India needs a national protocol for treatment of substance use disorders

India has enacted a Mental Healthcare Act 2017 to ensure emotional, psychological, and social well-being, of its citizens. It incorporates a wide range of issues, from clinically diagnosed mental disorders to substance abuse and addiction.

In the National Mental Health Survey of India 2015-16, it was revealed that alcoholism and substance abuse have a grip on 22% of the population. In India, Kerala is the only state that meets the requirement of at least one psychiatrist per lakh population and also has the greatest number of clinical psychologists (0.6 per lakh population).

India lacks a National strategic program on substance use management; investment plans to improve access to effective substance use management; capacity building and quality assurance to meet the guidelines and standards for evidence-based best practices in substance use management; integrating substance use management in the health care and social welfare system in the comprehensive continuum of care.

The growing global burden of substance use disorders cannot be overemphasized. The World Health Organization (WHO) estimates that the global burden of disease attributable to alcohol and illicit drug use amounts to 5.4% of the total burden of disease.

The United Nations Office of Drugs and Crimes (UNODC), estimates that a quarter of a billion people (5 per cent of the global adult population), use drugs. Even more worrisome is the fact that about 29.5 million of those drug users suffer from drug use disorders. This means that their drug use is harmful to the point that they may experience drug dependence and require treatment. Several studies have highlighted the serious nature of substance use in India, ranging from alcohol and tobacco to cannabis, heroin and others.

Health consequences of substance use are numerous and hence the need for public health systems to spearhead the prevention, treatment and care. The most recent trend is the diversion, illicit distribution and abuse of prescription drugs that are classified as controlled substances such as synthetic pain medicines, sedative hypnotics, and psychostimulants. Those medicines have legitimate use under medical supervision but their use can quickly become problematic if used inappropriately.

In order to avert legal efforts at controlling distribution of psychoactive substances, hundreds of New Psychoactive Substances (NPS) are synthesized, distributed, and abused every year with unpredictable and often dramatic adverse consequences in users. The production and trafficking of NPS, that can be purchased through the internet makes monitoring and control even more difficult.

Very few countries have in place an early warning system to collect and share information on these new substances. Concurrently, the mechanism of control relies on national legislations, typically with a long term process necessary to schedule new drugs under the various international conventions. This expansion of NPS will continue to place an added burden on the already challenged healthcare systems.

Because of the emergence of NPS and changes in the distribution routes of the traditional drugs of abuse in many countries and parts of the world, health institutions are poorly prepared and less able to respond appropriately to the emergence of new behavioural and medical problems in drug users. For example, in parts of the world where opioids were previously used, there are now large increases in prevalence of psychostimulant use disorders and treatment system developed to manage opioid–related disorders is not able to respond appropriately to the new type of patients.

Similarly, the trend toward poly-drug use among the young consumers, combining “traditional” drugs, prescription drugs, alcohol and new psychoactive substances, has evidenced an even more dramatic picture that requires urgent investment treatment programs and human resources.

What is needed is a protocol on the treatment of substance use disorders. In this protocol, treatment can be divided into: medical detoxification, management of intoxication and overdose, maintenance treatment, management of co-morbid medical and psychiatric disorders, relapse prevention and psychosocial interventions.

An effective national system for the comprehensive treatment of substance use disorders requires a coordinated and integrated response of many actors to deliver policies and interventions based on scientific evidence in multiple settings and targeting different groups at different stages with regard to the severity of their substance use disorder.

The public health system is best placed to take the lead in the provision of effective treatment services for people affected by drug use disorders, often in close coordination with the social care services and other community services.

At the systems level it needs to be ensured that treatment services are: available, accessible, affordable, evidence-based, and diversified. It should also be ensured that there is effective coordination between the criminal justice system, health and social services.

Drug use disorders should be seen primarily as a health problem rather than a criminal behaviour and wherever possible, drug users should be treated in the health care system rather than in the criminal justice system. Law enforcement, court professionals and prison officers should be appropriately trained to effectively engage with the treatment and rehabilitation efforts.

