What is chitta, a street term for heroin, and how is it treated in patients with opioid addiction, particularly in the Indian population?

What is Chitta?

Chitta is a street term used in India, particularly in Punjab and northern regions, referring to heroin—specifically impure, adulterated heroin that is typically smoked or injected. This represents part of the broader heroin epidemic that has affected India since the early 1980s, with steady increases in heroin abuse documented in treatment facilities 1.

Background and Epidemiology in India

• Heroin abuse in India emerged as a significant problem starting in the early 1980s, with no recorded heroin addicts in treatment facilities prior to 1981 1
• The majority of heroin users in India are young (87.6% under 30 years), unmarried (67.6%), and have completed high school or college education (80%) 1
• In regions like Nagaland, 83.8% of drug addicts were primary heroin abusers, with a mean age of first use at 17.6 years 2
• The injection route is particularly prevalent (80.9% in some regions), creating significant public health concerns regarding HIV transmission 2
• Friends are the main source of introduction to heroin use 2

Clinical Characteristics of Heroin/Chitta Use

• Users typically consume up to one gram per day, with most having used for one year or less at initial presentation 1
• Heroin is mainly smoked (74.3%) but also inhaled, sniffed, or injected 1
• Concurrent use of tranquilizers and codeine-containing cough syrups is common when heroin supply is limited 2
• The proximity to the Golden Triangle facilitates illicit trafficking and contributes to the epidemic 2

Treatment Approach for Opioid Use Disorder

For patients presenting with heroin/chitta addiction, medication-assisted treatment with methadone or buprenorphine represents the gold standard, as these medications significantly improve outcomes by reducing relapse, preventing overdoses, and preventing HIV transmission 3.

Medication-Assisted Treatment Options:

• Methadone: A full mu-opioid receptor agonist used for long-term maintenance therapy, dispensed only through certified Opioid Treatment Programs 3, 4
• Buprenorphine: A partial mu-opioid receptor agonist (mu agonist-kappa antagonist) that can be prescribed in office-based settings 3
• Naltrexone: An opioid antagonist option, though methadone and buprenorphine show superior effectiveness for increasing treatment retention and decreasing illicit opioid use 3

Acute Withdrawal Management:

• Buprenorphine is more effective than clonidine or lofexidine for treating opioid withdrawal, with patients experiencing less severe symptoms, fewer adverse effects, and longer treatment retention 3
• Emergency departments may administer (but not prescribe) buprenorphine or methadone for up to 72 hours while arranging treatment referral 3
• Nonopioid adjuncts include α2-adrenergic agonists (clonidine, lofexidine), antiemetics, benzodiazepines for anxiety and muscle cramps, and loperamide for diarrhea 3

Critical Risk Factors and Monitoring

Patients with opioid use disorder require assessment for overdose risk factors, including history of prior overdose, concurrent benzodiazepine use, respiratory compromise, renal/hepatic dysfunction, and suicidal ideation 3.

Essential Interventions:

• Naloxone prescription and training for overdose reversal, which significantly reduces opioid overdose fatalities 3
• Urine drug screening to detect concurrent substance use 3
• More frequent clinical follow-up when risk factors are present 3
• Avoidance of high-dose or long-acting opioids in high-risk patients 3

Common Pitfalls to Avoid

• Do not confuse physical dependence and tolerance with addiction—these are predictable physiologic consequences of opioid exposure and do not indicate substance use disorder without loss of control or continued use despite harm 3, 5
• Do not assume maintenance opioids (methadone/buprenorphine) provide analgesia for acute pain—these patients require additional opioid analgesics for acute painful conditions 3
• Do not withhold medication-assisted treatment due to concerns about "substituting one addiction for another"—methadone and buprenorphine are evidence-based treatments that dramatically improve outcomes 3
• Recognize that 4-6% of individuals with prescription opioid addiction transition to heroin due to lower cost and greater availability 3