Deaddiction programme in india

Problem statement
Factors influencing drug addiction
Deaddiction programme and scheme
Control measures

1. Deaddiction programmes in India Dr. Raghavendra Huchchannavar Junior Resident, Deptt . o f Community Medicine, PGIMS, Rohtak.

2. Contents Introduction Definitions Problem statement Factors influencing drug addiction Deaddiction programme and scheme Control measures Other related programme: NTCP

3. Introduction The Hindu mythology says that during Amrit Manthan one of the “14 Jewels” that the ocean delivered was Varuni - the Goddess of wine. 5000 B.C .: The Sumerian people used the “joy plant”, which is believed to be opium. Amrit Manthan Sumerian Civilization

4. Introduction Smoking of Cannabis is known in India since 2000 B.C . The Code of Hammurabi ( 1792-1750 BC ) the oldest known form of legal code, had guidelines and regulatory provisions for preventing alcohol abuse . King Hammurabi ( 1792-1750 BC) Code of Hammurabi

5. Introduction By the middle of sixteenth century, drugs like cocaine, tobacco and hallucinogens were introduced from America to Europe, in exchange of wine, cannabis and narcotics . By the late 19 th century cocaine kits were readily available in western world. Harrison Act ( 1914): made the possession of narcotics without a prescription a criminal offense. Cocaine Kits

6. Definitions Drug Use: is simply the ingestion of substance/substances without experiencing any negative consequences. It may be social use, like in parties; recreational or experimental use, dietary practice or may be religious ritual. Drug abuse: the use of any substance for purposes other than medical and scientific , including use without prescription, in excessive dose levels, or over an unjustified period of time .

7. Definitions Addiction : is defined as the repeated use of substance/drugs to the extent that the user is periodically or chronically intoxicated, shows a compulsion to take the preferred substance (or substances), has great difficulty in voluntarily ceasing or modifying substance use, and exhibits determination to obtain psychoactive substances by almost any means . Dependence : is defined as “a cluster of cognitive, behavioural and physiological symptoms indicating that the individual continues use of the substance despite significant substance-related problems ”.

8. Definitions

9. Problem statement According to World Drug Report 2012 about 230 million people, or 5 per cent of the world’s adult population , are estimated to have used an illicit drug at least once in 2010. 10-13 per cent of drug users continue to be problem users . The prevalence of HIV (20 per cent), hepatitis C (46.7 per cent) and hepatitis B (14.6 per cent) among injecting drug users continues to add to the global burden of disease.

10. Problem statement Annual prevalence of the use of alcohol is 42 per cent (the use of alcohol being legal in most countries), which is eight times higher than annual prevalence of illicit drug use (5.0 per cent). Approximately 1 in every 100 deaths among adults is attributed to illicit drug use.

11. A

12. Problem statement India is located close to the major illicit   opium growing areas of the world , with- “ Golden Crescent ” on the Northwest and “ Golden Triangle ” on the North–East . Licit substances (alcohol and tobacco) are the most commonly used substances. Among illicit substances, cannabis and opiates are most frequently used.

13. “Golden Crescent” and “Golden Triangle”

14. Drugs of Abuse The major categories include: Alcohol Nicotine and tobacco Depressants ( barbiturates, benzodiazepines) Stimulants ( amphetamines, cocaine) Marijuana Opioids ( morphine, heroin, methadone) Psychedelics ( LSD, mescaline, ecstasy )

15. Factors influencing substance abuse and dependance

16. Symptoms of addiction Loss of interest in daily routine. Loss of appetite and weight. Unsteady gait or clumsy movement . Reddening of eyes, unclear vision. Numerous injection sites, blood stains on the clothes. Nausea or vomiting and body pain. Drowsiness or sleeplessness, lethargy and passivity. Acute anxiety, depression and profuse sweating. Mood swings and tamper tantrums. Emotional detachment and depersonalization. Impaired memory.

17. DRUG DE-ADDICTION PROGRAMME IN INDIA In India, the abuse of alcohol , tobacco and cannabis is not entirely new. With the introduction of newer drugs and   medical remedies, which often contained cocaine or heroin derivatives, were freely distributed without prescription. Article 47 of the Constitution of India directs the State to regard the raising of the level of nutrition and the standard of living of its people and the improvement of public health as among its primary duties, and, in particular, to endeavour to bring about prohibition of consumption, except for medicinal purposes, of intoxicating drinks and drugs which are injurious to health .

18. DRUG DE-ADDICTION PROGRAMME IN INDIA The same principle of preventing use of drugs except for medicinal use was also adopted in the three international conventions on drug related matters , viz., Single Convention on Narcotic Drugs, 1961 Convention on Psychotropic Substances, 1971 and The UN Convention Against Illicit Traffic in Narcotic Drugs and Psychotropic Substances, 1988. India has signed and ratified these three conventions.

