DTC Scheme has not only expanded the De-addiction services but also attempted to create a better society which is free of drugs and crime. Thus, the mandate of Demand Reduction is being achieved through this scheme.
The patient load on the DTCs has increased manifold, and the faculties have to dedicate more time. Furthermore, since OST is a Directly Observed Treatment (DOT), managing patient crowds for sublingual dispensing is a challenge. Although patients are given time ranges to follow, there are time overlaps as all patients have to go to work. Dealing with hundreds of opioid dependence patients, many of them with comorbid personality disorders is another challenge. As there are medical and psychosocial intake sheets for the new and follow-up patients, history taking and record keeping is a mammoth task for the staff. However, it is possible to overcome these challenges with some division of work and time management, psychosocial interventions with group therapy sessions and with good teamwork.
As the DTC scheme is being implemented in the government sector, those service providers in the Western region interested in starting a DTC can approach KEM RRCC at dtc. firstname.lastname@example.org. The above processes will be followed in collaboration with the nodal center and if found feasible, a new DTC can be established.
The authors would like to thank Dr. S. R. Parkar, Professor and Head, Department of Psychiatry, In charge: Drug DAC, Seth GSMC and KEMH and Dr. Kranti S. Kadam, Professor (Additional), Department of Psychiatry and De-addiction Centre of Excellence, Seth GSMC and KEMH.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |