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 Table of Contents  
EDITORIAL
Year : 2018  |  Volume : 34  |  Issue : 3  |  Page : 189-192

Current legislation governing the care of individuals with substance use disorders in India: Rationale and implications


1 Department of Psychiatry, Drug De-addiction and Treatment Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, India
2 Department of Psychiatry, National Drug Dependence and Treatment Centre, All India Institute of Medical Sciences, New Delhi, India

Date of Web Publication27-Sep-2018

Correspondence Address:
Dr. Abhishek Ghosh
Department of Psychiatry, Drug De-addiction and Treatment Centre, Postgraduate Institute of Medical Education and Research, Chandigarh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijsp.ijsp_60_18

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How to cite this article:
Ghosh A, Sarkar S. Current legislation governing the care of individuals with substance use disorders in India: Rationale and implications. Indian J Soc Psychiatry 2018;34:189-92

How to cite this URL:
Ghosh A, Sarkar S. Current legislation governing the care of individuals with substance use disorders in India: Rationale and implications. Indian J Soc Psychiatry [serial online] 2018 [cited 2018 Dec 11];34:189-92. Available from: http://www.indjsp.org/text.asp?2018/34/3/189/242355



The Mental Health Care Act (MHCA) was published in the Gazette of India by the Ministry of Health and Family Welfare in April 2017 and the rules were notified on May 29, 2018. These rules shall come into force very soon following the publication in the Official Gazette. The Act has made several significant changes and added new dimensions to the 3-decade-old Mental Health Act. One such fresh addition is the inclusion of the “mental conditions associated with abuse of alcohol and drugs” under the new Act. The background and the implications of this change are discussed herewith.


  The Background of the Inclusion of the Substance Use Disorders Top


Recognition of substance use disorders as brain disease

Gone are the days when substance use disorders (SUDs) were seen exclusively through the moral lens of the society and thought to be a disease of character. No wonder, people who use drugs would find themselves trapped in the prisons for eternity. Incarceration was equated with treatment. Things have started to look up since 1980s with progressive investment in research and clinical practice of SUDs. Late 1990s will be remembered as the watershed when drug addiction was recognized officially as chronic disease of the brain.[1] Over the next couple of decades, an increasing amount of research has further supported the view of a brain disease model of addictions. It has produced significant preventive, treatment, and public health-related advancements in SUDs.[2] The outcome document of the United Nations (UN) General Assembly Special Session on drug abuse, which was ratified by 193 member states, collectively expressed, “drug addiction is a complex multifactorial health disorder characterized by chronic and relapsing nature.” This statement has echoed the general consensus among the scientists, policymakers, right group activists, and various other stakeholders from different walks of life. The outcome document also recommended that the stigma and discrimination toward people with SUDs must be eliminated, and substance use should come under the purview of the public health system rather than the criminal justice system. Nora Volkow, the Director of the National Institute of Drug Abuse of the United States and one of the main architects of this consensus outcome document, described it as “unprecedented and positive step toward a world where science guides nations' approach to drug misuse.”[3]

The burden of substance use disorders

The latest global status report on alcohol showed that globally, harmful use of alcohol causes approximately 3.3 million deaths every year (or 6% of all deaths), and 5% of the global burden of disease is attributable to alcohol consumption. Causal relationship has been examined between alcohol consumption and >200 health conditions.[4] Cardiovascular disease, liver disease, cancer, and accidents are the most common causes of mortality due to risky alcohol use.[4] Alcohol was reported to be the second important preventable causes of death, the first one being tobacco. According to the recently published World Drug Report (2018), there were nearly 275 million people (5.6% of global population of 15–64 years) who had used drugs at least once in 2016.[5] Among them, nearly 31 million people would need treatment for drug use disorders. The Global Burden of Disease study 2010 showed that illicit drug dependence directly accounted for 20 million disability-adjusted life years (DALYs), accounting for 0·8% of global all-cause DALYs. Opioid dependence was the largest contributor to the direct burden of DALYs. Injecting drug use as a risk factor for HIV accounted for 2·1 million DALYs and as a risk factor for hepatitis C accounted for 0.5 DALYs.[6] Drug use was responsible either directly (mainly by overdose) or indirectly (by blood-borne infections) for nearly 145,000 deaths in 2015.[5]

