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Additional Professor, NDDTC, AIIMS, New Delhi
Member: Strategic Advisory Group, IDU and HIV, United Nations
Member: National Task Force on Drug Demand Reduction, MSJE, Govt. of India
Member: Technical Advisory Group on Alcohol Control, MOHFW, Govt. of India
CONTENTS
Historical context
Current situation: Patterns and Prevalence
The response: Treatment services
The response: Laws and Policies
Ideas: Germinating, in-pipeline, nascent,
future…
CONTENTS
Historical context
Current situation: Patterns and Prevalence
The response: Treatment services
The response: Laws and Policies
Ideas: Germinating, in-pipeline, nascent,
future…
The use of alcohol in India has been known since the dawn of history Early Indo-Aryans (2000 B.C.) used alcohol freely in the form of “Soma” and “Sura” Brewing and drinking of various liquors was developed into an art in ancient India
Under the patronage of British, the popularity of alcohol started increasing
The basic difference regarding drinking among Indians and Western world was:
for Indians,
• it was largely amusement (Vihara or Krida),
for westerners,
• it was [and is] part of food (Ahara) in moderation
15
16
Indians introduced the world to properties of cannabis,
European travelers provided detailed description of ‘bhang’ to people in Europe
– Indian laborers going to Jamaica (West Indies) took Cannabis with them and made ‘Ganja’ popular
17
18
Opium was cultivated, eaten, and drunk by all classes as a household remedy;
It was used by rulers as an indulgence, and given to soldiers to increase their courage.
19
20
Early 1980s: Along with increased tourism and ?Asiad Games, Opium replaced with heroin
Rural areas: Opium users continued with Opium, some switched to heroin
Urban areas: Heroin use started spreading
21
Early 1990s: Injecting Drug Use started in North East India; gradually spread to other parts
CONTENTS
Historical context
Current situation: Patterns and Prevalence
The response: Treatment services
The response: Laws and Policies
Ideas: Germinating, in-pipeline, nascent,
future…
(Ray, 2004)
National Household Survey: Sample Size: 40,697 males (12-60 yrs)
Prevalence of ‘current’ use (i.e., during last month)
Alcohol: 21%
Cannabis: 3%
Opiates: 0.7%
(heroin 0.2%)
Any illicit drug: 3.6%
IDUs (‘ever’): 0.1%
22.3% are poly-drug users
National Household Survey: Sample Size: 40,697 males (12-60 yrs)
Prevalence of ‘current’ use (i.e., during last month)
Alcohol: 21% 62.5 m
Cannabis: 3% 8.7 m
Opiates: 0.7% 2.0 m
(heroin 0.2%)
Any illicit drug: 3.6%
IDUs (‘ever’): 0.1%
22.3% are poly-drug users
ALCOHOL 62.5 m 16.8% 10.5 m
CANNABIS 8.7 m 25.7% 2.3 m
OPIATES 2.0 m 22.3% 0.5 m
# of dependent users # of current users % of dependent users
New Treatment Seekers in 3 months: 16,942
Age: <20 yrs - 5%, 21-30 yrs - 33%,
31-40 yrs - 37%, >40 yrs - 25%
Unemployed : 20%
Single : 23%
Illiterate : 16%
Rural : 52%
2. DATA HIGHLIGHTS – DAMS
203 TREATMENT CENTRES
Drugs used
Alcohol: 44% Stimulants (ATS): 2%
Opiates: 26% Others: 16%
Cannabis: 12% IDU (ever): 14%
Other Features
Onset of use: 21-30 yrs (46%)
Duration: used drugs for more than 5 years: 53%
Previous treatment: 27%
2. DATA HIGHLIGHTS – DAMS
203 TREATMENT CENTRES
3. RAS
UNDCP Sites
Amritsar
Jamshedpur
Shillong/ Jowai
Dimapur
Hyderabad
Bangalore
Thiruvananthapuram
Goa
Ahmedabad
UNESCO Sites Imphal
Chennai
Mumbai
Delhi
Kolkata
