Ambekar anciapp- kochi - epidemiology

Additional Professor, NDDTC, AIIMS, New Delhi

Member: Strategic Advisory Group, IDU and HIV, United Nations

Member: National Task 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…

CONTENTS

Historical context

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 and Western world was:

for Indians,

• it was largely amusement (Vihara or Krida),

for westerners,

• it was [and is] part of food (Ahara) in moderation

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

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.

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

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

CONTENTS

Historical context

future…

(Ray, 2004)

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

Ahmedabad

UNESCO Sites Imphal

Chennai

Mumbai

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

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

Source: Murthy et al 2010

• Ahmed et al 2009 • Akoijam et al 2013 • Bagchi et al 2014 • Bal et al 2010 • Bishwalata et al 2014 • Das et al 2011 • Juyal et al 2009 • Kelkar et al 2013 • Kokiwar et al 2011 • Mathur et al 2008 • Mukhopadhyay et al 2012 • Narain et al 2013 • Ningombam et al 2011 • Praveen et al 2010 • Sharma et al 2011 • Soni et al 2013 • Tsering et al 2010

Children / Adolescents / Students

• Kermode et al 2012 • Kermode et al 2013

• Ahongshangbam et al 2013 • Basu et al 2011 • Gupta et al 2013 • Jain et al 2009 • Kalpana et al 2012 • Mathur et al 2009 • Mohanty et al 2013 • Saddichha et al 2010

Youth / College students

• Deswal et al 2012 • Goel et al 2010 • Kim et al 2013 • Mohindra et al 2011 • Nattala et al 2014 • Saddichha et al 2010

General Population (Rural / Urban / tribal)

• Tiwari et al 2013

Elderly Population

• Ayirolimeethal et al 2014

Elderly Population

Prison Inmates

• Medhi et al 2012

Elderly Population

Prison Inmates

Sex workers

Elderly Population

Prison Inmates

Sex workers

Some general population studies

Author and year

Location Population Sample size

Focus Prevalence

Deswal et al 2012

Pune Household 3000 SUD 1.39%

Nattala et al 2014

Bangaluru “Mall visitors” 717 Non medical sedative use

Kim et al 2013

Vellore Urban slum 2811 Alcohol Use Hazardous use Dependence

46% 31% 5%

Goel at al 2010

Rural Sikkim Household 118 households

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

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

NFHS - 2 (1999) NFHS - 3 (2006)

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

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

Multiplier Method

HOSPITAL

Multiplier Method

HOSPITAL

No. of IDUs admitted

Multiplier Method

Sample of 20 IDUs

HOSPITAL

Multiplier Method

Sample of 20 IDUs

5 out of 20 = 25% IDUs report having

been admitted in the HOSPITAL

HOSPITAL

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) =

HOSPITAL

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

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

N=1000 (M=900, F=100)

The sample

North-east (Manipur,

Meghalaya, Mizoram, Nagaland)

Central and East (MP,

Orissa, West Bengal)

South (Kerala)

North and Northwest

(Delhi, Punjab, UP)

Distribution of sample: n=1000

Heroin , BYCHASING /

SMOKING route

Opium (oral) Other oralpharmaceutical

opioids

Buprenorphine tablets sub-lingual

– NON PRESCRIBED

Pattern of non-injecting Opioid Use (in %)

Last 1 year

Lat 3months

Heroin Buprenorphine Pentazocine Dextropropoxyphene PharmaceuticalSedatives

Pattern of Injecting Drug Use (in %)

Last 1 year

Last 3 months

Age of onset

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

Heroin 63% 25

Buprenorphine 18% 25

Pentazocine 11% 27

Progression of drug use career

Drug Proportion

reporting

Mean age

of onset

in years

1st illegal NON-

INJECTING drug

Cannabis 70% 19

Oral Pharma

Opioids

14% 21

Heroin 63% 25

Pentazocine 11% 27

Drug Proportion

reporting

Mean age

of onset

in years

1st illegal NON-

INJECTING drug

Cannabis 70% 19

Oral Pharma

Opioids

14% 21

Heroin 63% 25

Pentazocine 11% 27

Drug Proportion

reporting

Mean age

of onset

in years

1st illegal NON-

INJECTING drug

Cannabis 70% 19

Oral Pharma

Opioids

14% 21

Heroin 63% 25

Pentazocine 11% 27

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 and West 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?

CONTENTS

Historical context

future…

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

• Medical Treatment: 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

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

10000000

versus

144000

CONTENTS

Historical context

future…

Principle of regulatory framework:

“Balance between:

curbing misuse

ensuring access for medical and scientific purpose”

Principle of regulatory framework:

“Balance between:

curbing misuse

ensuring access for medical and scientific purpose”

National Health Policy (2002)

Does not mention drug abuse / dependence as a major area of concern

National AIDS 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

CONTENTS

Historical context

future…

Debate: Is Alcohol and Drugs, primarily a … Health issue ?

Social Welfare 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

Clinical services (for complex / referred

cases)

Training (of general psychiatrists /

general physicians)

Programme design / management / evaluation

Three roles psychiatrists could

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

National Project: Trainings of Doctors on Substance Use Disorders

supported by NFCDA, Ministry of Finance

1. NDDTC, AIIMS, New

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 “Technical Training 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: National Workshop 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 and TRAINING

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

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