For India, according to the recently published National Mental Health Survey (2015–2016), the prevalence of active alcohol and drug use disorders was 4.6% and 0.6%, respectively. In terms of absolute numbers, there were around 3 million people with alcohol or drug use disorders in the country.[7]

Treatability of substance use disorders

Scores of research have unequivocally established the presence of evidence-based care for SUDs. There is resounding research support for the efficacy of treatment in the form of behavioral approaches and medication-assisted treatments for alcohol, opioids, and tobacco use disorders.[8],[9],[10] Treatment of substance abuse is cost-effective as well. At a minimum level, there is 3:1 saving. However, when the cost-savings linked with the crimes, social productivity, and health were considered, the savings rose to 13:1.[11] There has been robust research evidence that treatment of drug use disorders reduces mortality.[12] Treatment can reduce the acquisition and improve outcome of HIV and HCV as well.[13],[14]

Suboptimal treatment for substance use disorders

Despite the availability of evidence-based and cost-effective treatment, management of the SUDs has met with a lot of challenges. The problems are with the treatment availability and accessibility and the standard of care. The results of the World Mental Health Survey, consisting of data from 26 countries, showed that only 7% of the individuals with current SUDs receive minimally adequate treatment.[15] For the low- and middle-income countries, the figure was 1%. In India, the treatment gap has been estimated to be about 91% and 86% for tobacco and alcohol use disorders, respectively.[7] The global health observatory data from 147 countries have also depicted a dismal scene. Available bed for the treatment of people with SUDs was 1.7 in 100,000; 30% of the countries had provisions of buprenorphine or methadone for the treatment of opioid use disorders and 9% of the countries had existing routine screening and brief intervention services. Authors have identified three potential barriers to treatment: awareness and recognition of problem, access to treatment, and compliance to the treatment standards (for the providers) or to the treatment protocol (for patients).[15] In 2017, the UN Office of Drug and Crimes (UNODC) in collaboration with the World Health Organization (WHO) took the onerous task to publish the draft of the International Standards for the Treatment of Drug Use Disorders.[16] The aim of the document is to help the member states to develop and implement an evidence-based and ethical treatment for drug use disorders with comparable standards and opportunities provided by the healthcare establishments for any chronic disorders.

Recognition and endorsement by the international bodies

Taking cognizance of the huge burden of drug use disorders, the UNODC started to publish World Drug Report yearly, since 1997. The first Global Status Report on Alcohol and Health was published by the WHO in 1999 and four such reports have been published to date. Tobacco and alcohol have found their place in the UN high-level meeting on Noncommunicable Disease Prevention and Control in 2011. In 1998 and in 2016, United Nations General Assembly special sessions were dedicated to drug use disorders and its prevention; the next one is scheduled in 2019. This is remarkable as health-related issues are not commonly discussed in the UN's special sessions. So far, among health issues, special sessions were convened only for noncommunicable diseases, AIDS, and Ebola.

To conform with the international scenario

In 2005, the WHO published a resource book to guide governments of various member states to formulate a mental health legislation centered on human rights. It has summarized the requirements in the form of “checklist on mental health legislations.” It has recommended well-defined inclusion of SUDs in mental health legislation.[17] A study which has compared the mental health legislation across various commonwealth countries found that except in Pakistan, SUDs are included in the legislation of all the countries.[18] Although substance abuse has long been a part of the mental health legislation in the United States, recently the Affordable Care Act has embraced SUDs and has provided comparable insurance benefit.[19] This too is a remarkable and positive step, suggesting changing views and attitudes toward people who use drugs.

All these points discussed above either directly or indirectly might have influenced the decision of including SUDs in the MHCA of India.


  Implications of the Inclusion of Substance Use Disorders Top


Ensuring rights and nondiscrimination

Although the Universal Declaration of Human Rights by the UN applies to all, somehow individuals with drug use disorders have been exempted from that. Drug possession is criminalized in most of the countries. Therefore, arbitrary arrest and violation of bodily integrity are the norms rather than the exception. The so-called rehabilitation centers are at the risk of becoming drug detention centers for forced labor and imprisonment.[20] The healthcare access and service provision are grossly inadequate. Barely 10% people who inject drugs had access to the harm-reduction provisions and only 8% would receive either opioid substitution therapy or fresh needle syringe.[21] The MHCA has envisioned that the treatment services for the SUDs should comply with the human rights obligations and respect the autonomy and dignity of an individual. All individuals with SUDs should have the access to evidence-based and ethical treatment, without any discrimination. This is a huge leap forward with regard to ensuring human rights for individuals with SUDs.

