|Year : 2020 | Volume
| Issue : 2 | Page : 111-112
Six decades of natural opiate use in a nonagenarian
Saumya Mishra, Siddharth Sarkar
Department of Psychiatry and National Drug Dependence Treatment Centre, All India Institute of Medical Sciences, New Delhi, India
|Date of Submission||01-Jul-2020|
|Date of Decision||04-Jul-2020|
|Date of Acceptance||25-Jul-2020|
|Date of Web Publication||21-Jan-2021|
Dr. Saumya Mishra
Department of Psychiatry and National Drug Dependence Treatment Centre, All India Institute of Medical Sciences, Ansari Nagar, New Delhi - 110 029
Source of Support: None, Conflict of Interest: None
Elderly natural opiate users are often forced to seek treatment when they cannot avail opioids. We present here a case of a 98-year-old male who came to us with six decades of natural opiate use in the form of raw opium and poppy husk. The patient was managed symptomatically with tramadol and diazepam for about 6 months. The case highlights the long duration of natural opiate use for nearly six decades, its impact and outcome in terms of psychosocial functioning, and the successful management of elderly patients with natural opiate use in outpatient settings.
Keywords: Elderly, natural opioids, outpatient, tramadol
|How to cite this article:|
Mishra S, Sarkar S. Six decades of natural opiate use in a nonagenarian. J Geriatr Ment Health 2020;7:111-2
| Introduction|| |
People have been using opium since very early times in the Indo-Pakistan subcontinent, and culturally sanctified use has been described. Before the advent of heroin, which is a more potent drug and can be used through the injectable route, raw opium and poppy husk were the common forms of opioids being abused in South Asia. A survey conducted 40 years back, suggested that about 2' of the population was a regular user of opium, while about the same percentage were past users. Interestingly about 1' were seasonal users taking during the harvesting and sowing season. A study in North India found that new patients came less frequently with natural opiate use and more frequently with heroin use in recent successive decades. In addition, it has found that raw opium and poppy husk have been common forms of opioid use in the elderly population., Many of the elderly did not seek treatment for long durations of time, suggesting that the opioid use disorder (natural opiates) did not cause much impairment in the day-to-day functioning. We present the case of a nonagenarian who presented with the use of natural opiates and did fairly well on treatment with tramadol.
| Case Report|| |
Mr. BS is 98-year-old married male, previously electrician by profession (retired in 1996, sitting in his electrical shop till 4–5 years back), belongs to Sikh Joint Family of Middle Socioeconomic Status and resident of Meerut, Uttar Pradesh. He came to National Drug Dependence Treatment Center (NDDTC) around 6 months back for treatment of his addiction to natural opiates (afeem, i.e., raw opium, and dodda, i.e., poppy husk). He reports of starting opioid use around six decades back at the age of 30–35 years when he was introduced to it by family. He was able to work for a longer duration and did not feel tired with opioid use. Initially, he would take only once in a day and its effect would last 24 h, but later, this duration decreased and he had to consume afeem three times in a day over the next two decades. He was able to earn well during this time and was able to sustain substance use and take care of family with the money he was earning in a month, with opioid use helping him to work and earn more. With stricter law enforcement, it became difficult for the patient to procure afeem, and he was introduced to dodda (poppy husk) use around two decades back. He would consume dodda when he would not get afeem with currently spending Rs. 3000/month on opioid use. He reports of attempts to reduce and quit opioids and also took treatment for it locally around 2–3 decades back but could abstain or reduce opioids. Among the other substance, he reported consuming alcohol occasionally, had regular cannabis use for about 3–4 months six decades ago, and is now abstinent, and regular use of chewable tobacco for the past six decades. He denied any involvement in illegal activities to procure substance. He has a bilateral hearing impairment and has been using a hearing aid. He denies any other medical or psychiatric comorbidity. His two younger brothers also had natural opiate use.
