Post on 14-Aug-2015
transcript
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
10
11
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
12
13
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.
14
15
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
16
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
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
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
atul.ambekar@gmail.com www.facebook.com/atul.ambekar