Ambekar anciapp- kochi - epidemiology

Additional Professor, NDDTC, AIIMS, New Delhi
Member: Strategic Advisory Group, IDU and HIV, United Nations
Member: NationalTask Force on Drug Demand Reduction, MSJE, Govt. of India
Member: Technical Advisory Group on Alcohol Control, MOHFW, Govt. of India

CONTENTS
Historical context
Current situation: Patterns and Prevalence
The response: Treatment services
The response: Laws and Policies
Ideas: Germinating, in-pipeline, nascent,
future…

The use of alcohol in India has been known
since the dawn of history
Early Indo-Aryans (2000 B.C.) used alcohol
freely in the form of “Soma” and “Sura”
Brewing and drinking of various liquors was
developed into an art in ancient India

 Under the patronage of British, the popularity
of alcohol started increasing
 The basic difference regarding drinking among
Indians andWestern world was:
for Indians,
• it was largely
amusement
(Vihara or Krida),
for westerners,
• it was [and is] part
of food (Ahara) in
moderation

16
 Indians introduced the world to properties of
cannabis,
 European travelers provided detailed description of
‘bhang’ to people in Europe
– Indian laborers
going to Jamaica
(West Indies)
took Cannabis
with them and
made ‘Ganja’
popular

18
 Opium was cultivated, eaten, and
drunk by all classes as a household
remedy;
 It was used by rulers as an
indulgence, and given to soldiers
to increase their courage.

20
 Early 1980s: Along with
increased tourism and
?Asiad Games, Opium
replaced with heroin
 Rural areas: Opium users
continued with Opium,
some switched to heroin
 Urban areas: Heroin use
started spreading

21
 Early 1990s: Injecting
Drug Use started in
North East India;
gradually spread to
other parts

National Household Survey: Sample Size: 40,697 males (12-60 yrs)
Prevalence of ‘current’ use (i.e., during last month)
Alcohol: 21%
Cannabis: 3%
Opiates: 0.7%
(heroin 0.2%)
Any illicit drug: 3.6%
IDUs (‘ever’): 0.1%
22.3% are poly-drug users

National Household Survey: Sample Size: 40,697 males (12-60 yrs)
Prevalence of ‘current’ use (i.e., during last month)
Alcohol: 21% 62.5 m
Cannabis: 3% 8.7 m
Opiates: 0.7% 2.0 m
(heroin 0.2%)
Any illicit drug: 3.6%
IDUs (‘ever’): 0.1%
22.3% are poly-drug users

ALCOHOL 62.5 m 16.8% 10.5 m
CANNABIS 8.7 m 25.7% 2.3 m
OPIATES 2.0 m 22.3% 0.5 m
# of dependent users# of current users % of dependent users

New Treatment Seekers in 3 months: 16,942
 Age: <20 yrs - 5%, 21-30 yrs - 33%,
31-40 yrs - 37%, >40 yrs - 25%
 Unemployed : 20%
 Single : 23%
 Illiterate : 16%
 Rural : 52%
2. DATA HIGHLIGHTS – DAMS
203 TREATMENT CENTRES

Drugs used
Alcohol: 44% Stimulants (ATS): 2%
Opiates: 26% Others: 16%
Cannabis: 12% IDU (ever): 14%
Other Features
 Onset of use: 21-30 yrs (46%)
 Duration: used drugs for more than 5 years: 53%
 Previous treatment: 27%
2. DATA HIGHLIGHTS – DAMS
203 TREATMENT CENTRES

3. RAS
UNDCP Sites
 Amritsar
 Jamshedpur
 Shillong/ Jowai
 Dimapur
 Hyderabad
 Bangalore
 Thiruvananthapuram
 Goa
 Ahmedabad
UNESCO Sites
 Imphal
 Chennai
 Mumbai
 Delhi
 Kolkata
Total no. of sites – 14
( UNDCP – 9, UNESCO – 5 )
Note:The boundaries and names shown on this map do not imply official endorsement or acceptance by the United Nations
UNODC
UNODC

Drugs used
Heroin : 36% Alcohol: 5%
Other Opiates: 29% Sedatives: 4%
Cannabis: 22% IDU (ever): 43%
Other Features
 Using for more than 5 years: 42% (UNODC sites)
 Drug-using friends: 90%
 Sharing of needles: 0.2 - 51% (different sites)
3. DATA HIGHLIGHTS – RAS
Sample size: 4,648 (recruited from street;
not in treatment)

 No National level survey in the general
population after 2001
 Planning for a fresh national survey ongoing since
2008
 Studies on specific population groups /
specific geographical areas do exist

• Soni et al 2013
• Tsering et al 2010Children / Adolescents /
Students

Women
Children / Adolescents /
Students

Women
Students
Youth / College students

Women
Students
General Population (Rural
/ Urban / tribal)

