Perceptions on Treatment Utilization and Risk of Overdose Among Opioid Users in Kolkata: A Qualitative Study

Abstract

Background:

This study was performed to explore the perceptions of treatment utilization patterns and the risk of overdose of both opioid users and their peer educators in Kolkata, India.

Methods:

This study used a qualitative approach for data collection between September and December 2023. In-depth interviews (IDIs) of 20 opioid users from two authorized opioid substitution therapy (OST) centers (10 registered clients) and their respective field practice areas (10 unregistered clients) in Kolkata were conducted. Key informant interviews (KIIs) of six peer educators were also conducted. Semi-structured interviews were conducted; audio was recorded, transcribed, and translated for coding and analysis. An inductive thematic analysis was performed.

Results:

Six broad themes (individual knowledge, logistics, legal/administrative, treatment effectiveness, self-confidence of treatment, and poor knowledge about the antidote of opioid poisoning, i.e., naloxone) emerged from the data analysis of IDIs. Four broad themes (high-risk behavior, raising awareness, the benefits of OST, and poor knowledge about naloxone) emerged from the data analysis of KIIs. Both opioid users and their peer educators were aware of the dangers of opioid overdose. However, they lacked sufficient knowledge in recognizing and offering immediate assistance in instances of opioid overdose, including the administration of naloxone.

Conclusion:

The findings recognize the necessity of drawing and retaining opioid users in an efficient healthcare facility, such as OST centers, and providing them adequate training to identify and provide immediate assistance in cases of overdose, including naloxone administration. Our findings will assist policymakers in designing programs to prevent and treat opioid overdoses.

Key Messages:

• This study was performed to explore the perceptions of treatment utilization patterns and the risk of overdose of both opioid users and their peer educators in Kolkata, India.

• Both opioid users and their peer educators were aware of the danger of opioid overdose; however, they lacked sufficient knowledge in recognizing and offering immediate assistance in instances of opioid overdose, including the administration of naloxone.

• The findings recognize the necessity of drawing and retaining opioid users in an efficient healthcare facility, such as OST centers, and providing them adequate training to identify and provide immediate assistance in cases of overdose, including naloxone administration.

Substance overdose and poisoning contribute to about one-third of drug-related deaths globally ¹ and are a major public health problem in India, too. The National Mental Health Survey reported a 0.6% prevalence of drug use disorders in India. ² Illicit opioid use increased from 0.7% in 2004 to >2% in 2019. ³ The rate of opioid poisoning among injectable drug users (IDUs) is quite high (around 70%). ⁴ Interestingly, studies in the West have shown that opioid users have very poor knowledge about opioid overdose and its prevention and treatment. ⁵ A study conducted in South India showed that opioid overdose was the leading cause of mortality among IDUs. ⁶ Another study conducted in New Delhi demonstrated that the prevalence of non-fatal opioid overdose and the risk factors for overdose among IDUs from India are high, and the subjects had limited knowledge and casual attitudes about overdose management. ⁷ Likewise, it was found that in Punjab, there is a substantive problem of opioid dependence with low treatment access. ⁸

Opioid substitution therapy (OST) has shown superior retention rates compared to alternative treatment approaches and contributes to enhancing individuals’ functioning and quality of life. Its utilization in India extends over 30 years and has been integrated into the National AIDS Control Program. Practice guidelines, standard operating procedures, and capacity-building mechanisms have been established to facilitate effective OST implementation. However, despite its widespread adoption, numerous challenges persist in implementing OST. Meeting the targets for sufficient population coverage with this treatment remains a distant objective, leaving a significant portion of opioid users without access to structured treatment.^9,10 It is difficult to estimate the exact burden of this problem, given that opioid users constitute a “hidden population” who are difficult to access due to legal issues, stigma, and displacement.^10,11 To form an effective roadmap or policy targeting this high-risk population, it is elementary to understand this problem’s unique attributes from the affected population’s point of view.^12-16

India is a culturally diverse country, influencing drug use. According to the report of the Ministry of Social Justice and Empowerment, Government of India, West Bengal is among the top 10 states concerning the number of people who need help with opioid-use-related problems. ³ Naturally, this underscores the burden of opioid overdose in this region, necessitating access to treat and prevent such episodes. No study has thoroughly explored the perspectives and attributes of treatment utilization patterns and knowledge about overdose among opioid users in the state of West Bengal. This study was performed to explore the perceptions of treatment utilization patterns and the risk of overdose of both opioid users and their peer educators in Kolkata, West Bengal, India.

