AWARD PAPERS: DR. A. VENKOBA RAO ORATION
Year : 2019 | Volume
: 35 | Issue : 1 | Page : 13--18
Substance use disorders: Need for public health initiatives
Rakesh Kumar Chadda
Department of Psychiatry, National Drug Dependence Treatment Centre, All India Institute of Medical Sciences, New Delhi, India
Dr. Rakesh Kumar Chadda
Department of Psychiatry and National Drug Dependence Treatment Centre, All India Institute of Medical Sciences, New Delhi
Substance use disorders (SUDs) are associated with substantial contribution to the global burden of disease due to high prevalence, early age of onset, and chronic course. The associated physical health complications such as HIV, hepatitis B and C, and opportunist infections, stigma, myths and misconceptions, and a huge treatment gap further increase the problem. Thus, there is a strong need to take public health initiatives. Conventionally, common substances of abuse include licit substances such as tobacco and alcohol and illicit substances such as opioids, cannabis products, cocaine, barbiturates, amphetamines, and prescription drugs. The new psychoactive substances have brought a new challenge. Conventionally, the three approaches of supply reduction, demand reduction and harm reduction have been used to deal with the problem of SUDs. Preventive strategies encompassing primary, secondary, and tertiary methods need to be formally planned to meet this massive challenge. Creating awareness about the problem in the community and targeting myths and misconceptions are important to reduce the treatment gap. There is need to ensure availability and accessibility of affordable and acceptable treatment facilities, provide evidence-based treatment, and ensure ethical standards in care including coordination between health, social, and legal agencies. Relapse prevention and rehabilitation also need to be an important component of the public health policy. A well-planned public health approach involving all stakeholders is likely to be the most appropriate method to deal with the challenges imposed by the SUDs.
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Chadda RK. Substance use disorders: Need for public health initiatives.Indian J Soc Psychiatry 2019;35:13-18
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Chadda RK. Substance use disorders: Need for public health initiatives. Indian J Soc Psychiatry [serial online] 2019 [cited 2020 Jun 6 ];35:13-18
Available from: http://www.indjsp.org/text.asp?2019/35/1/13/254991
Substance use disorders (SUDs) are now recognized as an important health problem of great public health significance, considering an early age of onset with often a chronic deteriorating course. It is now well established that the SUDs have a multifactorial etiology, encompassing psychosocial and biological mechanisms including genetic influences. SUDs are highly disabling, being associated with considerable disability and contribution to the global burden of disease. In the recently concluded National Mental Health Survey of India, SUDs have been identified as the most common mental disorders with prevalence going to be >20%, with tobacco leading the list followed by alcohol and other substances. There is a huge treatment gap going to the extent of 90%. Myths and misconceptions associated with substance use and lack of adequate treatment facilities are important contributors to the large treatment gap and huge burden. In this background, there is need to take public health initiatives to deal with this problem.
Extent of Problem
The psychoactive substances can be broadly grouped into licit substances such as tobacco and alcohol and illicit substances including opioids, cannabis products, cocaine, amphetamine-type substances (ATSs), and a range of new psychoactive substances (NPS). Tobacco and alcohol, being easily available, are the most commonly used substances and have also got social acceptance although the use of both is associated with serious, life-threatening harmful consequences. The illicit substances (drugs), including opioids, cannabis and its derivatives, cocaine, ATS, stimulants, and NPS, though affect a small fraction of population (except cannabis), have a fast route toward dependence and run a devastating course. Benzodiazepines and other prescription drugs and inhalants are two other important groups of psychoactive substances, which are commonly abused. The World Drug Report of 2017 estimates that 5% of global population used (illicit) drugs at least once in 2015 and 0.6% of the global population suffers from use disorders. Twenty-eight million health life years is lost by premature death and disability due to drug use disorders, and less than 1 in 6 persons with drug use disorders receive treatment. India, because of its geographic location between the golden crescent and the golden triangle (the two major opium growing regions of the world), and also political conflicts with some of the neighboring countries, is especially vulnerable to the illicit drug use as well as trade. Large quantities of opioids smuggled into India are trafficked ahead. Alcohol and tobacco, the two socially acceptable substances, have also shown substantial increased use in the last few decades in India. Rise in use and abuse of alcohol is attributed to the globalization or westernization. Regarding tobacco, the state's efforts at controlling smoking have led to a rise in use of smokeless tobacco which has become popular because of ease of use, despite having equally harmful health consequences.
