Ministry of Health & Family Welfare, Government of India

Scheme for Strengthening of Drug De-addiction Services

MONTHLY REPORTING FORMAT FOR DRUG TREATMENT CLINICS

State / UT: Maharashtra District: City / Town: DTC code:
Name of the Centre: KEM Hospital Name of the Hospital: (in which DTC is located)
Complete Postal Address: Phone No (Centre):
E-mail ID (Centre):
Type of DTC: Government Hospital Type of Facility:
Month & Year of Roll-out: Specify nature of facility here if Any Other selected above
Month & Year of Reporting: October 2015 DTC support for: MMT + BPN + BPN-N
Name of the Nodal Officer: Dr.S.R.Parkar Phone No: Email-ID:
Name of Reporting Officer: Designation: Email-ID:

INDICATORS FOR REPORTING

Value
S.No. Indicator Source Male Female Total

1 Total number of patients registered at the DTC till the reporting month (Cumulative) RF - 01 27 1 28

SECTION 1 : TREATMENT FOR OPIOID USE DISORDERS

Value
S.No. Indicator Source Male Female Total
2 PATIENTS ON BUPRENORPHINE (BPN) MAINTENANCE TREATMENT

2.1 Total number of individual patients started on BPN maintenance by the centre:

a) During the reporting month RF - 03 20 0 20

b) From the roll-out of services till the end of reporting month (cumulative) RF - 03 0

Total number of individual patients who completed treatment and were taken off BPN
2.2 maintenance by the treating team:

a) During the reporting month Patient Files / RF - 14 0

b) From the roll-out of services till the end of reporting month (cumulative) Patient Files / RF - 14 0

2.3 Out of the total registered BPN maintenance patients, cumulative number of patients 0

a) Transfered to other DTCs / OST Centres till the beginning of the reporting month Patient Files / RF - 14 0

b) Shifted to BPN-N / MMT / NTX till the beginning of the reporting month Patient Files / RF - 14 0

2.4 Out of the registered BPN maintenance patients, number of patients who did not receive even one Patient Files / RF - 14 0
dose during the reporting month due to death, migration or imprisonment
2.5 Of the total registered BPN maintenance patients, number of patients receiving Buprenorphine for: 0

a) 25 or more days in the reporting month RF - 14 0 0 0

b) 15 to 24 days in the reporting month RF - 14 0 0 0

c) 1 to 14 days in the reporting month RF - 14 0 0 0

Total number of times plain BPN dosages were dispensed during the reporting month (sum of
2.6 head count of individuals receiving BPN on each day of the reporting month) RF - 14 0

3 PATIENTS ON BUPRENORPHINE - NALOXONE TREATMENT (BPN-N)

3.1 Total number of individual patients shifted to BPN-N from BPN maintenance by the centre:

a) During the reporting month RF - 16 0

b) From the roll-out of services till the end of reporting month (cumulative) RF - 16 0

Total number of individual patients who completed treatment and were taken off BPN-N
3.2 maintenance by the treating team:

a) During the reporting month Patient Files / RF - 16 0

b) From the roll-out of services till the end of reporting month (cumulative) Patient Files / RF - 16 0

3.3 Out of the total registered BPN-N maintenance patients, cumulative number of patients 0

a) Transfered to other DTCs / OST Centres till the beginning of the reporting month Patient Files / RF - 16 0

b) Shifted to BPN / MMT / NTX till the beginning of the reporting month Patient Files / RF - 16 0

Out of the registered BPN-N maintenance patients, number of patients who did not receive even
3.4 one dose during the reporting month due to death, migration or imprisonment Patient Files / RF - 16 0

3.5 Out of the registered BPN-N maintenance patients, number of patients receiving BPN-N on: 0

a) All occasions as scheduled (twice per week, weekly, etc.) during the reporting month RF - 16 0

b) 50% or more of the scheduled occasions (twice per week, weekly, etc.) but missed at least RF - 16 0
one dispensing visit during the reporting month

c) Less than 50% of the scheduled occasions (twice per week, weekly, etc.) but received
medicines at least once in the reporting month RF - 16 0