Methods

Study Design

This study followed a qualitative research approach with a participation action research design. In-depth interviews (IDIs) of opioid users and key informant interviews (KIIs) of peer educators were also conducted. This approach enabled participants to freely exchange experiences within a secure setting, fostering openness without reservation. Additionally, it permitted researchers to explore emerging themes that arose during the interviews, facilitating the discovery of novel insights. ¹⁷ The study was conducted between September and December 2023.

Study Setting

This study was conducted at authorized opioid substitution therapy (OST) centers and their respective field practice areas in Kolkata. There are only two such authorized OST centers in Kolkata, namely, the Department of Psychiatry, Calcutta National Medical College (a state-funded government hospital) and The Calcutta Samaritans (a non-government organization). Both of these OST centers provide free services, including providing buprenorphine as an OST and anti-retroviral medicines and behavioral counseling for drug abuse and sexually transmitted diseases.

Participant Selection: Study Population

All registered beneficiaries (clients) of the Department of Psychiatry, Calcutta National Medical College and The Calcutta Samaritans who came daily for OST during the study period were considered the study population. Five participants were selected by purposive sampling technique, each from the Department of Psychiatry, Calcutta National Medical College and The Calcutta Samaritans based on their experience of opioid usage for at least the last two years. All participants were registered at the respective centers for more than one year. Peer educators also facilitated the selection process. The participants were interviewed face-to-face in the OST center, that is, in their known environment. All interviews were conducted so that only a single participant and investigators were present at a time to gain the participant’s confidence and maintain a safe environment for confidential discussion. Thus, IDI was performed with the participants alone without the presence of any non-participant, including any peer educator.

Opioid users dwelling in and visiting 10 selected hot-spot areas (field practice areas of the two OST centers) who were not registered for OST during the study period were also considered as the study population. Convenience and snowball sampling techniques were used to select five participants from two field practice areas. Peer educators at the Department of Psychiatry, Calcutta National Medical College and The Calcutta Samaritans facilitated this selection during their daily work. Opioid users were interviewed individually face-to-face by the investigators in the field itself in the presence of peer educators to facilitate the discussion in a friendly environment. Opioid users diagnosed with severe psychiatric disorders with the intent to harm themselves and others were excluded.

Three peer educators (employed by the OST centers) each from the two OST centers (a total of six peer educators) were selected from the two OST centers by purposive sampling based on their work experience for more than three years. These peer educators were earlier (more than five years ago) opioid users. The investigators performed each KII with a single peer educator face-to-face at the OST center. No other member (even any other peer educator or supervisor) was present during the interview to facilitate an uninterrupted, free-flowing discussion.

Research Team, Interview Guide, and Data Collection

The investigators (scientists and technical staff) were trained and had documented experience (scientific publications) in conducting qualitative research. All team members who conducted the interview (SD, KB, and SM) were males. Initially, IDI and KII guides were separately developed following a literature review with the study objectives in mind. Finally, it was prepared in consultation with all investigators, comprising an addiction psychiatrist, a clinical pharmacologist, and a public health expert. A pretest was conducted with the IDI and KII guides. The investigators conducted all IDIs and KIIs in Bengali and/or Hindi.

A rapport with the study participants was established before the study commenced by repeatedly visiting the OST centers and talking to the administrators and facilitators. This way, the study participants became familiar with the researcher and were briefed about the study’s objectives and purpose. The participants who readily agreed to participate were recruited for the study. Seven participants refused to take part in this study. Semi-structured, open-ended questions were framed for this study. It helped in generating responses based on the pre-determined interview guide on the focused topics, as well as provided the scope to ask some associated questions depending on the responses related to attitudes and perceptions behind treatment utilization for opioid use along with prevention and treatment of opioid overdose. All interviews were audiotaped and stored. Besides, field notes and memos were taken by two research assistants. Each IDI and KII lasted for 20–25 minutes. The interview transcription underwent multiple readings and discussions among investigators to determine the saturation point. No repeat interview was conducted.