However, there are a few concerns. The Narcotic Drugs and Psychotropic Substances Act and the policy still mandate punitive measures for drug possessions and prohibit certain treatments such as the needle–syringe exchange program and opioid substitution therapy for prison population. It also imposes a restriction to the duration of treatment with substitution therapy. These directives are in contradiction with the MHCA's principle of human rights and nondiscrimination.

Ensuring minimum standard of care

The MHCA mandates that minimum standard of care for mental health services should be specified by the state authority and the quality of care should be comparable with other medical care. This should take care of the suboptimal treatment provided to individuals with SUDs. In this regard, the International Standards for the Treatment of Drug Use Disorders may come handy.[16] The current draft of this document is undergoing field trials and should be available for implementation in a few years. The Government needs to take a proactive stance to first implement the minimum standard of care and then to monitor the quality of care in a seamless manner.

Provision of medical insurance and availability of essential drugs

The MHCA requires all the insurance agencies and the government to ensure the provision of medical insurance for all mental illness, including SUDs. This dictate is in line with the Parity Act or the Affordable Care Act of the US. This would possibly increase the access and availability of treatment and might also ensure the quality of care or evidence-based treatment. Medical insurance should also deter long-term detention (in the name of rehabilitation) of individuals with SUDs. Nevertheless, the willingness of the government and other agencies to implement this provision remains to be seen.

The WHO publishes a list of essential narcotic drugs, which includes methadone and buprenorphine for opioid substitution therapy. Now, as the MHCA orders the government to make all essential drugs available at all time and at all health establishments funded by the government, it is to be seen whether the government includes these narcotic drugs in the essential drug list.

Integrated care of substance use disorders

The MHCA dictates that appropriate mental health services should be made available in all government-run hospitals and even community health centers' basic and emergency services should be available. This policy is in line with the international standard of care which has envisaged an integrated care model for the treatment of drug use disorders. This integrated care will probably aid in the management of commonly encountered medical comorbidities such as HIV and hepatitis. However, in India, there is a dearth of trained taskforce to ensure evidence-based care at each level of the health care system.

Ensuring ethical treatment

The MHCA mandates that informed consent must be obtained from all individuals with SUDs for any treatment. It is based on the assumption that all individuals have the capacity to make their own decisions and exercise their free will. Although this is true to a large extent but in a proportion of people with severe SUD, the decisional capacity and the free will might be affected owing to the infliction of the motivational circuits.[22] This group of individuals would not qualify for the “patients with high support needs,” as defined by the MHCA. Therefore, these “independent patients” might be left untreated or their treatment might get delayed inadvertently. Similar problems might also be encountered because of the provision of the advance directive. The concern is because of the lack of awareness and recognition of SUDs as medical illness and availability of evidence-based treatment individuals with SUD are less likely to make rational choices in their advance directives. Nevertheless, this is a speculation and the actual effect remains to be seen.

Having said this, decisional autonomy in the treatment is of paramount importance and should never be undermined. This is all the important for SUD where coercion and punitive treatment have apparently been commonplace.[23]

The MHCA also mandates full confidentiality and privacy to all patients with mental illness with respect to his mental health, mental and physical health care and treatment. In countries like India where family plays a significant role in the treatment and care of individuals with SUD, this provision of right to confidentiality might pose some problem.[24]

In sum, the current legislation governing the treatment and care of individuals with SUDs has envisioned conforming to the international standards and obligations. In our opinion, the Act echoed the UN recommendations for ensuring available, accessible, affordable, evidence-based, and diversified care. The rights-based, scientifically informed, and ethically admissible care and provisions made in this are remarkable and laudable. However, with the existing healthcare resources, delivery of such comprehensive care seems challenging. Moreover, the government requires to reconciling the contradictions between other existing legislation related to drug use and the current legislation. The Act probably could have given some more consideration to the contextual factors unique to India, like the family support. The MHCA appears to have a promising prospect, but the implementation is also challenging. To see how it fares in the long run, we need to wait and watch.



