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LETTERS TO EDITOR  
Year : 2020  |  Volume : 62  |  Issue : 5  |  Page : 604-606
Multiple suicide attempts in an individual with opioid dependence: Unintended harm of lockdown during the COVID-19 outbreak?


1 Department of Psychiatry, Post Graduate Institute of Medical Education and Research, Chandigarh, India
2 Department of Psychiatry, Drug De-Addiction and Treatment Centre, Post Graduate Institute of Medical Education and Research, Chandigarh, India

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Date of Submission05-May-2020
Date of Acceptance20-May-2020
Date of Web Publication10-Oct-2020
 

How to cite this article:
Ghosh A, Sharma K, Mahintamani T, Pandiyan S, Roub Fe, Grover S. Multiple suicide attempts in an individual with opioid dependence: Unintended harm of lockdown during the COVID-19 outbreak?. Indian J Psychiatry 2020;62:604-6

How to cite this URL:
Ghosh A, Sharma K, Mahintamani T, Pandiyan S, Roub Fe, Grover S. Multiple suicide attempts in an individual with opioid dependence: Unintended harm of lockdown during the COVID-19 outbreak?. Indian J Psychiatry [serial online] 2020 [cited 2020 Oct 30];62:604-6. Available from: https://www.indianjpsychiatry.org/text.asp?2020/62/5/604/297762




Sir,

Coronavirus disease-19 (COVID-19) was declared a pandemic by the WHO on March 11, 2020.[1] To contain the spread, a nationwide lockdown was enforced in India on 24 March. Since the lockdown, there is a suspension of routine outpatient care and restricted movement, limiting access to psychiatric treatment. The revised telemedicine practice guideline approved online prescription of psychotropics (including benzodiazepines).[2] However, the guideline does not permit online prescription of buprenorphine or methadone, which are controlled substances in India. Therefore, individuals on opioid agonist treatment are likely to be disproportionately affected.

Here, we reported multiple suicide attempts in an individual on buprenorphine-naloxone-based agonist treatment, in the absence of any other psychiatric comorbidity.

A 26-year-old male with heroin and tobacco dependence was on treatment from our addiction psychiatry clinic since October 2019. He had impulsive and dissocial traits. He was started on buprenorphine-based agonist treatment in November 2019. For the initial 2 months, he was not adherent to treatment. Since February 2020, his dose of buprenorphine-naloxone was increased (from 4 mg to 6 mg), leading to better control of craving and improved adherence. On March 18th follow-up, his abstinence was confirmed by negative urine screen for morphine. As per our treatment protocol, he was prescribed take-away buprenorphine for a week. However, the nationwide lockdown, starting from March 24th led to immediate suspension of public conveyance, sealing of state borders and suspension of his daily income, due to which he was unable to attend for follow-up on next scheduled date. Unable to procure buprenorphine from any other sources he suffered from intense craving and withdrawal. On the 3rd day, while experiencing unbearable pain, he found a bottle of Phenyl (a disinfectant; composed of-carbolic acid, cresol, homologues of phenol, and pine oil). He drank a mouthful of it with an “intent to die,” to get rid of the suffering. However, he could not drink more due to local irritation and nausea. He was taken to the nearest health centre, was provided supportive care, and discharged within a few hours. Next day, he procured heroin from a known drug-peddler. He started injecting heroin but restricted availability and the high price forced him to abstain intermittently. He experienced guilt for restarting heroin. During those forced abstinences, to relieve withdrawal-related pain and insomnia, he managed ten tablets of 0.5 mg alprazolam from a health care worker. Next day, he consumed all ten tablets together with “intent to kill” himself. However, he revealed the same to his family and was brought to the emergency of our hospital. On examination, he was found to be sedated; responded to verbal commands. His vitals were within normal limits. However, his pupils were dilated. He was kept under overnight observation and was seen in the addiction psychiatry clinic on the next day. He expressed remorse for the attempts to kill himself and said “unbearable” withdrawal pain and inability to procure medication were motivations behind those attempts. Reinduction was done with buprenorphine-naloxone(BNX). He was told about the risk of co-administering BNX and benzodiazepines. His mother was asked to supervise treatment and one week's takeaway dose was dispensed.

Substance use disorders (SUD) increases the odds of suicide ideation, attempt, and completed suicide. The findings hold across substances, including opioids.[3] Worryingly, people with opioid use disorders are eleven times more likely to die of suicide and odds of mortality is higher among patients within 2 weeks of discontinuation or those who are irregular on opioid-agonist treatment.[4],[5] Behavioral impulsivity is known to increase risk of impulsive suicide attempts in SUD.[6] The presented case had some of these high-risk factors. However, the proximal and most important precipitating factor was COVID pandemic and consequent lockdown-both are purported to heighten the risk of suicide by decreased access to mental health treatment, economic hardships, social isolation, and provoking anxiety.[7] At least the first two factors contributed significantly in this case. Although the opioid substitution clinic has been functional, limited information in the public domain and multiple barriers to access treatment resulted in forced discontinuation of agonist treatment. The policy of no provision of opioid agonist through teleconsultation has added to his misery. Although he could not procure buprenorphine, heroin and alprazolam were still available.

Hence, in our opinion, this case exemplifies an unprecedented adverse consequence of lockdown. This is a learning lesson for countries lacking a public health-oriented opioid agonist treatment policy or those who are yet to change their existing policy to adapt to the new need arisen out of the pandemic.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
2.
Available from: https://www.mohfw.gov.in/pdf/Telemedicine.pdf. [Last accessed on 2020 May 02].  Back to cited text no. 2
    
3.
Poorolajal J, Haghtalab T, Farhadi M, Darvishi N. Substance use disorder and risk of suicidal ideation, suicide attempt and suicide death: A meta-analysis. J Public Health (Oxf) 2016;38:e282-91.  Back to cited text no. 3
    
4.
Sordo L, Barrio G, Bravo MJ, Indave BI, Degenhardt L, Wiessing L, et al. Mortality risk during and after opioid substitution treatment: Systematic review and meta-analysis of cohort studies. BMJ 2017;357:j1550.  Back to cited text no. 4
    
5.
Wilcox HC, Conner KR, Caine ED. Association of alcohol and drug use disorders and completed suicide: An empirical review of cohort studies. Drug Alcohol Depend 2004;76 Suppl: S11-9.  Back to cited text no. 5
    
6.
Wojnar M, Ilgen MA, Czyz E, Strobbe S, Klimkiewicz A, Jakubczyk A, et al. Impulsive and non-impulsive suicide attempts in patients treated for alcohol dependence. J Affect Disord 2009;115:131-9.  Back to cited text no. 6
    
7.
Reger MA, Stanley IH, Joiner TE. Suicide mortality and coronavirus disease 2019—A perfect storm? JAMA Psychiatry 2020. [doi: 10.1001/jamapsychiatry. 2020.1060].  Back to cited text no. 7
    

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Correspondence Address:
Abhishek Ghosh
Department of Psychiatry, Post Graduate Institute of Medical Education and Research, Chandigarh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/psychiatry.IndianJPsychiatry_447_20

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