© Springer India 2015
Savita Malhotra and Subho Chakrabarti (eds.)Developments in Psychiatry in India10.1007/978-81-322-1674-2_2020. De-addiction Services in India
(1)
Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh, India
Keywords
Substance abuseServicesIndiaS.K. Mattoo, Professor; S.M. Singh, Assistant Professor; S. Sarkar, Senior Resident
1 Introduction
Mankind has been using substances since time immemorial. India is no exception to this universal historical trend. While the ancient Indian mythological texts mention the consumption of alcohol by demons (Asuras) as well as gods (Devas), others document recreational and medicinal use of alcohol, opium and cannabis throughout history (Chopra and Chopra 1965). The Mughal period saw the curtailment of the use of alcohol due to the influence of the Islamic traditions; however, it is recorded that the emperors made recreational use of opioids and encouraged the cultivation of opium (Ganguly 2008). When the British took over from the Mughals, they used the opium farming and trade to increase the state revenue. Opium trade to China led to the British China Opium War of 1839–1842 (Cherry et al. 2002). Much later, the British in India tried to kerb and control the use of opium, distributing it through the opium registries of traders and users. District Medical Officers issued licenses to the users to purchase from the traders. Since independence, while this medicalised use of opium has receded, the use of licit and illicit alcohol and drugs has increased gradually.
While the rise in the use and abuse of alcohol is attributed to the globalisation or westernisation, the rise in the abuse of drugs in India, especially in the recent times, has been attributed to a variety of geopolitical circumstances (Charles and Britto 2002). India is located between the two major opium growing regions of the world: the Golden Triangle (Laos, Myanmar and Thailand) and the Golden Crescent (Afghanistan, Pakistan and Iran). Large quantities of opioids have been traditionally smuggled into India and trafficked ahead. The geopolitical situation since the late 70s (the Russian invasion followed by US intervention in Afghanistan, the Indo-Pak conflict, the Khalistan movement and terrorism in Punjab and the LTTE movement in Sri Lanka), led to the use of opioids as a currency in the arms trade. Moreover, the problem was accentuated with raw opium being gradually replaced by heroin, which is easily transported, less bulky, more potent and gives a greater rush when injected. This is not to undermine the fact that India is the largest producer of licit opioids being utilised for medicinal purposes (United Nations Office on Drugs and Crime 2012).
Substance use disorders pose a significant problem in India. As a large and diverse country, based on the cultural context and availability of substances, it has a different profile of substance use in different geographical regions. The survey, ‘Extent, Pattern and Trends of Drug Abuse in India’ revealed that the country has approximately 62.5 million alcohol users, 8.7 million cannabis users and 3 million opioid users (Ray 2004). A meta-analysis concluded that the prevalence of substance use in India is 6.9/1,000 population (Murthy et al. 2010). Such a large quantum of substance using population makes adequate de-addiction services a basic necessity. De-addiction services refer here to the provision of care to reduce or stop substance-taking behaviour and to decrease the harms associated with the use of substances.
Even though the use of different substances varies across different time periods, it is nonetheless associated with a considerable morbidity and mortality and poses a significant healthcare burden (Rehm et al. 2003, 2006). There are also related increases in social problems and criminality, translating into indirect costs to the society (Thavorncharoensap et al. 2009). Hence, to manage the issue of substance use and to reduce the medical and psycho-social problems associated with it, effective de-addiction services are required. This chapter deals with the de-addiction services in India, in a historical perspective. It discusses the service delivery pathways, the models how services are provided, followed by the components of the service delivery. The existing infrastructure and legal framework are discussed, followed by the future outlays and programmes. The needs of special populations are also touched upon.
2 Framework for the Evolution of De-addiction Services in India
Various approaches have been tried to curtail substance use disorders and the consequent harms. Substances had been categorised into licit and illicit substances with initial thrust on implementing legislative measures to control drug-taking behaviours. By bringing possession and consumption of wide range substances under probationary control, it was attempted to regulate the drug abuse problem in the country. However, despite enforcing such punitive measures, a marked decrement in drug-taking behaviours had not been observed, suggesting that deterrence may not work in isolation, and a need for expansion of treatment facilities was felt.
Thus, treatment services were organised, both through the governmental (primary health care, secondary health care, medical colleges and special de-addiction units) and outside of governmental facilities (non-governmental organisations (NGO) and private de-addiction centres). In therapeutic service too, the focus has been initially on abstinence-oriented treatment. Abstinence from any drug-taking behaviour was the aim and was effectuated through detoxification and maintenance on deterrent/antagonist treatment. With time it has been seen that abstinence-based treatment does not necessarily work, and elements of harm reduction were considered. Harm reduction strategy dwells on reducing the harms associated with substance use. Opioid substitution therapies and needle exchange programs are some of the harm reduction measures, which have received attention and have been found to be beneficial in patients with substance use disorders who otherwise have not been able to achieve abstinence.
3 Service Delivery Pathways
De-addiction services can be provided through various pathways and agencies which include the government facilities, the private practitioners, the NGOs or the self-help groups (Abou-Saleh 2006). Government de-addiction services are provided through the government hospitals, primary healthcare clinics and specialised de-addition centres. The funding is provided by the central and/or the state governments. The services are varied in terms of the intensity, expertise and funding. The common feature is that these services are provided for free or at a minimal cost. More intensive de-addiction services are provided mainly at specialised centres at the larger teaching hospitals, though efforts are being made to provide services at the primary care setting, by training the medical officers at the primary health centres. Less intensive detoxification, or mere counselling, may be provided by the less specialised general medical officers. The government service quite often suffers from issues of inadequacy of funding, poor staff motivation and large patient loads. Nonetheless, they provide the backbone of the de-addiction services to the masses.
