The drug problem in Punjab is serious. In terms of proportion of people affected by drug addiction (or ‘substance use disorders’ which is the more correct term), Punjab figures among top states in the country for almost all the categories of drugs.
Among various drug categories, the most serious problem for Punjab (and indeed for India) is the category of opioid drugs. Opioids are substances which have action similar to that of opium on the body, even though not all opioids are derived from opium (some are synthetically prepared as well). Among opioids, it is the heroin which is most addictive. Addiction to opium is associated with high risk of devastation and death.
India is a legally opium cultivating country with an established (socio-culturally accepted) practice of use of opium and other low potency opioid products. However, it is heroin that is used by a far higher number of people, as noted in the report, Magnitude of substance use in India (Ministry of Social Justice and Empowerment and All India Institute of Medical Sciences, 2019).
The data shows that the highest rates of opioid addiction in India are in states that are located along the known international heroin trafficking routes (those in the northeast and in the northwest). Thus, it seems that excessive control on legal opium cultivation, and on availability of low-potency opium products like doda or bhukki (poppy husk), has been followed by a higher demand for internationally trafficked heroin in India.
Dealing with the problems of drug addiction requires a judicious combination of three types of strategies—drug supply reduction, drug demand reduction and harm reduction. Unfortunately, almost everywhere in the world the knee-jerk (and populist) response to drug problems is that of supply control. Using brute force, the authorities (erroneously) believe that it will be possible to clamp down on drug availability.
Over-reliance on drug law enforcement is just not ineffective; it may in fact be counterproductive. As long as there is demand for drugs, the supply would continue (and a relatively less harmful drug will often be replaced by a more harmful drug).
Many countries have realised this and have taken demand reduction and harm reduction approaches along with supply reduction.
Demand reduction constitutes two broad sets of measures—those aimed at prevention of drug use and those aimed at treatment of drug use disorders. Harm reduction essentially means that reducing harms of drug use (such as death or spread of serious infections like HIV) is much more important than insistence on complete cessation of drugs use. Thus, supplying clean needles and syringes to people who use drugs or educating them on how to minimise the risk is an effective harm reduction approach employed in many parts of the world, including India.
In 2015, the report of Punjab Opioid Dependence Survey was released. In that report—looking at the high prevalence of opioid dependence in the state—we recommended a judicious combination of supply reduction, demand reduction and harm reduction. More specifically, as the treatment strategy for opioid dependence, we recommended not relying only on the conventional approach of inpatient or residential treatment in the de-addiction or rehabilitation centres (which was then, the predominant approach in Punjab).
Since opioid dependence is a chronic, relapsing non-communicable disease (just like hypertension or diabetes or depression), it requires a long-term medical and psychosocial treatment at the outpatient level (not just a few weeks stay in a restrictive setting).
Fortunately, over the years, we have seen the recommendation being followed in Punjab. The Outpatient Opioid Assisted treatment (OOAT) programme is the largest programme of its kind for any state of the country, delivering treatment to lakhs of patients. Indeed, many other states which are facing the opioid dependence epidemic need to develop and implement similar, state-specific treatment programmes which are based on scientific evidence of effectiveness.
The National Drug Dependence Treatment Centre at AIIMS has been proud to provide its assistance to Punjab over many years now in the form of research, guidance, mentoring and hand-holding to enhance the capacity of health systems and the treatment professionals in the state to respond effectively to the challenge posed by drug addiction.
Dr Ambekar is professor at the National Drug Dependence Treatment Centre and department of psychiatry at AIIMS, Delhi.