Complications of SUDs are wide-ranging and include serious physical health complications such as hepatitis B and C, HIV infection, and malignancies; social consequences such as stigma, discrimination, unemployment, family breakdown and homelessness; and legal issues such as indulging in illegal activities, commercial sex and trafficking to get drugs, and accidents and violent and risky behavior.
Impediments to a Solution
The society holds a conflictual attitude toward drug use, on one hand supporting cultivation of opium and tobacco, and accepting use of cannabis and alcohol in ceremonies and as recreation, and on the other hand stigmatizing the problem and frequently designating drug use as a habit rather than illness. Looking into its genesis, the problem dates back to prehistorian times with the use of alcohol and cannabis products being part of recreational use as well as in certain religious ceremonies., Raw opium was used in Punjab by the agricultural labor to increase their efficiency. Medicinal properties of opium products have been described in some ancient Indian medicinal texts. The use of hookah has been a part of socialization in rural India. Hookah bars are a new development in urban India. Hence, despite being a society believing in prohibition, the use of drugs has been deeply ingrained even in Indian society. The state also follows dual standards since alcohol and tobacco industry are an important revenue generator. The state as well as the public has also to suffer a substantial health cost because of premature mortality as well as morbidity, attributed to alcohol and tobacco. Opioids have also got medicinal properties, and hence, cultivation of opium and production of the compounds with medicinal properties cannot be stopped. India is the largest producer of licit opioids used for medicinal purposes.
In addition, the problem of drug use is often not perceived as a disorder or illness needing medical help but considered a bad habit and the user is blamed for it., Both patients as well as the family members often engage in denial and a belief, that willpower and individual's strong determination would lead to abstinence, prevents seeking medical help.
Initiation of Drug Use
Initiation of drug use is often in early life which could even be childhood or schooling years. Important reasons for initiation include peer pressure, curiosity, recreational use, or to relieve stress. The media, especially seeing an important character smoking or drinking on television or cinema screen, sometimes in a glamorizing way, seeing people dining or smoking on screen, and the surrogate advertisements, all add to the curiosity in the young mind. Easy availability of tobacco products and alcohol (though there are legal age limits for sale) further adds to the problem. Inhalants are another important group of substances used by the young population, especially the street children. Sometimes, drugs and alcohol may be used as performance enhancers at stage or in sex. Tobacco, inhalants, and cannabis are often the entry drugs before one goes for illicit substances. Switching to opioids is very risky since there is a rapid development of dependence.
Need for Public Health Initiatives
Considering the high prevalence and chronic course of SUDs with associated huge burden and costs to the society, major public health initiatives are required. Stigma, discrimination, and nonrecognition of the problem by the sufferers and their families further add to the problem. Public health approach needs to include ensuring availability and accessibility of affordable and acceptable treatment facilities, providing evidence-based treatment, and ensuring ethical standards in care including coordination between health, social, and legal agencies. Prevention remains an important component of the public health approach, which includes primary, secondary, and tertiary prevention. Primary prevention includes approaches focused on preventing the development of drug use; secondary prevention aims at early identification and effective treatment; and tertiary prevention focuses on relapse prevention, harm reduction, and rehabilitation back to the community. Targets of preventive approaches include the individual, the family, and the community. Conventionally, policies of tackling the problem of drug use have included demand reduction, supply reduction and harm reduction, many components of which work in parallel with the principles of primary, secondary, and tertiary prevention.
