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24 August, 2014, Ludhiana
• Is it working ?
International Drug
regulatory framework
• Implications for mental health professionals
The Indian Scene
» About 1 in 20 persons between the ages of 15 and 64 uses an illicit drug at least once a year ˃ Large majority of them use CANNABIS
» Fewer than 1 in 160 are “problem drug users”
» Overall value of the illicit drug market: about $320 billion (0.9 % of global GDP)
AlcoholTobacco
Illicit Drugs
35%
25%
2.50%
Global Prevalence of 'past month' use
» Today’s ‘narcotics’ have had a long history of use throughout the world
» Plants have been major source of drugs: ˃ Opioids
˃ Cannabis
˃ Cocaine
» Drugs have been used as medicines, for recreation and as part of social / cultural rituals
19th Century: Indian Opium exports to China
1909: Shanghai Opium Commission
1912: Hague Convention
UN Conventions: 1961, 1971, 1988
International Drug treaties
Opiates Cocaine Cannabis
12.9 13.4
147.4
17.35 17
160
Number of users in millions 1998 2008
"Sadly, the illicit
manufacture and
illicit consumption
of drugs occur
everywhere.”
Yury Fedotov, Executive Director, UNODC, 2012
Pettus, 2014
“Evil” reflects influence of missionaries in early prohibition policy”
» The stated intention behind the establishment of the global drug prohibition regime was to protect the world from the dangers of drugs.
» At different points in history, drug production, use and supply have all been presented as threats to security:
˃ human,
˃ national or
˃ international security.
“Menace” “Social evil”
“Existential threat”
Creation of a criminal black
market
Policy displacement
Geographical displacement
Substance displacement
Marginalization of drug users from social mainstream
UNODC 2008
Decrease
from 14.1 % in
2001 to
10.6 % in 2006
http://www.globalcommissionondrugs.org/
“The war on drugs has failed”
» Drug policies must be based on scientific evidence human rights and public health principles ..
» …legal regulation of drugs …
» …evidence-based prevention ... treatment and care for drug dependence..
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
» 124 in number
» Established by the Union MOHFW (DDAP division)
» Attached with district hospitals and medical colleges (Department of Psychiatry)
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!
» ‘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
Gaps in service demand and service provision » 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
Gaps in service demand and service provision
10000000 versus
Gaps in service demand and service provision
144000
Clearly, reliance only on the existing number of services and the in-patient, ‘de-addiction’ model is not enough!
Do our laws and policies facilitate treatment of opioid dependence ?
» 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”
» Drug Use a criminal act
» Provision for treatment in lieu of jail term for Drug Users ˃ Onus on accused to prove that s/he is a
drug user; not a trafficker !
» Three amendments: 1988, 2001, 2014
» 1988 amendment ˃ Stringent punishment for harboring offenders and
financing illicit traffic including death
˃ Forfeiture of property derived from/ used in illicit traffic
» 2001 amendment ˃ Punishment based on quantity found
˃ Further strengthened powers to trace and seize illegally acquired properties
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
» 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
» National Narcotic Drugs and Psychotropic Substances (NDPS) Policy (2012)
˃ Talks about a combination of supply, demand and “Harm Reduction” approaches
˃ Harm reduction – reluctantly endorsed; Only for IDUs
»National Drug and Alcohol Demand Reduction Policy (DRAFT) ˃ (Was) Being Developed by the MSJE
˃? Draft under the process of review and refinement
˃No clear stand on evidence-based pharmacological treatment of opioid addiction
Methadone
Buprenorphine
Buprenorphine+naloxone
Morphine
Tramadol
Non Opioids (Clonidine; Naltrexone etc.)
Methadone
Buprenorphine
Buprenorphine+naloxone
Morphine
Tramadol
1961 convention
1971 convention
1971 convention
1961 convention
Not under control*
International Control
Methadone
Buprenorphine
Buprenorphine+naloxone
Morphine
(Essential) Narcotic
Psychotropic
Psychotropic
(Essential) Narcotic
Indian Law
Methadone
Buprenorphine
Buprenorphine+naloxone
Morphine
?
Schedule H1
Schedule H1
Schedule K
Indian Scheduling and regulations
“The preparation shall be supplied only to the designated de-addiction centres set up by the Govt. of India funded by the Ministry of Health and Ministry of Social Justice and Empowerment and Hospitals with De-addiction facilities and a list of the centres to whom the supply of the drug is made should be made to this Directorate periodically indicating the quantities supplied to each centre.”
» The Punjab chaos spreads to other parts of the country. Some over-zealous official proposes to totally ban Buprenorphine
» Methadone and Morphine get listed as ENDs (and become available easily, even with prescription). Buprenorphine remains tightly regulated.
» Buprenorphine becomes de-regulated and starts being available in the pharmacy shops. Soon, it becomes OTC (like practically everything else) and we see a fresh epidemic.
» The ideal scenario
» Buprenorphine or Methadone are not available in pharmacies.
» They are available only through licensed and accredited facilities:
˃ Drug Treatment centres / Clinics (Govt. / NGO / Private)
˃ Prescribed by specifically trained doctors
˃ Records are maintained; M & E framework exists
» Methadone and plain Buprenorphine available only as DOTS
» Buprenorphine + Naloxone available as ‘take-home’ option (with standard procedures, and an upper limit)
Conceptual basis for a ‘rational drug policy’
» Prevention
» Supply reduction
» Treatment and harm reduction
» Criminal sanctions and decriminalisation
» Control of the legal market through prescription drug regimes
Drug policy and the public good, Babor et al, 2010
Is there something we can do?
» Ensuring only evidence-based practice
» Advocacy
˃Realizing that our role goes much beyond the service provision
˃Making our presence felt as professional bodies
˃Generating the discourse on policy reforms
˃Pressurizing our governments to take right stand in the International forums
Acknowledgement:
Dr. Sathya Prakash Senior Resident,
AIIMS, New Delhi