Indian Journal of Social Psychiatry

EDITORIAL
Year
: 2019  |  Volume : 35  |  Issue : 2  |  Page : 99--101

The magnitude and vicissitudes of substance use disorders in India


Siddharth Sarkar1, Abhishek Ghosh2,  
1 Department of Psychiatry and National Drug Dependence Treatment Centre, All India Institute of Medical Sciences, New Delhi, India
2 Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh, India

Correspondence Address:
Dr. Siddharth Sarkar
Room No 4096, Teaching Block, All India Institute of Medical Sciences, Ansari Nagar, New Delhi - 110 029
India




How to cite this article:
Sarkar S, Ghosh A. The magnitude and vicissitudes of substance use disorders in India.Indian J Soc Psychiatry 2019;35:99-101


How to cite this URL:
Sarkar S, Ghosh A. The magnitude and vicissitudes of substance use disorders in India. Indian J Soc Psychiatry [serial online] 2019 [cited 2019 Oct 13 ];35:99-101
Available from: http://www.indjsp.org/text.asp?2019/35/2/99/261484


Full Text



Substance use disorders in India have occupied an important consideration in the public health policy approach in India. Dealing effectively with the problem of substance use disorders requires understanding of the extent and the pattern of these disorders. Moreover, to that effect, two large-scale epidemiological studies have provided answers to the question of how common are substance use (and disorders) in India. The first one, the National Mental Health Survey conducted in 2015–2016 covered 12 states and found that tobacco use disorder was present in about 20.9% of the population, alcohol use disorder in about 4.7% of the population, and other substance use disorder in 0.6% of the population.[1] A more recent survey the National Survey on Extent and Pattern of Substance Use in India covered all states and union territories of India and presented data on individual substances.[2] The survey found that after alcohol, cannabis and opioids were the most commonly used substances and variations existed in the prevalence of substance use and disorders across the states. The survey showed that among opioids, heroin and pharmaceutical opioids were more commonly used as compared to the natural forms (raw opium and poppy husk), and inhalants emerged as an important substance of use in the younger population. The use of illicit opioids has been found to be disproportionately higher in India (2%), compared to the worldwide estimate (0.7%).[3] In addition to the magnitude of the substance use, both the national-level surveys suggested a glaring treatment gap for substance use disorders. The National Mental Health Survey reported 86% and 73% treatment gaps for alcohol and drug use disorders, respectively.[1] The recent survey reported a more worrisome state of affairs.[2] In addition to the poor treatment seeking, the former survey has also observed lowest treatment retention (“in treatment”) for alcohol use disorders, when compared to other psychiatric disorders.[1]

The findings above suggest that substance use disorders would have an adverse effect on the health, economy, and society in India. As the magnitude of substance use disorders in India increases, the consequent health effects are likely to increase. Alcohol contributes to a significant proportion of admission to medical facilities but are often under-recognized by primary care physicians.[4] Alcohol use is contributory to accidents, self-harm, liver and gastroduodenal diseases, and high-risk behaviors. All these increase the morbidity and mortality in the population. Similarly, cannabis use is associated with mental health conditions, including psychosis, while opioids can lead to overdose-related deaths and hospitalizations.[5],[6] Not only health-care problems but also substance use disorders are associated with social and economic problems, such as loss of productivity, familial strife, criminal activities, and additional policing costs. Thus, substance use disorders are associated with considerable health-care and social-economic costs.[7]

Despite considerable problem of substance use disorders in the country, there also exists a substantial treatment gap. Many patients with substance use disorders do not enter treatment processes, either due to unavailability or inaccessibility of the treatment services or due to absence of a felt need of treatment. The last few decades has seen the scaling of services and enhanced training of health-care providers for the treatment of substance use disorders. There has been focus on setting up deaddiction wards and rehabilitation centers, empowering doctors through training to provide specialized services, integrating treatment approaches in curricula of health professionals, and expansion of services in the outpatient clinics. Despite this, the services do not reach many of those who need it because of the issues of cost, availability of facilities, trained workforce, or stigma experienced by the substance users.[8],[9] The substance user may encounter exclusion or therapeutic nihilism from the service providers, who may inaccurately construe that substance users are not likely to change their consumption. Substance use disorders, such as many psychiatric illnesses, are often concealed by the patients and their caregivers until it assumes magnanimous proportions. In addition, many patients may minimize the problem (consciously or unconsciously) or think that they do not require assistance and have adequate self-efficacy to deal with problematic substance use. Help offered during the initial stages might prevent the problem from become acute and sizeable.