19. DRUG DE-ADDICTION PROGRAMME IN INDIA Following the Convention on Psychotropic Substances (1971) The Government of India, Ministry of Health and Family Welfare in 1976 appointed a expert committee to examine the problem of Drug De-Addiction and suggest future guidelines. The report of committee was submitted in 1977. The Planning Commission and the Central Council of Health Ministers reviewed this report in 1979 . The recommendations of the report emphasized the need to evolve appropriate strategies and to bring about better coordination among different Ministries and Departments working in this area.

20. DRUG DE-ADDICTION PROGRAMME IN INDIA The Drug De-addiction Programme of the Ministry of Health & Family Welfare was started in 1985-86 Modified as scheme in 1994 and once again revised in 1999 The scope of the scheme was enlarged to include assistance to State Governments/Union Territories for developing De-addiction Centres in identified medical colleges/district-level hospitals.

21. DRUG DE-ADDICTION PROGRAMME IN INDIA The activities to reduce the drug use related problems in the country could broadly be divided into two arms Supply reduction and Demand reduction . The supply reduction activities which aim at reducing the availability of illicit drugs within the country come under the Ministry of Home Affairs, with Department of Revenue as the nodal agency. The demand reduction activities focus upon awareness building, treatment and rehabilitation of drug using patients. These activities are run by agencies under the Ministry of Health and Family Welfare, and the Ministry of Social Justice and Empowerment .

22. DRUG DE-ADDICTION PROGRAMME IN INDIA The Ministry of Health & Family Welfare is mainly involved in providing treatment services to the addicts whereas the Ministry of Social Justice & Empowerment deals with other aspects of the problem like awareness creation, counselling and rehabilitation . Union Health Ministry’s contribution has been largely limited to providing one-time grants for construction / refurbishment of the buildings. Only a few centres (about 43, those in the north-eastern states of the country) receive recurrent grants from the union health ministry .

23. SCHEME FOR PREVENTION OF ALCOHOLISM AND SUBSTANCE (DRUGS ) ABUSE Implemented by the Ministry of Social Justice and Empowerment , The non-governmental organisations have been entrusted with the responsibility for delivery of services and the Ministry bears substantial financial responsibility (90% of the prescribed grant amount ). In case of the seven North Eastern States, Sikkim and J & K, the quantum of assistance will be 95% of the total expenditure . The balance of the approved expenditure shall have to be borne by the implementing agency out of its own resources.

24. SCHEME FOR PREVENTION OF ALCOHOLISM AND SUBSTANCE (DRUGS) ABUSE The aims and objectives of the scheme are To create awareness about the ill-effects of alcoholism and substance abuse to the individual , the family and the society at large. To develop culture-specific models for the prevention of addiction and treatment and rehabilitation of addicts. To evolve and provide a whole range of community based services for the identification , motivation, detoxification, counselling, after care and rehabilitation of addicts . To promote community participation and public cooperation in the reduction of demand for dependence-producing substances.

25. To promote collective initiatives and self-help endeavours among individuals and groups vulnerable to addiction. To establish appropriate linkages between voluntary agencies , working in the field of addiction and government organisations. To support activities of non-governmental organisations , working in the areas of prevention of addiction and rehabilitation of addicts. SCHEME FOR PREVENTION OF ALCOHOLISM AND SUBSTANCE (DRUGS) ABUSE

26. The following legal entities are eligible for assistance under the Scheme: A society registered under the Societies’ Registration Act, 1860 (XXI of 1860) or any relevant Act of the State Governments / Union Territory or under any State law relating to registration of charitable societies. A registered public Trust . A Company established under Section 25 of the Companies Act, 1956. An organisation / institution fully funded or managed by Government or a local body . An organisation or institution, which has been approved by the Ministry of Social Justice and Empowerment . SCHEME FOR PREVENTION OF ALCOHOLISM AND SUBSTANCE (DRUGS) ABUSE

27. The eligible organisations as defined above should also: Have a properly constituted managing body with its powers, duties and responsibilities clearly defined and laid down in writing. Have resources, facilities and experience for undertaking the programme. Not be run for the financial profit of any individual or a body of individuals. Have existed at least for a period of three years . Be of a sound financial position . SCHEME FOR PREVENTION OF ALCOHOLISM AND SUBSTANCE (DRUGS) ABUSE

28. The Scheme is providing financial support for the following components Drug Awareness and Counselling Centres Treatment-cum-Rehabilitation Centres Workplace Prevention Programmes Deaddiction Camps Innovative Interventions to Strengthen Community Based Rehabilitation Technical Exchange & Manpower Development Surveys, Studies, Evaluation and Research Awareness and Preventive Education Any other activity considered suitable to meet the objectives of the Scheme.

