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Abstract
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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
Language: en |