 
  References Top

1.
Leshner AI. Addiction is a brain disease, and it matters. Science 1997;278:45-7.  Back to cited text no. 1
    
2.
Volkow ND, Koob GF, McLellan AT. Neurobiologic advances from the brain disease model of addiction. N Engl J Med 2016;374:363-71.  Back to cited text no. 2
    
3.
Volkow ND, Poznyak V, Saxena S, Gerra G; UNODC-WHO Informal International Scientific Network. Drug use disorders: Impact of a public health rather than a criminal justice approach. World Psychiatry 2017;16:213-4.  Back to cited text no. 3
    
4.
World Health Organization. Management of Substance Abuse Unit. Global Status Report on Alcohol and Health, 2014. World Health Organization; 2014.  Back to cited text no. 4
    
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United Nations Office of Drugs and Crime. World Drug Report 2018. United Nations Publications, Vienna.  Back to cited text no. 5
    
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Degenhardt L, Whiteford HA, Ferrari AJ, Baxter AJ, Charlson FJ, Hall WD, et al. Global burden of disease attributable to illicit drug use and dependence: Findings from the global burden of disease study 2010. Lancet 2013;382:1564-74.  Back to cited text no. 6
    
7.
National Mental Health Survey of India. 2015-2016 Prevalence, Patterns and Outcomes, Supported by Ministry of Health and Family Welfare, Government of India, and Implemented by National Institute of Mental Health and Neurosciences (NIMHANS). Bengaluru: In Collaboration with Partner Institutions; 2015-2016.  Back to cited text no. 7
    
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National Institute on Drug Abuse. Principles of Drug Addiction Treatment: A Research-Based Guide. 3rd ed. Bethesda: National Institute on Drug Abuse; 2012.  Back to cited text no. 8
    
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Müller CA, Geisel O, Banas R, Heinz A. Current pharmacological treatment approaches for alcohol dependence. Expert Opin Pharmacother 2014;15:471-81.  Back to cited text no. 10
    
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UNODC-WHO. Principles of Drug Dependence Treatment. Vienna: United Nations Office on Drugs and Crime; 2008.  Back to cited text no. 11
    
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Sordo L, Barrio G, Bravo MJ, Indave BI, Degenhardt L, Wiessing L, et al. Mortality risk during and after opioid substitution treatment: Systematic review and meta-analysis of cohort studies. BMJ 2017;357:j1550.  Back to cited text no. 12
    
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Mukandavire C, Low A, Mburu G, Trickey A, May MT, Davies CF, et al. Impact of opioid substitution therapy on the HIV prevention benefit of antiretroviral therapy for people who inject drugs. AIDS 2017;31:1181-90.  Back to cited text no. 13
    
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Platt L, Minozzi S, Reed J, Vickerman P, Hagan H, French C, et al. Needle syringe programmes and opioid substitution therapy for preventing hepatitis C transmission in people who inject drugs. Cochrane Database Syst Rev 2017;9:CD012021.  Back to cited text no. 14
    
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Degenhardt L, Glantz M, Evans-Lacko S, Sadikova E, Sampson N, Thornicroft G, et al. Estimating treatment coverage for people with substance use disorders: An analysis of data from the World Mental Health Surveys. World Psychiatry 2017;16:299-307.  Back to cited text no. 15
    
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UNODC-WHO. International Standards for the Treatment of Drug Use Disorders. Vienna: United Nations Office on Drugs and Crime; 2016.  Back to cited text no. 16
    
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Duffy RM, Kelly BD. Concordance of the Indian Mental Healthcare Act 2017 with the World Health Organization's checklist on mental health legislation. Int J Ment Health Syst 2017;11:48.  Back to cited text no. 17
    
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Fistein EC, Holland AJ, Clare IC, Gunn MJ. A comparison of mental health legislation from diverse commonwealth jurisdictions. Int J Law Psychiatry 2009;32:147-55.  Back to cited text no. 18
    
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22.
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23.
Angad A. Report Uncovers Torture, Abuse and Deaths in de-Addiction Centres in Delhi. New Delhi: The Indian Express; 25 June, 2018. Available from: https://www.indianexpress.com/article/india/report-uncovers-torture-abuse-and-deaths-in-delhi-de-addiction-centres-5232022/. [Last accessed 2018 Jul 22].  Back to cited text no. 23
    
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