Few months back, he had difficulty in procuring opioids and also did not have money for it. He then came to our center about 6 months back. On examination of cognitive function, he had intact memory (registration and recall of three words intact). He was mobile and had good functional status, as he had traveled around 200 km alone to reach a hospital with no difficulty. He was found to have hypertension for which medicine referral was sought. Considering his age and long duration of substance use, a harm reduction approach was considered more suitable for him. He could not come to our center for the daily dispensing of buprenorphine (as per center policy) due to logistic reasons. He was started on tramadol 300 mg/day dispensed for 2 weeks at a time along with diazepam 5 mg at night for symptomatic management. He has been able to abstain from natural opiates on the same dose and no side effects were reported. Further plan is to continue tramadol as he is able to abstain with it and was unwilling for taper and detoxification.
| Discussion|| |
The present case describes an elderly with six decades of opioid use with intact psychosocial functioning, physical and mental health, and the successful use of tramadol for the treatment of opioid dependence in outpatient settings. Previous studies have presented the use of natural opiates in the elderly opioid users,, but this patient was the highest age of opioid use in our literature search. The patient was well functional in cognitive terms and mobility, which also suggests that opioid use did not impair his physical health to a significant extent. In fact, it was the financial difficulty and unavailability of natural opiates that made him seek treatment at our center. In our previous experience, we have found that the adverse impact of natural opioids on different facets of life was minimal.
The present case also suggests that tramadol may be a suitable option for managing opioid dependence in selected elderly individuals. The present patient did not report any adverse events with tramadol and continued it for about 6 months. He had relief in withdrawal symptoms and hence continued the usage of the medication. While both buprenorphine and tramadol have been used for long-term natural opioid users,, drug dispensing policies and logistical issues may dictate one medication over the other. Substance use disorders in the elderly present their own challenges in management, especially with pharmacodynamic and pharmacokinetic changes with age. Yet, in patients with opioid dependence, providing opioid agonist medications, preferably with close supervision and monitoring, can help elderly patients by alleviating discomforting withdrawals. Due to prolonged opioid use and pharmacodynamic tolerance, tapering of medications or detoxification may be a difficult choice to implement in elderly individuals. Furthermore, with the epidemic of heroin dependence which is associated with worse psychosocial functioning, recent cases of buprenorphine and tramadol misuse, it becomes imperative to reflect on the implications of drug control policies and treatment modalities in recent decades.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Ganguly KK, Sharma HK, Krishnamachari KA. An ethnographic account of opium consumers of Rajasthan (India): Socio-medical perspective. Addiction 1995;90:9-12.
Mohan D, Sharma NK, Sundaram KR. Patterns and prevalence of opium use in rural Punjab (India). Bull Narc 1979;31:45-56.
Basu D, Aggarwal M, Das PP, Mattoo SK, Kulhara P, Varma VK. Changing pattern of substance abuse in patients attending a de-addiction centre in north India (1978-2008). Indian J Med Res 2012;135:830-6.
] [Full text]
Grover S, Irpati AS, Saluja BS, Basu D, Mattoo SK. Drug dependence in the geriatric age group: A clinic-based study. Ger J Psychiatry 2008;11:10-15.
Parmar A, Patil V, Sarkar S. Natural opioid use in elderly in India: A case series. J Subst Use 2017;22:156-8.
Nanjayya SB, Murthy P, Chand PK, Kandaswamy A, Nikketha BS, Benegal V, et al
. A case of poppy tea dependence in an octogenarian lady. Drug Alcohol Rev 2010;29:216-8.
Gyawali S, Sarkar S. Tramadol for maintenance treatment for an elderly “doda” (poppy husk) user. J Geriatr Ment Health 2016;3:179-81. [Full text]
Parmar A, Patil V, Sarkar S, Rao R. An Observational Study of Treatment Seeking Users of Natural Opiates from India. Subst Use Misuse 2018;53:1139-45.
Sarkar S, Lal R, Varshney M, Balhara YP. Tramadol for maintenance in opioid dependence: A retrospective chart review. J Opioid Manag 2017;13:329-34.
Kathiresan P, Ambekar A, Sarkar S. Opioid substitution treatment using buprenorphine for management of dependence on natural opioids: Case series. Indian J Psychol Med 2019;41:586-8.
] [Full text]
Sarkar S, Parmar A, Chatterjee B. Substance use disorders in the elderly: A review. J Geriatr Ment Health 2015;2:74-82. [Full text]