Approaches at primary prevention
Primary prevention needs to focus especially on gateway substances, such as tobacco, alcohol and cannabis. Since the onset of substance use can often be traced to late childhood or early adolescence, this age group needs to be targeted for primary prevention. Creating awareness about harmful effects of drugs in the community, especially in the younger population, is an important component of primary prevention. The awareness programs could be organized in educational institutions, which should start at an early age, and continue throughout childhood and adolescence., In early childhood, the focus should be on developing social and emotional competence and not on creating awareness. It is important to emphasize on development of normative behavior with a message that substance use is not a common phenomenon and not the usual behavior among the peers. The children and adolescents should be equipped with a skill “how to refuse, when offered a substance,” and refusal should be perceived as a sign of strength, rather than weakness. It is important to use a participatory approach, based on peer learning rather than a didactic or prescriptive method.,
Teachers need to be equipped with skills at early identification of the problem in the students and refer such cases to school counselor. All schools should have a qualified counselor and the school environment should be tobacco- and alcohol-free. The teachers should also set an example of not using tobacco or other substances. Children with behavioral or academic difficulties need special attention and support, and teachers need to be sensitized for their early identification and suitable referral. Parent–teacher meetings can be used to sensitize the parents about drug use and also about parenting aspects since unhealthy parenting is also a risk factor toward initiation of drugs. Parental education focuses on adequate supervision and monitoring of the children, especially of being aware of how and with whom they spend time. It is also important to develop a positive healthy relationship and family environment.
High-risk children such as school dropouts, street children, children of drug users, or those from disturbed family environment or with mental health issues and behavior problems need special attention and counseling. Such children and adolescents need to be brought to mainstream and also provided vocational guidance, training, and rehabilitation.
Community resources such as religious institutions, spiritual organizations, community clubs, health clubs, workplace settings, panchayats, and resident welfare organizations can also be involved in raising awareness about the problem. Both audiovisual and print media can be used for this purpose. A special focus is required on use of tobacco and alcohol in the youth and the women in the reproductive age group. Community approach can also include a focus on good parenting practices as a method of prevention as well as early identification of drug use. However, education and awareness though important are not sufficient for prevention. There is also need to identify risk and protective factors for drug use. Ameliorating the risk factors and enhancing protective factors for substance use go a long way in developing resilience against initiation on drug use. Strategies used should be evidence based and not based on scare. Messages about availability of treatment in healthcare settings and that treatment helps should be publicized also. This will further help in improving the understanding of the community about the medical model of substance dependence and thus reduce stigma as well.
Supply reduction is also an important primary prevention strategy, aimed at reducing availability of the drugs by seizures of the illicit drugs by the law enforcement agencies. In India, the Narcotics and Psychoactive Substances Act puts a special focus on this aspect and the Narcotics Control Bureau (NCB) of India has been involved in taking active measures in this area. Increasing costs of the licit substances such as alcohol and tobacco products and restricting the number of their outlets have been found to be associated with some successes.,
Early identification and treatment are crucial in the management of SUDs. Raising public health awareness about early signs of SUDs and need for intervention at an early stage, and also creating facilities where help can be sought, are very important. Educational institutions, workplace settings, different types of community settings, media, and healthcare institutions are the places which can be involved in this campaign. Treatment facilities need to be created in different community settings and should be easily accessible, affordable, and approachable. Educational institutions and workplaces can have the basic facilities for early identification and referral to the specific treatment settings. Workplace interventions need to include encouraging nontreatment seekers to seek treatment and providing such avenues by linkages with the healthcare institutions.
Treatment facilities for SUDs need to be set up at primary, secondary, and tertiary healthcare settings with expanding roles. The primary care settings can be used for the identification of SUDs and psychoeducation for tobacco and alcohol dependence. Doctors at the primary care need to be trained in form of refresher courses to identify patients with SUDs, especially alcohol and tobacco dependence, offer basic counseling, and refer to the secondary care settings.
The secondary care settings or the district-level hospitals can have weekly deaddiction clinics with a facility of dispensing the essential medicines, whereas the tertiary care settings need to have comprehensive treatment facilities for all SUDs. Patients requiring more intensive interventions may be referred to tertiary care settings. Most patients with SUDs can be treated on outpatient basis, and only a few require more intensive inpatient care. Psychiatrists at district hospitals should also sensitize all the medical staff in their hospitals to screen all patients for use of tobacco, alcohol, and other gateway substances prevalent in that region. At least two doctors from each district hospital should be trained for provision of services for SUDs. A similar provision of short-term sensitization training can be given to the paramedical workers including the nursing staff, focusing especially on identification and psychoeducation for SUDs.
