This document is an extract of an 88-page report by the National Drug Dependence Treatment Centre (NDDTC), All India Institute of Medical Sciences (AIIMS), New Delhi, released in 2019. The report unveiled significant findings on the prevalence and extent of substance use in India. The report presents in it, the survey which was conducted in terms of the proportion of the Indian population using various substances and those affected by substance use disorders.
The NDDTC, AIIMS, New Delhi, was entrusted with the responsibility to lead the technical and scientific aspects of this National Survey which was conducted in all the 36 states of the country and Union Territories (UTs), in collaboration with ten other medical institutes and a network of 15 NGOs. This is the first occasion in the history of the country when effort has been made to study and document substance use. More than 1500 personnel were involved in a data collection exercise which was conducted between December 2017 and October 2018.
The primary objective of the survey was to assess the extent and pattern of substance use and to achieve this objective; a combination of two data collection approaches was employed. Firstly, the Household Sample Survey (HHS) was conducted among a representative sample of the 10-75 year old population. During HHS, 200,111 households were visited in 186 districts of the country and a total of 473,569 individuals were interviewed. In addition, a Respondent Driven Sampling (RDS) survey was conducted covering 135 districts and 72,642 people suffering from dependence on illicit drugs. The data from HHS and RDS were analysed and collated to generate estimates for eight categories of psychoactive substances: Alcohol, Cannabis, Opioids Cocaine, Amphetamine Type Stimulants (ATS), Sedatives, Inhalants and Hallucinogens.
The key findings reveal that for use of psychoactive substances, a substantial number of people use psychoactive substances, and such substance use exists in all the population groups. However, adult men bear the brunt of substance use disorders. The survey also indicates that there are wide variations in the extent and prevalence of use across different States and between various substances. Alcohol is the most common psychoactive substance used by Indians (among the substances included in this survey).
Nationally, about 14.6 per cent of the population (between 10 and 75 year of age) uses alcohol. In terms of absolute numbers, there are about 16 crore persons who consume alcohol in the country. Use of alcohol is considerably higher among men (27.3 per cent) as compared to women (1.6 per cent). For every one woman who consumes alcohol, there are 17 alcohol using men. Among alcohol users, country liquor or local liquor (about 30 per cent) and spirits or Indian Made Foreign Liquor (about 30 per cent) are the predominantly consumed beverages. States with the highest prevalence of alcohol use are Chhattisgarh, Tripura, Punjab, Arunachal Pradesh and Goa.
After Alcohol, Cannabis and Opioids are the next commonly used substances in India. About 2.8 per cent of the population (3.1 crore individuals) reported having used any cannabis product within the previous year. The use of cannabis was further differentiated between the legal form of cannabis (bhang) and other illegal cannabis products (ganja and charas). Use of these cannabis products was observed to be about 2 per cent (approximately 2.2 crore persons) for bhang and about 1.2 per cent (approximately 1.3 crore persons) for illegal cannabis products. States with the highest prevalence of cannabis use are Uttar Pradesh, Punjab, Sikkim, Chhattisgarh and Delhi.
Besides Alcohol, Cannabis and Opioids, about 2.1 per cent of the country’s population (2.26 crore individuals) use opioids which include opium (or its variants like poppy husk known as doda/phukki), heroin (or its impure form – smack or brown sugar) and a variety of pharmaceutical opioids. Nationally, the most common opioid used is heroin (1.14 per cent) followed by pharmaceutical opioids (0.96 per cent) and opium (0.52 per cent). Sikkim, Arunachal Pradesh, Nagaland, Manipur and Mizoram have the highest prevalence of opioid use in the general population (more than 10 per cent).
The survey indicates that a sizeable number of individuals use sedatives and inhalants. About 1.08 per cent of 10-75 year old Indians (approximately 1.18 crore people) are current users of sedatives (nonmedical, non-prescription use). States with the highest prevalence of current sedative use are Sikkim, Nagaland, Manipur and Mizoram. However, Uttar Pradesh, Maharashtra, Punjab, Andhra Pradesh and Gujarat are the top five states which house the largest populations of people using sedatives.
Interestingly, when it came to our State Meghalaya, it appeared only in the list of states with the use of Cannabis, as the trend is visible in some of the eastern and north-eastern states like West Bengal, Bihar, Sikkim, Mizoram and Nagaland. Here, the illegal cannabis products (ganja/charas) are used by a larger proportion of people as compared to bhang.
The remarks in ‘The Way Forward’ are eye-catching. The report makes it evident that a sizeable population in India is affected by substance use disorders and is in need of urgent help. However, the reach of the national programmes for the treatment of substance use disorders is grossly inadequate. Considering the wide treatment gap (mismatch between demand and availability of treatment services) in the country,
India needs massive investments in enhancing the avenues for treatment. Optimum allocation of resources for the treatment of substance use disorders is imperative, based upon the evidence generated through this survey. Planning for a national level treatment programme must be guided by the absolute magnitude of the problem for prioritisation among the states. Addiction treatment programmes focused heavily upon inpatient treatment/hospitalisation (in a de-addiction centre) is unlikely to cater to the huge demand for treatment.
Enhancing treatment services as outpatient clinics, which have all the necessary components (trained human resources, infrastructure, medicines and supplies, a system of monitoring and mentoring) is urgently required. Scaling up of treatment services for substance use disorders would also require large-scale capacity-building mechanisms. Overall, a coordinated, multi-stakeholder response will be necessary to scale-up treatment programmes in the country.
The report has also stressed on the need to protect the youth of the nation, in particular in the prevention of drug use. Evidence for the effectiveness of awareness generation as the predominant preventive strategy is very weak. Research has demonstrated that best prevention strategies are those which are based on scientific evidence and which involve working with families, schools and communities in general. Prevention programmes must address the risk and protective factors aimed at not just preventing substance use, but also ensuring that young people grow and stay healthy into adulthood, enabling them to realise their potential and become productive members of their community and society.
The findings further indicate that despite the existence of strict drug control laws and a multitude of agencies working towards drug supply control, a wide variety of controlled drugs are being used and a sizeable number of Indians suffer from addiction to these drugs. Results also indicate a shift in demand for psychoactive substances from traditional, low-potency, plant-based products (e.g. opium) to more potent and processed products (e.g. heroin).
Thus, there may be elements of drug supply control which influence the pattern of demand. The non-medical, recreational use of controlled pharmaceutical products remains a concern. However, ensuring their adequate availability for medicinal purposes is vital for public health. It is important that laws and policies are aimed at providing health and welfare services to people affected by substance use (rather than subjecting them to the criminal justice system).
Overall, data from this survey indicate that there is a need for fresh thinking and innovative solutions as far as legal and policy measures aimed at drug supply control are concerned. More importantly, there needs to be efficient coordination between the drug supply control sector as well as the entities involved in drug demand reduction and harm reduction. The survey represents a comprehensive scientific approach to explore and document the dynamics of substance use in the country and utilise the evidence for informing policies and programmes. Such an approach needs to continue.
Subsequent surveys and studies need to be conducted with an incrementally enhanced refinement of methodologies. Every piece of the data would serve to incrementally inform evidence-based policies and programmes to protect and promote the health and welfare of Indian society. (Source: Ministry of Social Justice and Empowerment, in collaboration with the National Drug Dependence Treatment Centre (NDDTC), AIIMS, New Delhi, Report of the National Survey on Extent and Pattern of Substance Use in India, 2019) (The writer can be reached at [email protected])