Trustworthiness of the Study

The validity and reliability of the findings were assessed in terms of trustworthiness, encompassing credibility, transferability, dependability, and conformability, concerning the study participants. ¹⁸ The investigators conducting the IDIs and KIIs shared a common language and culture with most participants, facilitating rapport-building and formulating pertinent follow-up questions. Participants demonstrated a genuine willingness to engage in the study and freely provided relevant information. The collected data underwent transcription, translation, coding, and analysis to ensure the accuracy and consistency of the translations. Furthermore, the lead authors reviewed the analyzed results to identify any discrepancies. Data obtained from IDIs and KIIs were triangulated to identify similarities and variations. ¹⁹

Data Analysis

The data were manually analyzed employing an inductive thematic approach. Initially, codes were formulated by two researchers, and subsequently, three researchers convened to deliberate on the validity of these codes within a broader context. ²⁰ Transcripts were meticulously reviewed verbatim by investigators, and codes and higher-order themes were developed until consensus was achieved. Codes were scrutinized to derive themes. As the qualitative data were translated into English, some quotes underwent minor edits to enhance clarity for readers. However, efforts were made to maintain the original meanings as much as possible.

Data Reporting

The participants’ quotations were presented to illustrate the themes/findings. There was a consistency between the presented data and the findings. The major themes were presented in the findings.

Results

Demographic Characteristics of Study Participants

All opioid users hailed from Kolkata or surrounding regions. The average age of the opioid users was 45.5 years (range: 18–58 years), and out of 20, 18 (90%) were males. Twelve (60%) had never attended school, and four (20%) had attended but not finished school. The opioid users were mainly manual laborers (10; 50%), rickshaw pullers (6; 30%), drivers (2, 10%), and fruit/vegetable sellers (2, 10%). On the other hand, the average age of the six peer educators was 38.5 (range: 30–47 years), and all were male. They all completed school education, and two (33%) graduated. All the opioid users were IDUs and had addictions to substances other than opioids, including nicotine, alcohol, central nervous system stimulants and depressants, solvents, cannabis, and anabolic steroids. The opioids commonly used by them were morphine, buprenorphine, heroin, pethidine, hydrocodone, codeine, tramadol, and fentanyl alone or in combination with other substances. Five of the 20 had a human immunodeficiency virus infection and were under anti-retroviral medicine treatment.

Treatment Utilization: Views of the Opioid Users Who Were Not Registered to OST

Six broad themes (individual knowledge, logistics, legal/administrative, treatment effectiveness, self-confidence in treatment, and poor knowledge about the antidote of opioid poisoning, i.e., naloxone) emerged from the data analysis of IDIs. These are explained below.

Risks of Opioid Overdose

Most participants acknowledged the risk of opioid overdose, especially because of their high-risk behavior, adulteration with street opioids, and the absence of a regulated way of opioid consumption. However, some chronic long-term users expressed that they were non-cognizant of the risks of opioid overdose and opined that they were “tolerant” to all the effects of opioids. The most common effects of opioids experienced were sedation, dizziness, constipation, and respiratory depression.

• Yes, nowadays all these products (opioids) are not original (adulterated). The way we consume, sometimes with other substances, increase the risk of overdose. (IDI, male participant, age: 29 years)

• I have been taking these (opioids) for the last 30 years. I am used to it. I understand when to stop taking. I will not get any overdose. (IDI, male participant, age: 58 years)

Logistic Reasons for Not Registering to OST

Some participants shared that they were unaware of the location, exact services, and cost of treatment provided by the OST centers. On the other hand, a few of the participants were concerned about the necessity of daily visits to the OST centers and cited the fact that regular visits to the OST centers might affect their job schedule. However, they expressed the necessity of availing treatment for their opioid dependence and guidance for the prevention of overdose.