Tertiary care settings, such as departments of psychiatry in medical colleges, already provide services for substance users. The departments need to be encouraged to develop comprehensive outpatient as well as inpatient services for SUDs and also sensitize the doctors from other disciplines, students, staff, and also the patients visiting other disciplines in the hospital about the problem of drug use. The tertiary care centers can also undertake CME programs on SUDs for the primary care physicians of their respective areas.
Focus on tertiary prevention is on relapse prevention and rehabilitation of the patients with SUDs in the community. SUDs run a chronic relapsing course like any other chronic medical illness. There are often issues related to treatment adherence, a compromise on which is a common cause for relapse. The patient and the family both feel frustrated on relapse and need to be reassured about it. Rehabilitating a patient with SUD is a long-drawn process and needs continued efforts. Approaches for harm reduction are used in cases where it is considered not possible to keep the user away from the illicit substances., The principle was initially applied for the injecting drug users (IDUs) in form of needle and syringe exchange programs. Methadone maintenance programs and opioid substitution therapy are the approaches used as harm reduction in the management of opioid dependence., Role of social welfare department as well as the voluntary organizations is important in rehabilitation, which can help the recovered patient in getting suitable employment. The treating team needs to have occupational therapists and vocational counselors, who can help in assessing the vocational skills of the patient and guide him/her in finding a job. Some patients may benefit by daycare programs, where the improving and recovered patients can be taught vocational skills. Many a times, the patient is able to find a job but does not have a place to stay. Such patients need facility of night hospitalization or halfway homes, where they can stay at night after returning from work. Thus, there is a need for creation of such aftercare facilities in the community. Long-term follow-up of patients can be continued at the community outreach clinics and district hospitals.
Initiatives Taken at State Level in India
In India, many nodal government departments including the Ministry of Health and Family Welfare (MoHFW), Ministry of Social Justice and Empowerment (MoSJE), National AIDS Control Organization (NACO), and NCB are working in the field of drug use. The MoHFW has started Drug De Addiction Program, under which drug treatment clinics (DTCs) are being started across the country, which provide outdoor treatment services for various SUDs. The services include counseling services, pharmacological interventions, and opioid substitution therapy (OST). About 20 DTCs have already been set up across different parts of the country, mainly in existing hospitals, and it is proposed to expand the services in a graded manner. Various settings for the provision of OST need to be explored across the country, especially in the high-risk areas to expand availability of this intervention. Many state governments have already also taken initiatives in starting drug use treatment services particularly in secondary and tertiary care hospitals; however, given the magnitude of problem, these are not adequate. The NACO has developed targeted intervention sites for provision of services for the IDUs in healthcare and community settings, which provide syringe and needle exchange and OST as approaches toward harm reduction. The MoSJE has taken special initiatives in rehabilitation by establishing integrated rehabilitation centers for addiction (IRCAs), in collaboration with various voluntary organizations. IRCAs have been started all across the country. Many state governments have also taken such initiatives.
The National Drug Dependence Centre (NDDTC) has developed resource materials in form of training manuals on SUDs for doctors, nurses, and para-medical staff and also conducted training programs for primary care doctors and paramedical staff for more than two decades. The modules are also available in online form. The NDDTC has also developed a website www.alcoholwebindia.in, which provides facility of self-assessment and early intervention to persons having problems with alcohol. The facility has been developed by the NDDTC with support from the WHO. There is a dire need to maintain separate records of services provided for substance users for better understanding of the pattern and profile of substance users. The NDDTC has taken an initiative in this area by establishing a drug abuse monitoring system for collecting data on new treatment seekers from across the country. A similar pattern for collecting information about drug use is also used by the MoSJE. The MoSJE and NDDTC have also been involved in conducting nationwide surveys on the SUDs across the country. A nationwide survey is about to be completed, which has covered about 180 districts across the country.
The National Tobacco Control Programme (NTCP) has set up district tobacco control cells in around 400 districts of the country. The NTCP has also started a helpline/quitline by the name National Tobacco Cessation Quit Line India 1800-22-77-87. The MoHFW has recently launched a Task Force on Nasha Mukti Abhiyan, constituted as an initiative under the National Health Policy, 2017.