4 PATIENTS ON METHADONE MAINTENANCE TREATMENT (MMT)

 4.1 Total number of individual patients started on Methadone maintenance by the centre:

a) During the reporting month RF - 04 19 1 20

b) From the roll-out of services till the end of reporting month (cumulative) RF - 04 0

Total number of individual patients who completed treatment and were taken off Methadone
4.2 maintenance by the treating team:

a) During the reporting month Patient Files / RF - 15 0 0 0

b) From the roll-out of services till the end of reporting month (cumulative) Patient Files / RF - 15 0

4.3 Out of the total registered MMT patients, cumulative number of patients: 0

a) Transfered to other DTCs / OST Centres till the beginning of the reporting month Patient Files / RF - 15 0

b) Shifted to BPN / BPN-N / NTX till the beginning of the reporting month Patient Files / RF - 15 0

Out of the registered MMT patients, number of patients who did not receive even one dose during
4.4 the reporting month due to death, migration or imprisonment Patient Files / RF - 15 0

4.5 Of the total registered MMT patients, number of patients receiving Methadone for: 0

a) 25 or more days in the reporting month RF - 15 0 0 0

b) 15 to 24 days in the reporting month RF - 15 0 0 0

c) 1 to 14 days in the reporting month RF - 15 0 0 0

4.6 Total number of times MMT dosages were dispensed during the reporting month (sum of head RF - 15 0
count of individuals receiving MMT on each day of the reporting month)

SECTION 2 : TREATMENT FOR ALCOHOL USE DISORDERS

Value
S.No. Indicator Source Male Female Total

5.1 Total number of individual patients of Alcohol Dependence started on Disulfiram by the centre:

a) During the reporting month RF - 16 0

b) From the roll-out of services till the end of reporting month (cumulative) RF - 16 0
 5.2 Total number of individual patients of Alcohol Dependence who completed treatment and were
taken off Disulfiram by the treating team:

a) During the reporting month RF - 16 0

b) From the roll-out of services till the end of reporting month (cumulative) RF - 16 0

Number of patients currently receiving Disulfiram tablets from the centre during the reporting
5.3 month (dispensed at least one dose during the month) RF - 16 0

SECTION 3 : PATIENTS RECIEVEING NALTREXONE TREATMENT

Value
S.No. Indicator Source Male Female Total

6.1 Total number of individual patients started on Naltrexone by the centre:

a) During the reporting month RF - 16 0

b) From the roll-out of services till the end of reporting month (cumulative) RF - 16 0

Total number of individual patients who completed treatment and were taken off Naltrexone
6.2 maintenance by the treating team:

a) During the reporting month Patient files / RF - 16 0

b) From the roll-out of services till the end of reporting month (cumulative) Patient files / RF - 16 0

6.3 Out of the total patients started on Naltrexone maintenance, cumulative number of patients: 0

a) Transfered to other DTCs / OST Centres till the beginning of the reporting month Patient files / RF - 16 0

b) Shifted to BPN / BPN-N / MMT till the beginning of the reporting month Patient files / RF - 16 0

Number of individual patients of Opioid Dependence currently receiving Naltrexone tablets from
6.4 the centre (dispensed at least one dose during the month) RF - 16 0

SECTION 4 : TREATMENT FOR OTHER SUBSTANCE USE DISORDERS*

Value
S.No. Indicator Source Male Female Total
Number of new patients receiving treatment for Tobacco use disorders from the centre during the
7.1 reporting month Patient Files 0

Number of new patients receiving treatment for Cannabis use disorders from the centre during
7.2 the reporting month Patient Files 0
 7.3 Number of new patients receiving treatment for Benzodiazepine use disorders from the centre Patient Files 0
during the reporting month

Number of new patients receiving treatment for Inhalant use disorders from the centre during the
7.4 reporting month Patient Files 0

Number of new patients receiving treatment for Other substance use disorders from the centre
7.5 Patient Files 0
during the reporting month
*In the above section, report for all patients receiving a particular type of treatment irrespective of whether they are also receiving treatment for other comorbid substance use disorders