Women
Students
/ Urban / tribal)
Elderly Population

Women
Students
/ Urban / tribal)
Elderly Population
Prison Inmates

Women
Students
/ Urban / tribal)
Elderly Population
Prison Inmates
Sex workers

Some general population studies
Author
and year
Location Population Sample
size
Focus Prevale
nce
Deswal et al
2012
Pune Household 3000 SUD 1.39%
Nattala et al
2014
Bangaluru “Mall visitors” 717 Non medical
sedative use
12%
Kim et al
2013
Vellore Urban slum 2811 Alcohol Use
Hazardous use
Dependence
46%
31%
5%
Goel at al
2010
Rural Sikkim Household 118
househ
olds
Alcohol Use
Cannabis Use
Opioid Use
55%
14%
6%

 135 sites
 4,024 substance using
children (5-18 years)
 4% girls
 70% urban
 59% out of school
 22% street children

 109 NGOs
 1865 female
substance users
 About 1/4th rural
 6% below 20 years
 64% married
 31% illiterate
 33% sex work /
peddling

18.4
19.3
20.9 20.3
21.8
22.7
0
5
10
15
20
25
Tobacco Cough Syrup Alcohol Proxyvon Cannabis Heroin
Mean Age of onset (in years)

Increased health burden
• Greater risk of illness (NCDs including alcohol dependence)
Economic costs
• Reduced productivity and increased absenteeism
• reduced money spent on food and essential commodities,
• greater debt, greater costs due to and lowered productivity,
Unmonetizable social costs
• Poorer nutrition and health and well being
• Violence.

 Younger age of initiation
 Prevalence of alcohol use (in %) among 15-19 years, male
2.4
11
0
2
4
6
8
10
12
NFHS - 2 (1999) NFHS - 3 (2006)
Male

Age of Initiation of drinking alcohol in Karnataka,
India
Source: Benegal V. India: Alcohol and Public Health, Globe Issue 2 2005. pp8, Global Alcohol Policy Alliance
Age of Initiation of drinking in Karnataka, India

Techniques for estimating size of
population
• Population survey
methods
• Network scale-up
methods
Data collected from the
general population
• Census
• Enumeration
• Capture-Recapture
• Multiplier
Data collected in an at-risk
population (IDU)
WHO/UNAIDS 2010

Census
Count all individuals
20, out of 100 are IDUs

Representative Sample
Population Survey

Sample of 20 people:
 4 out of 20 are IDUs
 Thus out of 100, 20 are IDUs
Representative Sample
Population Survey

Capture – recapture
1st wave (Capture):
Recruit purposive sample from
community

1st wave (Capture):
community
Tag positive individuals

1st wave (Capture):
community
Tag positive individuals
2nd wave (Recapture): Count the
number of ‘tagged’ individuals
Analysis of Probability of
recapture generates estimation of
size

Multiplier Method
HOSPITAL
No. of IDUs admitted
= 50
+

Multiplier Method
Sample of 20 IDUs
HOSPITAL
= 50
+

Multiplier Method
Sample of 20 IDUs
5 out of 20 = 25% IDUs report having
been admitted in the HOSPITAL
HOSPITAL
= 50
+

Multiplier Method
Sample of 20 IDUs
5 out of 20 = 25% IDUs report having
been admitted in the HOSPITAL
Estimated IDU size = 50 X (100 ÷25) =
200
HOSPITAL
= 50
+

Multiplier Method
HOSPITAL
+
Unbiased sample
of IDUs:
1st source of data
Records at
treatment centers:
2nd source of data

Size estimation of
Injecting drug use in
Punjab and Haryana
Ambekar & Tripathi, 2008
UNAIDS and SPYM, New Delhi

Nomination /Enumeration technique
Used in the study…

Treatment centre
‘IDU spots’
Vulnerability map and IDU spots

Nomination Technique: methodology

Field Researchers
(current IDUs)
2 FRs per spot

List List
Field Researchers
(current IDUs)
2 FRs per spot

Collect all the lists

Remove duplicate names

Count all the names

Estimated size
List List List List List List List List

Limitations
Caution in interpretation of the data
• We did not generate estimates of TOTAL
NUMBER of IDUs at the towns or cities
– The findings indicate the numbers of IDUs which
could be contacted in the PLI AREAS
• Assumptions:
– Sites have been mapped accurately and all the IDU
spots in the site have been mapped
– Two chosen field researchers were able to name
all the IDUs contactable at the particular spot
80

Size estimation of
Injecting Drug Users at
multiple sites in India
Ambekar & Tripathi, 2007
In Collaboration with SPYM, New Delhi
Funded by DfID (UK)

Association of
drug use pattern
with
vulnerability and
service uptake
among IDUS
Ambekar, 2012
UNODC & NACO
New Delhi