Tackling substance use disorders in the country would require several-pronged approaches to be effective. The three commonly encompassed domains to tackle substance use include supply reduction, demand reduction, and harm reduction. Health-care providers generally are involved in demand reduction and harm reduction approaches. The demand reduction approaches pertinent to health-care providers include providing treatment and education so that the substance user ceases the substance-taking behavior and does so for prolonged periods. It also entails preventive measures that identify substance users and encourage them to limit use and prevent them from progressing to disordered use. The harm reduction approaches aim at reducing the consequent harms of substance use without necessarily giving up the substance (for example, needle syringe exchange program or opioid substitution treatment). To cater to substance users, expansion of both outpatient and inpatient facilities is required. Since addiction is conceptualized as relapsing and remitting disorder, it is likely that many of those who quit substances resume to substance-taking behavior after a certain period. Continued engagement on the outpatient basis through drug treatment clinics or other outpatient services might help to identify relapses and offer treatment quickly. Furthermore, many patients are able to quit substances of use on the outpatient basis and do not require inpatient services to cease substance-taking behavior.

Apart from expansion of services, training of workforce is required to effectively deal with substance use disorders. Any clinical encounter provides an opportunity to intervene and encourage patient to quit substances of abuse. Thus, training of all health professionals in screening for substance use disorders (i.e., doctors, nurses, medical social workers, and health workers) and subsequent intervention or referral is likely to be of much benefit in tackling the issue of substance use disorders. Attention to teaching and learning methods would be useful to impart better training to the care providers.[10] Some standards of care should be developed and implemented so that the patients receive adequate care. One has to be cognizant of the fact that service characteristics vary across India and hence some flexibility would be required in the set of standards and the veracity of implementation. A common issue that affects the treatment of patients with substance use disorders is continuity of care. As patients' transition from a substance-taking lifestyle to nonsubstance-taking one, there could be challenges that deter them or provide impediment to keeping them off substances. Therein, family supports can be especially useful in helping patients remain sober and abstinent.[11],[12]

Apart from clinical matters, policy directions also influence the manner in which substance use disorders are catered to in the community and the clinic. While information education and communication (IEC) activities are commonly of significant use for other disorders, their role in addictive disorders requires cautious application, to avoid unwarranted experimentation by the youngsters. Rather message about treatment services and making such services available would be better focused upon. The demand reduction and supply reduction measures should go hand in hand. Adequate allocation of resources for providing care at the primary, secondary, and tertiary care levels would help to deal with the problem of addiction effectively. Financing of treatment and care through insurance mechanisms or subsidy can help in reducing overall costs to the health-care services and society.[13] Furthermore, research pursuits about developing models of care, improving implementation processes, understanding addiction from bio-psycho-social aspects from an Indian ethnic-cultural-service perspective, and testing intervention efficacies should be encouraged. A report published last year by the International Narcotics Board expressed serious concerns about India, citing the evidence of huge quantities of seizures of New Psychoactive Substances (NPS), namely mephedrone and ketamine. Therefore, the NPS, which are difficult to be reliably estimated through national surveys should receive its due focus.[14]

Substance use disorder has been there in India for centuries and likely to be there for times to come. The types of substances may change and their impact on the society may vary in context and in qualitative terms. Addressing the issue in a holistic manner would improve the lives of not only the patients but also their family members and caregivers. A mindset change in the community (including the community of health-care providers) about substance use disorders from a pessimistic and moralistic to a more informed, realistic, and scientific vantage point is required to better address the magnitude of substance use disorders in India.

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