SECTION 5 : OTHER TREATMENTS FOR SUBSTANCE USE DISORDERS

Value
S.No. Indicator Source Male Female Total
Number of new patients receiving out-patient management of acute Alcohol withdrawal
8.1 (detoxification) from the centre during the reporting month Patient Files 71 71

Total number of patients receiving out-patient management of acute Opioid withdrawal

8.2 (detoxification) from the centre during the reporting month Patient Files 23 23

Number of registered DTC patients who were referred for admission for treatment of any
8.3 substance use disorder during the reporting month Patient Files / RF - 07 0

Total number of patients receiving Inj Naloxone for management of opioid overdose from the
8.4 centre during the reporting month RF - 16 0

SECTION 6 : PSYCHOSOCIAL INTERVENTIONS

Value
S.No. Indicator Source Male Female Total

9.1 Number of patients for whom clinical follow-up (follow-up with the doctor) was conducted at the RF - 02 0
clinic during the reporting month

Number of patients for whom psychosocial follow-up (follow-up with the counsellor) was
9.2 conducted at the clinic during the reporting month RF - 02 0

Number of individual (one-to-one) counselling sessions taken with the patients during the
9.3 RF - 05 166 166
reporting month (excluding psychosocial follow-up visits)

9.4 Number of group counselling sessions taken with the patients during the reporting month RF - 06 9

9.5 Number of field visits made by the counsellor during the reporting month RF - 05

SECTION 7 : REFERRAL LINKAGES WITH OTHER SERVICES

Value
S.No. Indicator Source Male Female Total

10.1 Number of individual patients tested for HIV during the reporting month RF - 07 0

10.2 Number of individual patients testing positive for HIV during the reporting month RF - 07 0

10.3 Cumulative number of HIV positive patients linked with ART centre till this month RF - 07 0
 10.4 Number of individual patients referred to STI clinic during the reporting month RF - 07 0

10.5 Number of individual patients referred to TB treatment services in the reporting month RF - 07 0

Number of individual patients referred for "OTHER health conditions" (excluding HIV/STI/TB)
10.6 RF - 07 0
during the reporting month

Number of individual patients referred to "Tobacco Cessation Clinic (TCC)" of the hospital during
10.7 the reporting month (if a TCC is functional in the concerned hospital) RF - 07 0

Number of patients linked with other services (legal aid, shelter, nutrition, vocational
10.8 rehabilitation, etc.) RF - 07 0

SECTION 8 : STAFF STATUS & TRAINING

Staff status Training Status (Yes / No)** Remarks
S. No. Staff Designation (mention reasons for vacant positions / untrained
Number Sanctioned* Number In Place Date of Joining Induction Training Refresher Training staff and plan to address the same)
1 1 11th September, 2015
11.1 Doctor
1 1 27th July, 2015
11.2 Nurse
1 1 9th March, 2015
11.3 Counsellor
1 1 1st October, 2015
11.4 Data Manager
11.5
Any other staff (specify)
1 1 14th September, 2015
11.6 New Recuitments during the month
1
11.7 Total Staff positions vacant
1
*staff sanctioned as per scheme document / NDDTC communications **whether received induction / refresher training as outlined in the scheme document / NDDTC communications

SECTION 9 : STOCK STATUS

A. Stock utilization and movement details (Source - Central and DTC Stock Registers & Daily Dispensing Registers)
MEDICINE (Amount in No. of Tablets or ML)
S No Indicator
BPN 0.4mg BPN 2mg BPN - N METHADONE (ml) NALTREXONE DISULFIRAM
Opening stock at the beginning of the reporting
12.1 month (DTC + Central stock) 3000

12.2 Stock received from NDDTC during the reporting 8760 4500
month

Stock returned to NDDTC during the reporting

12.3 month (if any)*

Stock dispensed to clients during the reporting

12.4 month 118 1500 10

Stock expiring without use during the reporting

12.5 month
 12.6 Stock wastage during the reporting month**

Expected balance stock at the end of the reporting

12.7 month 0 8642 0 1500 4490 0

Actual balance stock at the end of the reporting

12.8 8642 0 1500 4490
month (DTC + Central stock)

Difference between expected and actual balance

12.9 stock 0 0 0 0 0 0

Stock projection as per the consumption during

12.10 the reporting month (in days) 2197.1186440678 #DIV/0! 30 13470 #DIV/0!