• I do not know where the clinic is. What help can they offer me? Do they charge money? I need treatment to go back to normal life. I need their advice to guide me to take the proper dose of these (opioids). (IDI, male participant, age: 23 years)

• I cannot go there daily (OST center). If I miss the morning train, I will be late to work, and my wage will be deducted. (IDI, male participant, age: 52 years)

Legal and Administrative Concerns

Some of the participants expressed that the hindrances to be faced due to the social stigma surrounding addiction have impacted individuals’ willingness to seek help. At the same time, the criminalization of drug use further deterred them from accessing treatment due to fear of legal repercussions. Procedural formality, such as the requirement of identification proof, was also a deterrent factor for some participants from visiting the OST centers.

• Once, I went to the (OST) center. I was asked to provide an Adhaar card (government identity card). I do not have that, and I was denied access to treatment. Likewise, if I go to treatment for overdose in a government hospital, I might be hassled by the police and the authorities. (IDI, male participant, age: 45 years)

• If I go to the center daily to get medicines, people in my neighborhood who are known to me will know that I am addicted and presently on treatment. They will boycott me, and this will impact my business. (IDI, male participant, age: 40 years)

Unsatisfactory Results from OST Centers

Unsatisfactory results and insufficient personalized care occasionally surfaced for individuals seeking treatment within these established facilities. Some participants opined that the buprenorphine dose adjustment in the OST center was not accurate, and they did not experience any pleasurable effects of buprenorphine. This might be due to adherence issues. Some participants were discouraged by the adverse effects of the concomitant anti-retroviral medicines.

• The medicines provided in the (OST) center are very weak; I hardly get any effect. I feel sleepy the whole day, and I do not go there daily. (IDI, male participant, age: 33 years)

• I am so lean and thin; I don’t get food all the time. These (anti-retroviral) medicines are strong enough to make me weak and dizzy. How can I work then? (IDI, male participant, age: 39 years)

Confidence in Treatment Modalities Provided by Self and Peers

Some participants possessed considerable knowledge about the substances they use, including their effects, risks, and potential harm-reduction strategies for overdose. Being IDUs, they were aware of the risks of sharing needles. There was a sense of protectionism, where a few participants believed that withholding information could maintain control or exclusivity within their community or social circle.

• We know how to take these (opioids) in the right quantity to prevent overdose. We also know what to do if an (opioid) overdose happens. We would sprinkle water on the face, air the mouth, and make the person lying down. He (the victim) would automatically regain consciousness in a while. Nevertheless, this is not always the case. Once, a person was left like this, and he died. Finally, the police caught us!” (IDI, male participant, age: 38 years)

• I do not share needles. They (peer educators) warned us. They often come to us and guide us. I might contract a disease from him (pointing toward another participant) if I share a needle with him. However, I do not know what to do if an overdose happens. (IDI, male participant, age: 50 years)

Unaware of the Antidote to Opioid Poisoning (Naloxone)

None of the participants were aware of the antidote for opioid poisoning, that is, naloxone, or its availability. Some participants were inquisitive about naloxone and wanted to know its availability status and how to use it.

• I have been using these (opioid) drugs for over 20 years. I have never heard of such a name (naloxone). (IDI, female participant, age: 55 years)

• Could you please write the name of it (naloxone) on this paper? I will buy and stock it in case I need it for an overdose. (IDI, male participant, age: 21 years)

Treatment Utilization: Views of Opioid Users Who Were Registered to OST

Four broad themes (overdose, individual satisfaction, knowledge about treatment, and poor knowledge about naloxone) emerged from the data analysis of IDIs. These have been explained below.

Risks of an Opioid Overdose

Most participants acknowledged the risk of opioid overdose; however, as they were under OST, the risk was relatively less. Still, they admitted that if they consume opioids in excessive quantities, they might get toxicities. Previous experience with overdoses rendered them more cautious.

