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Ambekar dibrugarh - management drug dependence - india

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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
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Page 1: Ambekar   dibrugarh - management drug dependence - india

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

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CONTENTS

Historical context

Current situation: Patterns and Prevalence

The response: Treatment services

The response: Laws and Policies

Ideas: Germinating, in-pipeline, nascent,

future…

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CONTENTS

Historical context

Current situation: Patterns and Prevalence

The response: Treatment services

The response: Laws and Policies

Ideas: Germinating, in-pipeline, nascent,

future…

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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

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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

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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

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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.

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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

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Early 1990s: Injecting Drug Use started in North East India; gradually spread to other parts

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CONTENTS

Historical context

Current situation: Patterns and Prevalence

The response: Treatment services

The response: Laws and Policies

Ideas: Germinating, in-pipeline, nascent,

future…

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(Ray, 2004)

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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

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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

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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

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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

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Source: Murthy et al 2010

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Rising?

In terms of prevalence ?

In terms of newer geographical areas?

In terms of newer demographic groups?

In terms of newer substances?

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CONTENTS

Historical context

Current situation: Patterns and Prevalence

The response: Treatment services

The response: Laws and Policies

Ideas: Germinating, in-pipeline, nascent,

future…

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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

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Major ‘players’

Additionally, ‘Alternate approaches’: AA, spiritual / religious groups etc.

Availability of treatment services in India

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122 in number

Established by the Union MOHFW (DDAP division)

Attached with district hospitals and medical colleges (Department of Psychiatry)

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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

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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!

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Priority / Resource allocation

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‘Minimum standards of care’ exist

No structured, regular system for M & E

DAMS for new patients

Capacity Building: Through institutions located regionally

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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

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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

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Conservative estimate of number of Alcohol / drug dependent individuals

= 1 crore

(10000000)

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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

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10000000

versus

144000

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CONTENTS

Historical context

Current situation: Patterns and Prevalence

The response: Treatment services

The response: Laws and Policies

Ideas: Germinating, in-pipeline, nascent,

future…

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Principle of regulatory framework:

“Balance between:

curbing misuse

and

ensuring access for medical and scientific purpose”

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Principle of regulatory framework:

“Balance between:

curbing misuse

and

ensuring access for medical and scientific purpose”

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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

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Narcotic Drugs and Psychotropic Substances (NDPS) Act (1985)

Drug Use a criminal act

Provision for treatment in lieu of jail term for Drug Users

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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

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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

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CONTENTS

Historical context

Current situation: Patterns and Prevalence

The response: Treatment services

The response: Laws and Policies

Ideas: Germinating, in-pipeline, nascent,

future…

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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 ?”

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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

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Three roles psychiatrists could

play

Clinical services (for complex / referred

cases)

Training (of general psychiatrists /

general physicians)

Programme design / management / evaluation

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Three roles psychiatrists could

play

Clinical services (for complex / referred

cases)

Training (of general psychiatrists / general

physicians)

Programme design / management / evaluation

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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

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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

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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

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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!

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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

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Idea being floated Initial consultations being held Challenging, in view of federal structure of

governance (and alcohol being a state subject)

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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.)

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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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