Reasons for discrepancy (if any) between expected

12.11 and actual stock positions

Reasons for stock wastage (if any) during the

12.12 reporting month

*Any stock transferred to another DTC on instructions of NDDTC should also be reflected here **due to reasons such as theft, damage during storage or transit, spillage during dispensing, etc.

B. Balance Stock Details (Source - Central and DTC Stock Registers & Daily Dispensing Registers)
Balance Stock at the Centre (at the end of the reporting month)
S No Batch No Expiry Date
BPN 0.4mg BPN 2mg BPN - N METHADONE (ml) NALTREXONE DISULFIRAM

13.1

13.2

13.3

13.4

13.5

13.6

Total Stock 0 0 0 0 0 0

C. Expired Stock Details (Source - Central and DTC Stock Registers)

Balance Expired Stock at the Centre (at the end of the reporting month)
S No Batch No Expiry Date
S No Batch No Expiry Date
BPN 0.4mg BPN 2mg BPN - N METHADONE (ml) NALTREXONE DISULFIRAM

14.1

14.2

14.3

14.4

14.5

14.6

Total Stock 0 0 0 0 0 0

SECTION 10 : MISCELLANEOUS
(Use this section to provide any additional information for e.g. to enumerate / describe any specific challenges / problems / events occuring during the reporting month, add rows if required)
Support required from Regional / National
S No Issue / event Challenges / problems faced Whether resolved at DTC level and how Coordinating Centre (if any)

15.1

15.2

15.3

15.4

15.5
List of States / UTs Designation of Reporting OfGovernment Hospital Month Year DTC Support for Type of DTC

Andhra Pradesh Nodal Officer Medical College Hospital January 2014 MMT only Government Hospital
Arunachal Pradesh Medical Officer District Hospital February 2015 MMT + BPN GO-NGO collaboration
Assam Data Manager Community Health Centre March 2016 MMT + BPN + BPNAny other
Bihar Any Other Primary Health Centre April 2017
Chhattisgarh Any other (please specify) May 2018
Goa June 2019
Gujarat July 2020
Haryana August 2021

Himachal Pradesh Septembe 2022

Jammu & Kashmir October 2023
Jharkhand Novembe 2024

Karnataka Decembe 2025

Madhya Pradesh
Maharashtra
Manipur

Meghalaya

Mizoram

Nagaland

Odisha

Punjab

Rajasthan

Sikkim

Tamil Nadu

Telangana

Tripura

Uttarakhand
Uttar Pradesh

West Bengal

Andaman and Nicobar

Chandigarh

Delhi

Dadra and Nagar Haveli

Daman and Diu

Lakshadweep

Puducherry
OST - BPN BPN Type of Facilities Designation of Reporting Offi
BPN-N
OST - MMT Medical College Hospital Nodal Officer
NTX District Hospital Medical Officer
DS Community Health Centre Data Manager
Primary Health Centre Any Other
Any other (please specify)
 MaharashtrManipur Punjab

Thane Bishnupur Hoshiarpur

tion of Reporting Officer Pune Chandel Jalandhar
Mumbai SuChurachandAmritsar
Nashik Imphal-EastBarnala
Nagpur Imphal-WesBathinda
AhmadnagaSenapati Faridkot
Solapur TamenglonFatehgarh Sahib
Jalgaon Thoubal Fazilka
Kolhapur Ukhrul Firozpur
Aurangaba   Gurdaspur
Nanded Ludhiana
Mumbai City Kapurthala
Satara Mansa
Amravati Moga
Sangli Sahibzada Ajit Singh Nagar
Yavatmal Ropar
Raigarh Sri Muktsar Sahib
Buldana Shahid Bhagat Singh Nagar
Bid Sangrur
Latur Patiala
Chandrapur Pathankot
Dhule Tarn Taran
Jalna
Parbhani
Akola
Osmanabad
Nandurbar
Ratnagiri
Gondiya
Wardha
Bhandara
Washim
Hingoli
Gadchiroli
Sindhudurg