Total no. of sites – 14 ( UNDCP – 9 , UNESCO – 5 )
Note: The boundaries and names shown on this map do not imply official endorsement or acceptance by the United Nations
UNODC
UNODC
Drugs used
Heroin : 36% Alcohol: 5%
Other Opiates: 29% Sedatives: 4%
Cannabis: 22% IDU (ever): 43%
Other Features
Using for more than 5 years: 42% (UNODC sites)
Drug-using friends: 90%
Sharing of needles: 0.2 - 51% (different sites)
3. DATA HIGHLIGHTS – RAS
Sample size: 4,648 (recruited from street;
not in treatment)
No National level survey in the general population after 2001
Planning for a fresh national survey ongoing since 2008
Studies on specific population groups / specific geographical areas do exist
Source: Murthy et al 2010
• Ahmed et al 2009 • Akoijam et al 2013 • Bagchi et al 2014 • Bal et al 2010 • Bishwalata et al 2014 • Das et al 2011 • Juyal et al 2009 • Kelkar et al 2013 • Kokiwar et al 2011 • Mathur et al 2008 • Mukhopadhyay et al 2012 • Narain et al 2013 • Ningombam et al 2011 • Praveen et al 2010 • Sharma et al 2011 • Soni et al 2013 • Tsering et al 2010
Children / Adolescents / Students
• Kermode et al 2012 • Kermode et al 2013
Women
Children / Adolescents / Students
• Ahongshangbam et al 2013 • Basu et al 2011 • Gupta et al 2013 • Jain et al 2009 • Kalpana et al 2012 • Mathur et al 2009 • Mohanty et al 2013 • Saddichha et al 2010
Women
Children / Adolescents / Students
Youth / College students
• Deswal et al 2012 • Goel et al 2010 • Kim et al 2013 • Mohindra et al 2011 • Nattala et al 2014 • Saddichha et al 2010
Women
Children / Adolescents / Students
Youth / College students
General Population (Rural / Urban / tribal)
• Tiwari et al 2013
Women
Children / Adolescents / Students
Youth / College students
General Population (Rural / Urban / tribal)
Elderly Population
• Ayirolimeethal et al 2014
Women
Children / Adolescents / Students
Youth / College students
General Population (Rural / Urban / tribal)
Elderly Population
Prison Inmates
• Medhi et al 2012
Women
Children / Adolescents / Students
Youth / College students
General Population (Rural / Urban / tribal)
Elderly Population
Prison Inmates
Sex workers
Women
Children / Adolescents / Students
Youth / College students
General Population (Rural / Urban / tribal)
Elderly Population
Prison Inmates
Sex workers
Some general population studies
Author and year
Location Population Sample size
Focus Prevalence
Deswal et al 2012
Pune Household 3000 SUD 1.39%
Nattala et al 2014
Bangaluru “Mall visitors” 717 Non medical sedative use
12%
Kim et al 2013
Vellore Urban slum 2811 Alcohol Use Hazardous use Dependence
46% 31% 5%
Goel at al 2010
Rural Sikkim Household 118 households
Alcohol Use Cannabis Use Opioid Use
55% 14% 6%
135 sites 4,024 substance using
children (5-18 years)
4% girls
70% urban
59% out of school
22% street children
109 NGOs 1865 female
substance users
About 1/4th rural
6% below 20 years
64% married
31% illiterate
33% sex work / peddling
18.4 19.3
20.9 20.3 21.8
22.7
0
5
10
15
20
25
Tobacco Cough Syrup Alcohol Proxyvon Cannabis Heroin
Mean Age of onset (in years)
2012
Increased health burden
• Greater risk of illness (NCDs including alcohol dependence)
Economic costs
• Reduced productivity and increased absenteeism
• reduced money spent on food and essential commodities,
• greater debt, greater costs due to and lowered productivity,
Unmonetizable social costs
• Poorer nutrition and health and well being
• Violence.