• I take treatment here (OST center). There is hardly any chance of overdose. (IDI, male participant, age: 39 years)

• I had overdosed a few years back. I am now very cautious about how much to take these drugs (opioids). (IDI, male participant, age: 48 years)

Overall Satisfaction with OST Services

Most participants expressed high satisfaction with OST due to their access to medication-assisted treatment, counseling, and support services. They often appreciated the reduction in opioid cravings, improvement in overall health, and the stability these programs offered.

• My life has changed since I started visiting this (OST) center. I need to get treatment. These people (peer educators) have transformed my life. I can fulfill responsibility in my workplace and home. (IDI, male participant, age: 49 years)

• My health has improved so much. I no longer have cravings. I am coming out of the dark tunnel; people in my surroundings accept me now. These centers should be everywhere and fulfill our needs individually. (IDI, male participant, age: 30 years)

Confidence in Identifying and Helping to Treat Cases of Opioid Overdose

The knowledge and attitude toward the treatment of opioid overdose were satisfactory for almost all opioid users registered with the OST center. They knew the signs and symptoms of opioid overdose in case(s) of overdose, such as turning blue or turning unconscious. Instead of treating themselves, they opined to visit nearby recognized health facilities or inform the peer educators immediately in case of an opioid overdose.

• I know how the symptoms of (opioid)overdose. I will inform XXX (name of a peer educator) in case of overdose; he will guide me to a hospital. (IDI, male participant, age: 25 years)

• I will take him (anybody experiencing opioid overdose) immediately to our nearest hospital for treatment instead of treating him by ourselves. (IDI, male participant, age: 50 years)

Unaware of the Antidote of Opioid Poisoning (Naloxone)

Again, the participants visiting OST were aware of naloxone and extremely inquisitive about it. The lack of awareness about its existence, accessibility, or use remained a burning issue.

• I have never heard of naloxone. Could you explain how it helps? (IDI, female participant, 55 years)

• Can it prevent overdose if I inject it before taking this drug (opioid)? Will it mask the effect of this drug (opioid)? (IDI, male participant, age: 21 years)

Treatment Utilization: Views of the Peer Educators

Four broad themes (high-risk behavior, raising awareness, the benefits of OST, and poor knowledge about naloxone) emerged from the data analysis of KIIs. These have been explained below.

Burden and Causes of Opioid Overdose

The primary concern was the alarming rise in opioid-related overdoses and fatalities. Factors contributing to this include the widespread availability of potent opioids, lack of access to comprehensive addiction treatment, various kinds of high-risk behaviors among IDUs, stigma preventing individuals from seeking help, and the presence of counterfeit or highly potent opioids in the drug market. They reported that some participants do not consume crushed buprenorphine tablets administered under supervision in the OST; they manage to spit the crushed tablet out and accumulate and consume or sell it outside later, which has the potential to cause an overdose.

• Some of them have so much high-risk behavior. They inject heavy cocktails in high volume using thick needles in central veins as other peripheral veins collapse after continuous use. They die of overdose, embolism, and even bleeding. (KII, male participant, age: 25 years)

• I have seen people die after consuming cocktails of opioids and CNS suppressants. They do not know what to do after someone is knocked down. They need treatment. They are reluctant to go far or get recognized. We have to reach out to them where they are most comfortable. (KII, male participant, age: 30 years)

Raising Awareness About Opioid Overdose

The peer educators opined that the management of opioid overdose by street opioid users can be a critical and challenging situation. These opioid users often find themselves in situations where they or their peers overdose, and they may need to manage the crisis themselves before the peer educators are alerted. Efforts to educate them about overdose response and provide training in managing overdose situations can greatly impact the outcome.

• Once we counseled and educated them (opioid users) about ways of prevention and management of overdose, the incidence rate of overdose has dropped substantially. (KII, male participant, age: 35 years)

• It is still a matter of great concern for those whom we are unable to register to OST center yet and are still in the street. (KII, male participant, age: 45 years)

Factors Motivating Opioid Users to Register at OST Centers

Several factors motivate opioid users to register in OST centers for treatment, such as access to medication-assisted treatment, health improvements, reduction of harmful behaviors, social and psychological support, legal and employment stability, family and community support, desire for recovery, or very specific and unique reasons (e.g., availability of fine needles for injection). The peer educators emphasized the need for a holistic treatment facility for these individuals.

