|Year : 2016 | Volume
| Issue : 2 | Page : 179-181
Tramadol for maintenance treatment for an elderly "doda" (poppy husk) user
Shreeya Gyawali, Siddharth Sarkar
Department of Psychiatry, National Drug Dependence Treatment Centre, All India Institute of Medical Sciences, New Delhi, India
|Date of Web Publication||13-Dec-2016|
Department of Psychiatry, 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
Natural opioids have been in use in the North Western part of India for a long time. We present the case of an octogenarian "doda" (poppy husk) user, who sought treatment with us due to unavailability of natural opiates. The patient was treated successfully with tramadol maintenance for over 8 months. This case suggests that tramadol can be used as a harm reduction approach, for maintenance of patients with opioid dependence.
Keywords: Elderly, harm reduction, India, opioid, tramadol
|How to cite this article:|
Gyawali S, Sarkar S. Tramadol for maintenance treatment for an elderly "doda" (poppy husk) user. J Geriatr Ment Health 2016;3:179-81
|How to cite this URL:|
Gyawali S, Sarkar S. Tramadol for maintenance treatment for an elderly "doda" (poppy husk) user. J Geriatr Ment Health [serial online] 2016 [cited 2020 Jan 19];3:179-81. Available from: http://www.jgmh.org/text.asp?2016/3/2/179/195682
| Introduction|| |
Natural opioid use has been described in the elderly individuals, especially from the South Asian region. ,,,,, The natural forms include raw opium ("afeem"), poppy husk ("doda" or "bhukki"), and poppy seeds. The restrained use of natural opioids has been historically accepted in Indian culture, even in the elderly, especially in North-Western parts of India. However, the successful supply control measures for cessation of opioid use have made procurement of natural opioids difficult for those who had been dependent on the substance. Tramadol is a partial opioid agonist that can be helpful in alleviating the symptoms of opioid withdrawal. We put forth a case of an elderly gentleman who presented with the use of poppy husk for the past six decades, and who has been successfully abstinent from it on tramadol.
| Case report|| |
Mr. PS, an 82-year-old gentleman, previously a farmer by occupation, and originally hailing from Punjab came to our center for treatment for his addiction to "doda" (poppy husk). He reported that he started the use of poppy husk about six decades back when he was about 20 years of age, as its use was common amongst the farmers in the area. He would take the dry husk, and swallow it with water. He became a daily user gradually over a period of few months, and would take doda two to three times a day. He then had to increase the amount to get the same effect. Subsequently, he started having lacrimation, rhinorrhea, and body ache whenever he would attempt to contain the use of poppy husk. Even though he continued with his farming work while continuing its use, he would feel fatigued if the amount of the poppy husk consumed was less. Consequently, the amount of consumption of poppy husk gradually increased to about 3 kg/month, and he would procure it fairly easily from the dealers.
The prices of poppy husk from the dealer fluctuated over the period, which was apparently driven by law enforcement measures which were instilled to curb its supply. However, Mr. PS could manage to procure the poppy husk consistently over the period, and he reported that over the course of past six decades, he continued the use of poppy husk, without making an attempt to stop its usage. Mr. PS had also used raw opium ("afeem") on a couple of occasions, but he denied the use of heroin, injectable opiates, and other synthetic opiates throughout the course. He drank alcohol only on a few occasions and denied the use of other substances including tobacco. He also denied any involvement with the legal agencies over the use of poppy husk, or any medical problems associated with the use of this substance.
In the recent past, before his visit to our center, Mr. PS found it difficult to procure poppy husk from the dealers. He also reported of financial difficulties as he was not tending to his farm and found it difficult to ask his children for money to sustain his substance use. Thus, he came to our center on the recommendation of an acquaintance. After the initial evaluation, the patient was given the treatment options of, either attempting detoxification (inpatient or outpatient) or harm reduction measures (using opioid agonist). The patient was reluctant for detoxification, and opted for the harm reduction approach, in the form of daily supervised buprenorphine or tramadol "take home" medication. The center policy did not allow for buprenorphine to be given as take home medication in the initial few weeks of treatment, so the patient did not consider it feasible to come to the center on a daily basis. Hence, he was started on tramadol, which was dispensed for 2 weeks at a time. The dose of tramadol was initially 250 mg/day, which was subsequently increased to 300 mg/day. The patient was also given nitrazepam 10 mg/day as a sleep aid. No specific psychotherapeutic interventions were considered for this case, and the patient was primarily a candidate for pharmacological harm reduction measures. Over the course of the treatment, Mr. PS has not reported of any adverse events following the use of tramadol. He has been regularly following up at the center, and he has been able to successfully abstain from opiates on treatment with tramadol since the last 6 months. The present plan remains continuation of tramadol till it remains feasible and the patient requests tapering and cessation of this medication.
| Discussion|| |
Natural opioid use has been described previously in the Indian elderly, and this may represent a subset of patients who have not been using other "harder" opiates like heroin. , India is the largest producer of licit medicinal opiates and is flanked by two opioid rich areas of the world.  Hence, some diversion of opium to recreational use is anticipated. Use of natural opiates has been previously reported to be common among farmers, as in the present case, and the reason for initiation has usually been to relieve the fatigue of agricultural work in the harvest season. , Many such patients continue to take opiates for fairly long periods of time without much health concerns, as in the present case.
The present case highlights the successful use of tramadol in an elderly patient with opioid dependence. Agonist management was considered a more suitable option for the patient, as he was a long term user of opiates (period of over six decades) and since he was reluctant for cessation of opiates altogether. Tramadol was the option available for the present case, given the hospital policies and the logistic issues involved in daily dispensing. It has been encouraging to observe that the patient has been maintaining abstinence on tramadol. This suggests that tramadol may be another efficacious agent in the agonist management in patients with opiate dependence. Past evidence also suggests tramadol to be efficacious in decreasing the symptoms of opioid withdrawal but, as such, prescription misuse of this medication has also been reported.  Many patients have reported using tramadol as a substitute when other opiates of choice are not available,  suggesting that patients themselves use it as a replacement opioid.
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Conflicts of interest
There are no conflicts of interest.
| References|| |
Unnithan S, Strang J. Poppy tea dependence. Br J Psychiatry 1993;163:813-4.
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.
Mattoo SK, Singh SM, Sarkar S. De-addiction services in India. In: Malhotra S, Chakrabarti S, editors. Developments in Psychiatry in India. India: Springer; 2015. p. 405-16.
Ganguly KK, Sharma HK, Krishnamachari KA. An ethnographic account of opium consumers of Rajasthan (India): Socio-medical perspective. Addiction 1995;90:9-12.
Sharma HK. Sociocultural perspective of substance use in India. Subst Use Misuse 1996;31:1689-714.
Sarkar S, Parmar A, Chatterjee B. Substance use disorders in the elderly: A review. J Geriatr Ment Health 2015;2:74-82.
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;11:10-5.
Mohan D, Sharma NK, Sundaram KR. Patterns and prevalence of opium use in rural Punjab (India). Bull Narc 1979;31:45-56.
Lakshminarayana J, Singh MB. Opium addiction among rural population in desert districts of Western Rajasthan: Some observations from the study. J Hum Ecol 2009;25:1-4.
Sarkar S, Nebhinani N, Singh SM, Mattoo SK, Basu D. Tramadol dependence: A case series from India. Indian J Psychol Med 2012;34:283-5.