Younger age of initiation Prevalence of alcohol use (in %) among 15-19 years, male
2.4
11
0
2
4
6
8
10
12
NFHS - 2 (1999) NFHS - 3 (2006)
Male
Age of Initiation of drinking alcohol in Karnataka, India
Source: Benegal V. India: Alcohol and Public Health, Globe Issue 2 2005. pp8, Global Alcohol Policy Alliance
Age of Initiation of drinking in Karnataka, India
Techniques for estimating size of population
• Population survey methods
• Network scale-up methods
Data collected from the general population
• Census
• Enumeration
• Capture-Recapture
• Multiplier
Data collected in an at-risk population (IDU)
WHO/UNAIDS 2010
Census
Count all individuals
Census
Count all individuals
20, out of 100 are IDUs
Representative Sample
Population Survey
Sample of 20 people:
4 out of 20 are IDUs
Thus out of 100, 20 are IDUs
Representative Sample
Population Survey
Capture – recapture
1st wave (Capture):
Recruit purposive sample from
community
Capture – recapture
1st wave (Capture):
Recruit purposive sample from
community
Tag positive individuals
Capture – recapture
1st wave (Capture):
Recruit purposive sample from
community
Tag positive individuals
2nd wave (Recapture): Count the
number of ‘tagged’ individuals
Analysis of Probability of
recapture generates estimation of
size
Multiplier Method
HOSPITAL
+
Multiplier Method
HOSPITAL
No. of IDUs admitted
= 50
+
Multiplier Method
Sample of 20 IDUs
HOSPITAL
No. of IDUs admitted
= 50
+
Multiplier Method
Sample of 20 IDUs
5 out of 20 = 25% IDUs report having
been admitted in the HOSPITAL
HOSPITAL
No. of IDUs admitted
= 50
+
Multiplier Method
Sample of 20 IDUs
5 out of 20 = 25% IDUs report having
been admitted in the HOSPITAL
Estimated IDU size = 50 X (100 ÷25) =
200
HOSPITAL
No. of IDUs admitted
= 50
+
Multiplier Method
HOSPITAL
+
Unbiased sample of IDUs:
1st source of data
Records at treatment centers: 2nd source of data
Size estimation of Injecting drug use in Punjab and Haryana
Ambekar & Tripathi, 2008 UNAIDS and SPYM, New Delhi
Nomination /Enumeration technique
Used in the study…
Treatment centre
‘IDU spots’
Vulnerability map and IDU spots
Nomination Technique: methodology
Field Researchers (current IDUs)
2 FRs per spot
Nomination Technique: methodology
List List
Field Researchers (current IDUs)
2 FRs per spot
Nomination Technique: methodology
Nomination Technique: methodology
Collect all the lists
Remove duplicate names
Count all the names
Estimated size
List List List List List List List List
Nomination Technique: methodology
Limitations
Caution in interpretation of the data
• We did not generate estimates of TOTAL NUMBER of IDUs at the towns or cities
– The findings indicate the numbers of IDUs which could be contacted in the PLI AREAS
• Assumptions:
– Sites have been mapped accurately and all the IDU spots in the site have been mapped
– Two chosen field researchers were able to name all the IDUs contactable at the particular spot
80
Size estimation of Injecting Drug Users at multiple sites in India
Ambekar & Tripathi, 2007 In Collaboration with SPYM, New Delhi
Funded by DfID (UK)
Association of drug use pattern with vulnerability and service uptake among IDUS Ambekar, 2012 UNODC & NACO New Delhi
N=1000 (M=900, F=100)
The sample
North-east (Manipur,
Meghalaya, Mizoram, Nagaland)
30%
Central and East (MP,
Orissa, West Bengal)
30%
South (Kerala)
10%
North and Northwest
(Delhi, Punjab, UP)
30%
Distribution of sample: n=1000
0
10
20
30
40
50
60
70
80
90
100
Heroin , BYCHASING /
SMOKING route
Opium (oral) Other oralpharmaceutical
opioids
Buprenorphine tablets sub-lingual
– NON PRESCRIBED
67
38
65
2
46
17
51
0.7
38
14
45
0.6
Pattern of non-injecting Opioid Use (in %)
Ever
Last 1 year
Lat 3months
0
10
20
30
40
50
60
70
80
90
100
Heroin Buprenorphine Pentazocine Dextropropoxyphene PharmaceuticalSedatives
66
43
37
30
59
52
36
26
22
53
48
34
24
19
50
Pattern of Injecting Drug Use (in %)
Ever
Last 1 year