The sample
North-east
(Manipur,
Meghalaya,
Mizoram,
Nagaland)
30%
Central and
East (MP,
Orissa, West
Bengal)
30%
South
(Kerala)
10%
North and
Northwest
(Delhi,
Punjab, UP)
30%
Distribution of sample: n=1000

0
10
20
30
40
50
60
70
80
90
100
Heroin , BY
CHASING /
SMOKING route
Opium (oral) Other oral
pharmaceutical
opioids
Buprenorphine
tablets sub-lingual
– NON
PRESCRIBED
67
38
65
2
46
17
51
0.7
38
14
45
0.6
Pattern of non-injecting Opioid Use (in %)
Ever
Last 1 year
Lat 3
months

0
10
20
30
40
50
60
70
80
90
100
Heroin Buprenorphine Pentazocine Dextropropoxyphene Pharmaceutical
Sedatives
66
43
37
30
59
52
36
26
22
53
48
34
24
19
50
Pattern of Injecting Drug Use (in %)
Ever
Last 1 year
Last 3 months

Age of onset
-
5
10
15
20
25
30
15
18 19 19
21 21 22 22
23
25 25
27

Drug Proportion
reporting
Mean age
of onset
in years
1st Legal drug Tobacco 95% 15
1st illegal NON-
INJECTING drug
Cannabis 70% 19
Oral Pharma
Opioids
14% 21
1st illegal INJECTING
drug
Heroin 63% 25
Buprenorphine 18% 25
Pentazocine 11% 27
Progression of drug
use career

First Sharing – duration after onset of injecting
among those who ever shared
Daily injectors
(n=351)
Non-daily
injectors (n=416)
First Sharing occurred at the first
instance of injecting 47% 66%
First Sharing occurred almost
within a month of onset of
injecting
35% 22%
First Sharing occurred within a
Year of onset of injecting 13% 10%

The drug use career of
IDUs in India
Onset of
legal drug
use (tobacco
/ alcohol)
Onset of
illegal, NON-
injecting
drug use
Onset of
Injecting
Drug Use
First
instance of
sharing
injections
Contact with
IDU TI
15 years
25 years
19 years
25-26
years
30 years

 Five states- Manipur, Mizoram, Punjab,Tamil
Nadu andWest Bengal
 100 ATS users
 25 % female
 Median age – 25 years
 63% college level education
 62% were single

 Spent Rs. 3300 for one episode of ATS use
 Injecting ATS not reported
 Almost half, dependent on ATS

 Rising?
 In terms of prevalence ?
 In terms of newer geographical areas?
 In terms of newer demographic groups?
 In terms of newer substances?

Supply reduction
• Department of Revenue, Ministry of Finance
• Narcotics Control Bureau, Ministry of Home
• Central Bureau of Narcotics, Ministry of Finance
Demand reduction
• Prevention and Rehabilitation:
Ministry of Social Justice and
Empowerment  NGOs
• MedicalTreatment: DDAP, Ministry of
Health and Family Welfare  Govt.
Hospitals
Harm reduction (IDU)
• National AIDS Control
Organisation (NACO), MoH&FW
 NGOs and Govt. Hospitals

 Major ‘players’
 Additionally, ‘Alternate approaches’: AA, spiritual /
religious groups etc.
Availability of treatment services in India

 122 in number
 Established by the Union MOHFW (DDAP
division)
 Attached with district hospitals and medical
colleges (Department of Psychiatry)

Centres with substantial
patient load (data from
Drug Abuse Monitoring
system - DAMS)
Only some centres see large number
of patients!
Name of De-addiction centre Annual patient load
NDDTC, Ghaziabad 13,566
PGIMER, Chandigarh 5,433
NIMHANS, Bangalore 4,885
KEM Hospital, Mumbai 1,573
Assam Medical College, Dibrugarh 1,525
Govt Medical College Chandigarh 2,334
Central Jail, Tihar 1,849
IGMC, Shimla 2,030
Medical College, Patiala 2,476
Civil Hospital, Bhatinda 1,261
Medical College, Faridkot 1,108
Coimbatore Medical College,
Coimbatore
2,081

Out of 122 only a few get recurring grant
from the central government
Rest, dependent on the state governments
Drug dependence treatment is often seen as
a low priority area by the local state
governments
At some places, buildings meant for De-
addiction centers are being used for other
purposes!