If imprisonment is warranted, treatment should also be offered to prisoners with drug use disorders during their stay in prison and after their release also. Continuity of care after release is of vital importance and should be assured or facilitated.

In all justice related cases, people should be provided treatment and care of equal standards to treatment offered in the general population. Treatment policies, programs, procedures and coordination mechanisms should be defined in advance and clarified to all therapeutic team members, administration, and target population.

Treatment policies for drug use disorders should be based on the principles of universal health coverage, best available evidence and developed with the active involvement of key stakeholders including the target populations, community members (families), non-governmental organizations, religious organizations.

A coordinating team should include psychiatric and psychological carers, municipality, ASHA workers, housing and job skills/employment providers, legal assistants, and specialised health care providers (HIV, Hepatitis, other infections). The treatment system must be constantly monitored, evaluated and adapted.

Females are considered as a special population due to the unique way substance use impacts them and what cause addiction in them. For example, women experience the first signs of medical complications from alcohol and other drugs much sooner than men. Furthermore, women who drink excessively can experience changes in the menstrual cycle, menopause, and foetal development, higher incidence of mental illness compared to men, with higher risk of suicide and eating disorders.

As possible causes for addiction, women in treatment tend to have a high rate of sexual abuse and have past episodes of physical violence. Women face special challenges when getting help for drug and alcohol addiction such as greater resistance from family and friends and more negative consequences associated with treatment entry (lack of child care, job loss, and family responsibilities). Hence treatment program for substance-using pregnant women needs to be sensitive to specific biological as well as cultural, social, and environmental factors.

The three International Drug Control Conventions do not compel Member States to enforce criminal justice sanctions for use and possession of drugs for personal use. The provision of treatment and rehabilitation services as a complete alternative to criminal justice sanctions, including incarceration, is clearly articulated for minor drug-related crime. Those who use drugs regularly and end up in the criminal justice system are often offered drug treatment services in an effort to break the on-going cycle of drugs and crime.

Another feature that needs to be explored is the setting up of Drug Courts. Many countries have started a new trend of creating Drug courts that provide an alternative to incarceration. A specialized branch of courts (drug court) is created within existing jurisdictions to oversee court-supervised drug treatment and community supervision to individuals who have serious drug-related problems.

Unlike the standard adversarial court proceedings, drug courts are set up as supportive environments where judges will praise and reward individuals for successful program participation, limiting “punishment” to those who do not comply. The use of drug courts often is limited to non-violent individuals who have few (or no) prior convictions.

In some cases, the drug court option is only provided after a plea of guilty occurs. In most drug court programs, individuals who have successfully completed the program avoid prison or jail time and, in some cases, can have certain convictions (e.g., drug convictions) removed from their record.

The Ministry of Health and Family Welfare has released an e-book, in July 2020 titled “Standard Treatment Guidelines for the Management of Substance Use Disorders and Behavioural Addictions” that aims to tackle substance abuse and behavioural addiction in the country. This is to supplement the Drug Deaddiction Program (DDAP) under the Health Ministry and other stakeholders for implementing identical initiatives across the country.

Apart from drug addiction, other behavioural addictions like gambling, shopping, cyber-relational and cyber-sexual addictions including over-involvement in online relationship and pornography and addiction to online games has been included in the standard treatment guidelines.

The World Drug Report 2020 suggests that COVID-19 can have other fallouts also, like users seeking out cheaper synthetic substances, poor and disadvantaged turning to drug use as an escape from their sufferings. The battle against drug abuse is far from over, and many nations have been crippled by the extensive addiction problems plaguing their countries. India needs to take comprehensive steps to tackle the drug menace.

(The writer is former Director General, National Academy of Customs, Indirect Taxes & Narcotics and School of Multi-Disciplinary School of Economic Intelligence. He can be contacted at shreemenon48@gmail.com)