Last 3 months
Age of onset
-
5
10
15
20
25
30
15
18 19 19
21 21 22 22 23
25 25 27
Drug Proportion
reporting
Mean age
of onset
in years
1st Legal drug Tobacco 95% 15
1st illegal NON-
INJECTING drug
Cannabis 70% 19
Oral Pharma
Opioids
14% 21
1st illegal INJECTING
drug
Heroin 63% 25
Buprenorphine 18% 25
Pentazocine 11% 27
Progression of drug use career
Drug Proportion
reporting
Mean age
of onset
in years
1st Legal drug Tobacco 95% 15
1st illegal NON-
INJECTING drug
Cannabis 70% 19
Oral Pharma
Opioids
14% 21
1st illegal INJECTING
drug
Heroin 63% 25
Buprenorphine 18% 25
Pentazocine 11% 27
Progression of drug use career
Drug Proportion
reporting
Mean age
of onset
in years
1st Legal drug Tobacco 95% 15
1st illegal NON-
INJECTING drug
Cannabis 70% 19
Oral Pharma
Opioids
14% 21
1st illegal INJECTING
drug
Heroin 63% 25
Buprenorphine 18% 25
Pentazocine 11% 27
Progression of drug use career
Drug Proportion
reporting
Mean age
of onset
in years
1st Legal drug Tobacco 95% 15
1st illegal NON-
INJECTING drug
Cannabis 70% 19
Oral Pharma
Opioids
14% 21
1st illegal INJECTING
drug
Heroin 63% 25
Buprenorphine 18% 25
Pentazocine 11% 27
Progression of drug use career
First Sharing – duration after onset of injecting
among those who ever shared
Daily injectors
(n=351)
Non-daily
injectors (n=416)
First Sharing occurred at the first
instance of injecting 47% 66%
First Sharing occurred almost
within a month of onset of
injecting
35% 22%
First Sharing occurred within a
Year of onset of injecting 13% 10%
The drug use career of IDUs in India
Onset of legal drug use (tobacco / alcohol)
Onset of illegal, NON-injecting drug use
Onset of Injecting Drug Use
First instance of sharing injections
Contact with IDU TI
15 years
25 years
19 years
25-26 years
30 years
Five states- Manipur, Mizoram, Punjab, Tamil Nadu and West Bengal
100 ATS users
25 % female
Median age – 25 years
63% college level education
62% were single
Spent Rs. 3300 for one episode of ATS use Injecting ATS not reported Almost half, dependent on ATS
Rising?
In terms of prevalence ?
In terms of newer geographical areas?
In terms of newer demographic groups?
In terms of newer substances?
CONTENTS
Historical context
Current situation: Patterns and Prevalence
The response: Treatment services
The response: Laws and Policies
Ideas: Germinating, in-pipeline, nascent,
future…
Supply reduction
• Department of Revenue, Ministry of Finance
• Narcotics Control Bureau, Ministry of Home
• Central Bureau of Narcotics, Ministry of Finance
Demand reduction
• Prevention and Rehabilitation: Ministry of Social Justice and Empowerment NGOs
• Medical Treatment: DDAP, Ministry of Health and Family Welfare Govt. Hospitals
Harm reduction (IDU)
• National AIDS Control Organisation (NACO), MoH&FW NGOs and Govt. Hospitals
Major ‘players’
Additionally, ‘Alternate approaches’: AA, spiritual / religious groups etc.
Availability of treatment services in India
122 in number
Established by the Union MOHFW (DDAP division)
Attached with district hospitals and medical colleges (Department of Psychiatry)
Centres with substantial
patient load (data from
Drug Abuse Monitoring
system - DAMS)
Only some centres see large number of patients!
Name of De-addiction centre Annual patient load
NDDTC, Ghaziabad 13,566
PGIMER, Chandigarh 5,433
NIMHANS, Bangalore 4,885
KEM Hospital, Mumbai 1,573
Assam Medical College, Dibrugarh 1,525
Govt Medical College Chandigarh 2,334
Central Jail, Tihar 1,849
IGMC, Shimla 2,030
Medical College, Patiala 2,476
Civil Hospital, Bhatinda 1,261
Medical College, Faridkot 1,108
Coimbatore Medical College,
Coimbatore
2,081
Out of 122 only a few get recurring grant from the central government
Rest, dependent on the state governments
Drug dependence treatment is often seen as a low priority area by the local state governments At some places, buildings meant for De-addiction centers are being used for other purposes!