29. The minimum standards has been laid for each of these: Drug awareness and counselling centres Treatment–cum-rehabilitation centres De-addiction camps Workplace prevention programme Code of ethics for staff and rights of clients SCHEME FOR PREVENTION OF ALCOHOLISM AND SUBSTANCE (DRUGS) ABUSE

30. Drug Awareness and Counselling Centres Drug Awareness and Counselling Centres : will function as out-patient units and offer the following services. Awareness building in the community Screening and motivating clients to take help Referral services Follow-up services These centres are staffed by counsellors / social workers / psychologists / sociologists /recovering addicts with two years of sobriety.

31. Drug Awareness and Counselling Centres One awareness programme per week One article on addiction or the treatment services available to appear in daily newspaper, magazine or mass media (television, radio) once in six months . Awareness programme register to be maintained by the project-in-charge – Details of programmes conducted with feedback from 5 people for each programme. Copy of the article published / details of the programme telecast / broadcast.

32. Treatment-cum-Rehabilitation Centres Treatment-cum-Rehabilitation Centres : will have 15 or 30 bedded facility. Will admit the patient for a period of around 1 month, can be extended maximum upto 2 months. The after care / follow-up services are to be provided on an ongoing basis in an out-patient set up. Additional grant is provided to conduct treatment camps.

33. Treatment-cum-Rehabilitation Centre, Rohtak

34. Treatment-cum-Rehabilitation Centre, Rohtak Staff position : required and that available in Rohtak centre Medical Officer / Psychiatrist (One part- time post ): 1 Nurses (Two posts): 3 Ward boys (One post ): 2 Counselling staff (Three posts ): 2 Yoga/ other therapists (One post): Nil Accountant-cum-clerk (one post ): 1 Sweeper / Peon (Two posts ): 1

35. Awareness activity: Painting competition

36. Treatment-cum-Rehabilitation Centre, Rohtak Report for the month of May 2013: OPD cases: 42 Indoor patients: 20 Most common drug abuse: Alcohol – OPD 16 patient, Indoor 8 patients Most common age group: 31-50 yrs (21 OPD, 11 inpatients) Duration of stay: 15 days for alcohol addicts 21 days for other drug users Follow up: for 6 months Success rate: 70-75 % in alcoholics, 30-35% in other drug users

37. Indian Red Cross Society, Distt . Branch Bhiwani. Haryana State Council For Child Welfare, Bal Vikas Bhawan , 650 Sector 16-D, Chandigarh . Indian Red Cross Society, Red Cross Bhawan , Sector-12, Faridabad . Indian Red Cross Society, Distt . Red Cross Society, Fatehabad Indian Red Cross Society, Dist. Branch Hissar Amar Jyoti Foundation, Jind, Assistant Treasury Office, Ist Floor, Jhulana , Jind Indian Red Cross Society, Red Cross Bhawan , Jind Indian Red Cross Society, Distt.Branch Karnal Indian Red Cross Society, Dist. Branch Red Cross Bhawan , G.T.Road , Panipat Adarsh Saraswati Shiksha Samiti , Sant Garib Dass , Gali No.2 Kakroi Road, Sonepat . Modern Education Society, Mandouri Road, Village Mandoura , Distt . Sonepat Indian Red Cross Society Yamuna Nagar, Distt . Branch, Sector-18 , Housing Board, Yamuna Nagar Other centres in Haryana

38. De-addiction camps Involving the community in identification, intervention and providing support during recovery. Identification of addicts to be done through multiple contacts – formal / informal leaders, local physicians , community workers, teachers etc. Treatment to include detoxification and psychological therapy for the patients for a period of 15 days and counselling for family members. On completion of camp, to provide follow-up care for a minimum period of one year.

39. Workplace Prevention Programme Workplace Prevention Programme: has listed two types of interventions: A 15 or 30 bedded treatment cum rehabilitation centre to be established by the industry/enterprise . Financial assistance upto 25% of the expenditure for setting up such a centre shall be provided. Only an industry with a minimum strength of 500 workers will be eligible. A treatment cum rehabilitation centre (15 / 30 bedded) run by an NGO taking up work place prevention programmes as part of its activities.

40. Code of ethics Code of ethics for staff and rights of clients : Services are available irrespective of Religion, caste , political belief of all clients. Particular drug(s) abused or routes of administration History of prior treatment Patient's ability to pay or employment status. Exclusion criteria for admission to be clearly stated e.g. medical complications / psychiatric problems . Expulsion criteria to be clearly defined – e.g. being violent and abusing drugs / alcohol on the premises .