• Initially, there is difficulty in convincing them, but once they experience benefits, they will come and bring their peers to the (OST) center (KII, male participant, age 30 years)

• Some of them come just to take the narrow-gauge (26 G) needle for injection as their veins have dried up. (KII, male participant, age: 45 years)

Unaware of the Antidote of Opioid Poisoning (Naloxone)

Quite surprisingly, none of the peer educators have heard of naloxone. The lack of awareness about naloxone among peer educators of opioid users could present a concerning gap in harm reduction strategies for opioid overdose.

• I am used to so many drugs but never heard of naloxone. (KII, male participant, age: 25 years)

• How come I am unaware of such a useful medicine? (KII, male participant, 35 years)

Discussion

This study was performed to explore the treatment utilization patterns of opioid users and their peer educators in Kolkata. It was found that opioid users, as well as their peer educators, were cognizant of the risk of opioid overdose; however, they had poor knowledge about identifying and providing immediate assistance to cases of opioid overdose. The peer educators acknowledged the need for an effective and easy-to-access healthcare facility, like OST centers, to treat this population holistically.

Almost all the study participants acknowledged the risks of opioid overdose. However, they had little idea of how to prevent the occurrence of such an episode. The lack of awareness among some participants regarding the specifics of OST centers, including their locations, services, and costs, presents a significant hurdle to accessing crucial treatment. Additionally, concerns about the obligatory daily visits potentially interfering with job schedules reflect a tangible barrier for individuals seeking assistance. Addressing these issues necessitates comprehensive outreach efforts to inform participants about OST centers’ offerings, locations, and potential financial implications. Moreover, exploring flexible scheduling options could mitigate concerns regarding daily visits to balance treatment and employment obligations.^21,22

The apprehensions regarding legal implications and administrative obstacles associated with seeking treatment for opioid use significantly hinder individuals from accessing necessary care. The stigma surrounding addiction, compounded by the criminalization of drug use, amplifies fears of legal consequences, acting as a substantial barrier to seeking treatment. The procedural formalities also discourage some individuals from seeking care at the OST centers. Addressing these concerns requires a holistic approach, including destigmatization efforts, legal reforms, and streamlined administrative processes. ²³

The challenges faced by individuals seeking treatment within OST centers, including insufficient personalized care, varied responses to medications, and struggles with psychological and social support, underscore the multifaceted nature of addiction. Additionally, the adverse effects of anti-retroviral medicines further compound these challenges, impacting treatment adherence. ⁹ These complexities emphasize the crucial requirement for a comprehensive approach that not only addresses physiological aspects but also considers the diverse individual needs and circumstances of those seeking treatment for opioid abuse, aiming for more tailored and holistic interventions. These challenges highlight the complex nature of addiction and underscore the necessity for a multifaceted, holistic approach that addresses not only the physiological aspects but also the individual needs and circumstances of the clients. ²⁴

The diverse knowledge and concerns among participants regarding opioid use and harm reduction strategies illustrate the complex dynamics within communities affected by substance abuse. Fear of stigma, discrimination, and legal consequences inhibits open discussions about opioids, creating barriers to information sharing and support. Additionally, a sense of control or exclusivity linked to withholding information might impede collective efforts in managing opioid-related risks. ²⁵ Nonetheless, peer support and education on overdose response were found to enhance confidence levels among some participants. However, the veracity of knowledge regarding opioid overdose treatment remained uncertain. Increasing awareness, providing accessible training, and fostering a supportive environment can bolster confidence among both individuals and their peers in addressing opioid overdose effectively.^9,10 Outreach programs, community education initiatives, and making naloxone more widely available can play pivotal roles in addressing this knowledge gap among opioid users.