Priority / Resource allocation
‘Minimum standards of care’ exist
No structured, regular system for M & E
DAMS for new patients
Capacity Building: Through institutions located regionally
Supported by the MSJE About 450 in number Get funding from the ministry
Mainly residential (in-patient) treatment
Stand alone services – not a part of general health care
Recent revision of guidelines / scheme Functioning status? Capacity Building – through RRTCs
Number: unknown Qualifications of service providers: unknown
ranges from MD Psychiatry to no professional qualification (just an experience of having gone through the treatment)
Whether follow some standards / norms: unknown
Highly variable status for evaluation / functioning
Conservative estimate of number of Alcohol / drug dependent individuals
= 1 crore
(10000000)
Conservative estimate of number of Alcohol / drug dependent individuals
= 1 crore
(10000000)
Liberal estimates of Number of beds available for drug treatment
NGO sector 400 X 15 6000
Government sector 100 X 10 1000
Private sector --- 5000
Total 12000
Assuming minimum duration of acute-phase treatment = 1 month
144000
10000000
144000
10000000
versus
144000
CONTENTS
Historical context
Current situation: Patterns and Prevalence
The response: Treatment services
The response: Laws and Policies
Ideas: Germinating, in-pipeline, nascent,
future…
Principle of regulatory framework:
“Balance between:
curbing misuse
and
ensuring access for medical and scientific purpose”
Principle of regulatory framework:
“Balance between:
curbing misuse
and
ensuring access for medical and scientific purpose”
National Health Policy (2002)
Does not mention drug abuse / dependence as a major area of concern
National AIDS Prevention and Control Policy (2002)
Endorses “Harm Reduction” approach to address HIV among IDUs
Narcotic Drugs and Psychotropic Substances (NDPS) Act (1985)
Drug Use a criminal act
Provision for treatment in lieu of jail term for Drug Users
National Narcotic Drugs and Psychotropic Substances (NDPS) Policy (2012)
Does endorse a combination of supply, demand and “Harm Reduction” approach
Harm reduction – reluctantly endorsed
Only for IDUs
National Drug and Alcohol Demand Reduction Policy (DRAFT)
Being Developed by the MSJE
Draft under the process of review and refinement
Alcohol policies
Alcohol is a state subject; significant variations in alcohol polices
National Policy on Alcohol Control ???
Idea being mooted
CONTENTS
Historical context
Current situation: Patterns and Prevalence
The response: Treatment services
The response: Laws and Policies
Ideas: Germinating, in-pipeline, nascent,
future…
Debate: Is Alcohol and Drugs, primarily a … Health issue ?
Social Welfare issue ?
Law and order issue ? To what extent the approach should be .. Centralized ?
De-centralized ? Who should be mandated to provide treatment.. Health sector ?
“Civil Society ?”
Alcohol and Drugs, Is primarily a Health issue!
Health sector must take the lead in treatment provision
Mental health sector need to advocate for due attention
Three roles psychiatrists could
play
Clinical services (for complex / referred
cases)
Training (of general psychiatrists /
general physicians)
Programme design / management / evaluation
Three roles psychiatrists could
play
Clinical services (for complex / referred
cases)
Training (of general psychiatrists / general
physicians)
Programme design / management / evaluation
Train one medical doctor each from 500 districts (2011-2015)
NDDTC is jointly implementing it with five other medical institutions
Each institution to conduct two trainings in a year
with fifteen participants each to cover target
National Project: Trainings of Doctors on Substance Use Disorders
supported by NFCDA, Ministry of Finance
1. NDDTC, AIIMS, New
Delhi
3. Dept of Psychiatry,
KEM, Mumbai
4. De-addiction centre,
NIMHANS, Bangalore
5. Dept of Psychiatry,
CIP, Ranchi
6. Dept of Psychiatry,
RIMS ,Imphal
2. Dept of Psychiatry,
GMCH, Chandigarh
Project “Hifazat” funded by the GFATM, Round 9, India – HIV – IDU grant
Implemented by the Emmanuel Hospital Association in collaboration with NACO
Aimed at capacity building of all categories of service providers for IDU interventions
Medical institutions as “Technical Training Centers” for training for medical interventions
2014 amendment ‘Essential Narcotic Drugs’ for medical use Subject to central rules; state licenses not
needed Government to recognize and approve
treatment centres to regulate illegal / unethical practices
Punishment for users & traffickers increased!
28 July 2014: National Workshop on drafting NDPS rules
Dept of Revenue, Min. of Finance
All stakeholders welcomed the proposals: A uniform national set of regulations (as opposed to
state-specific rules)
Recognition that easy access and availability of medications as important as stringent regulations
ENDs – indicated for both – Pain relief and treatment of Opioid Dependence
Idea being floated Initial consultations being held Challenging, in view of federal structure of
governance (and alcohol being a state subject)
ATS now making inroads in the drug market Growing fluidity in the alcohol market
(Mizoram now a ‘wet’ state; Kerala on the way to
becoming a ‘dry’ state) Consumer / beneficiary groups getting more
organized (Indian Drug Users Forum, Indian Harm Reduction Network etc.)
Substance use: Sizable burden in India
Reliance on just supply control: not likely to be helpful
Addiction: “Too important to be left to psychiatrists only!”
Room at the top: for super-specialists - Addiction Psychiatrists
ADVOCACY: our responsibility as much as SERVICE PROVISION and TRAINING
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