Role of Voluntary Sector
Voluntary sector has an important role to play in public health initiatives for SUDs, which includes initiatives in raising awareness about the harmful effects of drug use and establishing treatment and rehabilitation facilities for persons facing the problem. A concept of community camps for patients suffering from SUDs has also been tused by many non-government organizations as well as by some psychiatrists, which helps in raising awareness, as well as identifying cases and introducing interventions for the persons interested in treatment. Many spiritual and religious organizations have also taken such initiatives. Since the voluntary sector has more reach as well as acceptability in the community, it is important for the government sector providing services for SUDs to develop linkages with the voluntary sector.
Developing a public health approach for SUDs is associated with a number of challenges, including conflicting attitudes of the society, inadequate community resources, large treatment gap, dual standards of the state, industry, and also the media, and low budget allocation for the problem. The society has deep-rooted conflicting attitudes in form of accepting ceremonial use of drugs, and also stigmatizing and discriminating it as a bad habit and not recognizing it as an illness needing help and treatment. Lack of adequate administrative support, low priority for the problem even among the health professionals including those in mental health, lack of sustained availability of medicines, especially in the far-flung areas, and lack of adequate para-medical staff remain important challenges in implementation of services.
Vulnerable populations such as street children, adolescents, women, IDUs, and prison inmates remain an important challenge, since they need dedicated services for SUDs, and such services are often lacking. There is a need to develop and implement age-appropriate and gender-sensitive interventions. Welfare services for women also need to support them in getting treatment for their relatives such as spouses.
Quality assurance indicators and accreditation processes need to be established to ensure quality of services. Accreditation processes are especially required for private drug treatment centers and rehabilitation centers across the country. Clear guidelines for the provision of services by stand-alone clinics run by psychiatrists and medical doctors need to be put in place for evidence-based services by all sectors. Mechanisms for monitoring preventive and treatment services for substance use at the state level should be available with an identified state nodal officer.
The government also has dual standards in dealing with the problem of drug use, since on the one hand, it promotes sale of substances such as tobacco and alcohol to generate revenue and also spends on creating treatment facilities for alcohol- and tobacco-related illnesses. In an estimate, direct and indirect costs attributable to alcohol dependence have been found to be more than three times the profits of alcohol taxation and several times more than the annual health budget of Karnataka. Extrapolating the findings to the whole of India, the total alcohol revenue for India for 2003–2004 was 216 billion rupees, which fell 28 billion rupees short of the total cost of managing the effects of alcohol addiction.
The industry associated with alcohol and tobacco also follows dual standards. For example, the alcohol industry promotes and nurtures a concept called “responsible drinking.” The concept, though lucrative for the global trade and excise, needs to be critically viewed from a health perspective. There is not enough evidence to promote drinking of alcoholic beverages, even at so-called responsible levels, from a public health and policy perspective., The tobacco industry which in the past had come with the concept of filtered cigarettes (which are equally harmful) has recently started promoting e-cigarettes, which are also harmful.
The media needs to be responsible and avoid surrogate advertisements. The movies have also often glamorized smoking and drinking. Recent addition of a clipping “smoking and drinking are dangerous to health” in all scenes showing smoking and drinking on movies and television in India is a welcome step in this direction. Sports events should not be allowed to be associated with brands of cigarette, alcohol and smokeless tobacco. Celebrities advertising for surrogate advertisements need to be socially responsible and avoid appearing in the surrogate advertisements.
A strong political will is essential on the part of the government to deal with the problem of drug use and also to take adequate legal measures at controlling the illegal cultivation and drug trafficking.
There is a need for aggressive implementation of public health approach for management of the problem of SUDs. Creating awareness about ill effects of drugs, early identification and intervention for SUDs, creating treatment facilities in the community, and focus on healthy living are important steps in this direction. There is need for a coordinated approach between different government departments such as health, social welfare, revenue, labor, education and law who are involved at different levels in dealing with this problem. The National Health Policy, 2017 of India has also given a special focus on the problem.
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Conflicts of interest
There are no conflicts of interest.
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