The incidence and management of opioid overdoses raise multifaceted concerns, notably the alarming surge in opioid-related overdoses and fatalities. Various factors contribute to this crisis, including the widespread availability of potent opioids, inadequate access to comprehensive addiction treatment, risky behaviors, and the stigma hindering individuals from seeking help. ⁷ Additionally, the revelation by peer educators about some participants bypassing supervised consumption of crushed buprenorphine tablets underscores challenges related to treatment adherence and diversion issues, potentially impacting treatment efficacy and community safety. ²⁶

Street opioid users frequently encounter overdose situations among themselves or their peers, necessitating immediate action before professional help arrives. Educating this demographic about overdose response and providing them with training in managing such crises can significantly influence the outcomes, potentially saving lives. However, access to resources and robust support for harm reduction initiatives remain pivotal in effectively reducing fatalities associated with opioid overdoses among street opioid users. Opioid overdose can be prevented by increasing the availability of opioid dependence treatment, reducing and preventing irrational or inappropriate opioid prescribing, monitoring opioid prescribing and dispensing, and limiting inappropriate over-the-counter sales of opioids.^27,28

Providing naloxone to people likely to experience an opioid overdose, in combination with training on the use of naloxone and the resuscitation of people following an opioid overdose, could reduce the number of deaths resulting from opioid overdose. ¹⁶ However, the absence of awareness about naloxone among peer educators of opioid users is concerning and highlights a significant gap in harm reduction strategies. The role of naloxone in preventing opioid overdose deaths is pivotal, yet its lack of recognition among these educators impedes its dissemination within communities affected by opioid abuse. Addressing this knowledge gap is crucial to equip peer educators with the necessary tools to intervene in opioid overdose emergencies, ultimately saving lives effectively. ²⁹ This is extremely important because there are effective treatment interventions for opioid dependence that can decrease the risk of overdose. However, less than 10% of people who need such treatment are receiving it. ³⁰ Take-home naloxone strategies are being implemented in many developed countries that suffer from high opioid overdose death rates. ³⁰

The non-adherence to treatment and irregular visits to the OST center among some participants pose significant challenges in addressing opioid abuse. Despite this, their satisfactory knowledge and positive attitude toward the treatment of opioid overdoses stand as encouraging factors. Their willingness to resort to nearby hospitals or seek assistance from peer educators and counselors in cases of opioid overdose incidents reflects a potential avenue for harm reduction and intervention strategies, contributing to improved responses to opioid-related emergencies. The multitude of motivations prompting opioid users to seek treatment at OST centers, including access to medication-assisted treatment, health enhancements, reduced harmful behaviors, social support, legal stability, family encouragement, and the aspiration for recovery, collectively could contribute to a potential decline in opioid overdose incidents.

The strengths of this study include that it is one of the first qualitative studies conducted in Kolkata that aimed to explore the factors that influence treatment utilization among opioid users. This study also provides a starting point for additional in-depth qualitative studies based on the findings and knowledge developed in this study. There are a few limitations to this study. First, the sample was small and not representative, so the findings should be cautiously generalized. The participants were recruited through the two OST centers in Kolkata, and it may be the case that IDUs not in contact with NGOs and those from suburban/rural areas are different from the participants in this study in ways relevant to the treatment utilization pattern. Next, as the participants were recruited in association with OST centers for harm reduction, social acceptability bias may have influenced some of the participants’ responses. Finally, data was not collected from family members, community members, and other stakeholders who could have provided more insights into this research area.

Conclusion

This study explored multiple factors that influence the treatment utilization of opioid users in Kolkata. We found that both opioid users and their peer educators were aware of the dangers of opioid overdose. However, they lacked sufficient understanding and knowledge in recognizing and offering immediate help, including the administration of naloxone, for opioid overdose cases warranting awareness campaigns. The findings recognize the necessity of drawing and retaining opioid users in an efficient healthcare facility, such as OST centers, and providing them adequate training to identify and provide immediate assistance in cases of overdose. These findings may assist policymakers in designing programs to prevent and treat opioid overdose. Future work should seek to identify interventions that address these factors to reduce opioid overdose and prevent subsequent harm.