The private sector de-addiction services are provided through the clinics and rehabilitation centres of private physicians and de-addiction specialists. These operate on fee-for-service basis, and the patients or the families pay for the treatment costs. The profit motive ensures some degree of efficiency and modulation of services according to the demand of the population. However, the services may not be accessible to the poor and downtrodden, who constitute the majority of the population, and whose social and financial spiral is accentuated due to substance use.
The NGO sector comprises of various providers who are not under direct government control and generally work on not-for-profit basis. They often get grants from the government or other benefactors, but work on their particular agenda towards relieving problems affecting the community. Their services can include drug awareness programmes, needle–syringe exchange programmes and rehabilitation shelter programmes. These programmes are useful adjuncts to the existing services and often promote proper utilisation of the services by the substance users (Patel and Thara 2003). However, due to the vast multitude of NGOs with differing interests and inadequate communication with each other, their efforts may not be directed in an efficient manner. For example, many different NGOs may be working in one urban locality on needle–syringe exchange, but with different motives of AIDS control, hepatitis prevention, as a component of opioid substitution, as an intermittent outreach or follow-up or awareness programmes, leading to duplication of efforts in one particular area, while other geographical areas lack in services.
Self-help groups provide yet another pathway of services. Organisations like Narcotic Anonymous, Alcoholic Anonymous, Al-Anon (for friends and family of alcoholics) and Alateen (for teenage or younger family members of alcoholics) provide good support to the substance users and their family members who are also affected due to the patient’s substance use problem. Through their weekly or more frequent meetings, these organisations provide inspiration from other’s successes at abstinence and foster bonds that promote abstinence from the substance using or substance use promoting behaviours. These are particularly useful in helping in maintaining sobriety and directing to other services when need arises. However, such self-help groups are concentrated in cities and towns and are not available everywhere.
The different service pathways do not necessarily operate exclusive of each other. Patients often shuffle from one service delivery system to another. Also, many a times, these service pathways provide complementary and concurrent services. Apart from the above mentioned modes, patients also take consult from the faith healers and religious institutions, who may help in cessation of substance use through prescription of rituals (e.g. 40 days jamaat) and proscription of certain behaviours.
4 De-addiction Treatment Components
De-addiction psychiatry is being increasingly recognised as a specialised branch with requires some degree of training for managing the patient with substance abuse problems. The management of patients with substance use disorders begins with the in-depth assessment of the pattern of substance use, physical harms due to substance abuse and associated psychiatric conditions. The treatment per se involves multiple components of pharmacotherapy, psychotherapy and counselling and rehabilitation measures. All of these are important in improving the outcomes of the patient.
4.1 Pharmacotherapy
Pharmacotherapy for substance use disorders includes medications for either detoxification, or for maintenance. Medications for detoxification vary with the type of substances consumed. Detoxification for alcohol is carried out using long-acting benzodiazepines (diazepam or chlordiazepoxide) or hepatic safe benzodiazepines in cases of liver dysfunction (lorazepam or oxazepam). Detoxification from opioids is carried out using either opioid agonists (like buprenorphine) or other drugs for symptomatic control of withdrawal signs and symptoms (like a combination of clonidine, ibuprofen and nitrazepam). Pharmacoprophylaxis intends at prevention of resumption of substance use or a relapse. This is accomplished by the use of deterrent agents (disulfiram), anti-craving drugs (baclofen or acamprosate) and antagonists (naltrexone). Another approach is to prevent the use of illicit substances by providing through a legalised medical channel the licit medications like agonist agents (buprenorphine or methadone). Many of these agents have been shown to be efficacious in systematic reviews and meta-analyses (Fareed et al. 2012; Minozzi et al. 2011; Rösner et al. 2010). Compliance to these agents is important to maintain abstinence and prevent relapses.
4.2 Counselling and Psychotherapy
It has been seen that pharmacotherapy alone does not work effectively in treatment of substance use disorders. Hence, de-addiction services usually employ some form of ‘talk’ therapy elements, in varying degrees. These are delivered knowingly or unknowingly and formally or informally while developing rapport with the patient and working with the patient long term in the quest for maintaining abstinence. The formal structured psychotherapies include psychoanalytic, cognitive-behavioural, mindfulness-based, marital and family therapies, eclectic and dialectical therapies among others. In relation to de-addiction services, motivation enhancement therapy and relapse prevention counselling has been found to be of considerable usefulness and effective for treatment of substance use disorders (Dutra et al. 2008).
4.3 Rehabilitation
Apart from pharmacotherapy and psychotherapeutic measures, rehabilitation services are also of relevance to substance users. As substance use disorder progresses, the process of procuring the substance, its use and enjoyment of the effects become the predominant occupation of the patient. As substance use ceases, the patients may have a lot of free time on their hands, which they may find difficult to fill, resulting in re-association with substance using peers and descending again into the loop of substance use and consequent harms. Hence, vocational rehabilitation and engagement can help these patients to remain abstinent. The family, friends or other social supports can play a crucial role in occupational rehabilitation. Social re-integration can also act as a safety net for preventing the person going back to substance use.
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