Priority / Resource allocation

 ‘Minimum standards of
care’ exist
 No structured, regular
system for M & E
 DAMS for new patients
 Capacity Building:
Through institutions
located regionally

 Supported by the MSJE
 About 450 in number
 Get funding from the ministry
 Mainly residential (in-patient) treatment
 Stand alone services – not a part of general health
care
 Recent revision of guidelines / scheme
 Functioning status?
 Capacity Building – through RRTCs

 Number: unknown
 Qualifications of service providers: unknown
 ranges from MD Psychiatry to no professional
qualification (just an experience of having gone
through the treatment)
 Whether follow some standards / norms:
unknown
 Highly variable status for evaluation /
functioning

 Conservative
estimate of
number of
Alcohol /
drug
dependent
individuals
= 1 crore
(10000000)

 Conservative
estimate of
number of
Alcohol /
drug
dependent
individuals
= 1 crore
(10000000)
 Liberal estimates of Number
of beds available for drug
treatment
NGO sector 400 X 15 6000
Government sector 100 X 10 1000
Private sector --- 5000
Total 12000
Assuming minimum duration of
acute-phase treatment = 1 month
144000
10000000
144000

 Principle of regulatory
framework:
“Balance between:
curbing misuse
and
ensuring access for
medical and scientific
purpose”

 National Health Policy (2002)
 Does not mention drug abuse / dependence as a
major area of concern
 NationalAIDS Prevention and Control Policy
(2002)
 Endorses “Harm Reduction” approach to address
HIV among IDUs

 Narcotic Drugs and Psychotropic Substances
(NDPS) Act (1985)
 Drug Use a criminal act
 Provision for treatment in lieu of jail term for Drug
Users

 National Narcotic Drugs and Psychotropic
Substances (NDPS) Policy (2012)
 Does endorse a combination of supply, demand
and “Harm Reduction” approach
 Harm reduction – reluctantly endorsed
 Only for IDUs

 National Drug and Alcohol Demand Reduction
Policy (DRAFT)
 Being Developed by the MSJE
 Draft under the process of review and refinement
 Alcohol policies
 Alcohol is a state subject; significant variations in
alcohol polices
 National Policy on Alcohol Control ???
 Idea being mooted

 Debate: Is Alcohol and Drugs, primarily a …
 Health issue ?
 SocialWelfare issue ?
 Law and order issue ?
 To what extent the approach should be ..
 Centralized ?
 De-centralized ?
 Who should be mandated to provide treatment..
 Health sector ?
 “Civil Society ?”

 Alcohol and Drugs, Is primarily a Health
issue!
 Health sector must take the lead in treatment
provision
 Mental health sector need to advocate for due
attention

Three roles
psychiatrists could
play
Clinical services (for
complex / referred
cases)
Training (of general
psychiatrists /
general physicians)
Programme design /
management /
evaluation

Three roles
psychiatrists could
play
Clinical services (for
complex / referred
cases)
Training (of general
psychiatrists / general
physicians)
Programme design /
management /
evaluation

 Train one medical doctor each from 500 districts
(2011-2015)
 NDDTC is jointly implementing it with five other
medical institutions
 Each institution to conduct two trainings in a year
with fifteen participants each to cover target
NationalProject:TrainingsofDoctorson
SubstanceUseDisorders
supportedby NFCDA,MinistryofFinance

1. NDDTC, AIIMS, New
Delhi
3. Dept of Psychiatry,
KEM, Mumbai
4. De-addiction centre,
NIMHANS, Bangalore
CIP, Ranchi
RIMS ,Imphal
GMCH, Chandigarh

 Project “Hifazat” funded by the GFATM, Round 9,
India – HIV – IDU grant
 Implemented by the Emmanuel Hospital
Association in collaboration with NACO
 Aimed at capacity building of all categories of
service providers for IDU interventions
 Medical institutions as “TechnicalTraining Centers”
for training for medical interventions

2014 amendment
 ‘Essential Narcotic Drugs’ for medical use
 Subject to central rules; state licenses not
needed
 Government to recognize and approve
treatment centres to regulate illegal /
unethical practices
 Punishment for users & traffickers increased!

 28 July 2014: NationalWorkshop on
drafting NDPS rules
 Dept of Revenue, Min. of Finance
 All stakeholders welcomed the proposals:
 A uniform national set of regulations (as opposed to
state-specific rules)
 Recognition that easy access and availability of
medications as important as stringent regulations
 ENDs – indicated for both – Pain relief and treatment of
Opioid Dependence

 Idea being floated
 Initial consultations being held
 Challenging, in view of federal structure of
governance (and alcohol being a state
subject)

 ATS now making inroads in the drug market
 Growing fluidity in the alcohol market
(Mizoram now a ‘wet’ state; Kerala on the way to
becoming a ‘dry’ state)
 Consumer / beneficiary groups getting more
organized (Indian Drug Users Forum, Indian Harm
Reduction Network etc.)


Substance use: Sizable burden in India
Reliance on just supply control: not likely to be
helpful
Addiction: “Too important to be left to psychiatrists
only!”
Room at the top: for super-specialists - Addiction
Psychiatrists
ADVOCACY: our responsibility as much as SERVICE
PROVISION andTRAINING

atul.ambekar@gmail.com
www.facebook.com/atul.ambekar

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