41. Mutual-help group Mutual-help group: A group in which participants support each other in recovering or maintaining recovery from alcohol or other drug dependence or problems, or from the effects of another’s dependence, without professional therapy or guidance. Prominent groups in the alcohol and other drug field include Alcoholics Anonymous, Narcotics Anonymous, and Al-Anon (for members of alcoholics’ families) ‘Self-help group’ is a more commonly used term, but ‘mutual-help group’ more exactly expresses the emphasis on mutual aid and support.

42. Treatment Models TTK Model, Chennai : TTK Hospital (T.T. Ranganathan Clinical Research Foundation) offers a comprehensive in-patient treatment programme. Also involves the family of the addict . The treatment programme includes detoxification, intensive psychological therapy, and follow-up. Detoxification is for a period of 7 to 10 days . After detoxification , the patient undergoes an intensive 3-5 week , in-patient therapeutic programme at the hospital, which includes individual counselling, lectures , group and family therapy, relaxation techniques and recreation .

43. Treatment Models NIMHANS, Bangalore : 2 models Medical Model : The medical model essentially involves admitting patients to the de-addiction centre, and detoxification. Counselling is also an important component of the treatment programme. The Behavioural Model : is based on learning theories , which states that all behaviour is learned one. Addictive behaviour hence can be unlearned . Behavioural procedures used in the broad spectrum treatment programmes include relaxation , aversion therapies , covert sensitization , self-control training, social skills and assertiveness training and contingency management .

44. Treatment Models Camp Approach : ( Jodhpur , Rajasthan) A community oriented approach was initiated about 15 years ago. The programme is primarily for opium dependent people , since there is a widespread use of opium by a large proportion of population . The camp lasts for 10 days . About 20 to 30 individuals who are motivated to give up opium are kept in a local school or local building and detoxified initially in a group setting . Group discussion , inspirational talks, and final oath taking to give up the drug use. This is cost effective since local resources are used and volunteers are mobilized for conducting the camp.

45. Treatment Models Social Support Person and the Community based Model ( Vivekananda Education Society, Calcutta , Kripa Foundation, Mumbai and many others) : A trained community volunteers or lay counsellor will Identify the dependent person in the community , Motivate the person for treatment Motivate and prepare the family for seeking treatment Liaison with the treatment centre Encourage the person and spouse or relative to continue follow up Provide psychological support - help engage in leisure time activities or to provide and develop a social support network for the person to maintain changed life style. In case of relapse, the social support person can repeat the cycle

46. National Nodal Centre A national nodal centre, the “ National Drug Dependence Treatment Centre”, has been established under the All India Institute of Medical Sciences (AIIMS), New Delhi which is located in Ghaziabad while two centres i.e. NIMHANS , Bengaluru and PGI , Chandigarh have also been upgraded by this Ministry (MoHFW). The additional purpose of these centres is to conduct research and provide training to medical doctors in the area of drug de-addiction.

47. Training and Manpower Development Training and Manpower Development – Development of Service Providers: The National Drug Dependence Treatment Centre at the All India Institute of Medical Sciences, New Delhi trains doctors in treatment of drug addicts. The National Centre for Drug Abuse Prevention ( NCDAP ) under the National Institute of Social Defence, New Delhi, trains those who work in NGOs in drug de-addiction

48. Inter- sectoral co-ordination and International Cooperation De-addiction requires the involvement of various ministries and departments At present, under this Scheme, the GOI supports 361 Non-Governmental Organisations (NGOs) running 376 Deaddiction-cum-Rehabilitation Centres , De-addiction Camps, and 68 Counselling and Awareness Centres . Programmes are being developed for the sensitisation of teachers, parents and peer groups in school environment through the participation of NGOs. International collaboration with International Labour Organization (ILO) , and United Nations Office on Drugs and Crime (UNODC)

49. Data collection Substance Use Problem: data can be obtained by direct and indirect methods Direct methods: Surveys: Normally surveys do not generate a diagnosis of abuse and dependence. They focus on information such as ‘ever use’ (any time in the past), ‘recent use’ (past 1 year), and ‘current use’ (past 1 month) of the substance Gives a reasonably accurate picture of extent of substance related problems . Additionally, this approach has the advantage of finding out about substance users who are not seeking treatment . Surveillance: to detect changes and identify trends .

50. Data collection Indirect methods: Production and consumption of substances Seizure of illicit drugs. Drug related illness. Reporting systems . The major limitation of this approach is that it touches only the tip of the iceberg since not all substance users come for treatment.

51. Data collection Major studies done to collect information across India: National Household Survey of Drug and Alcohol Abuse (NHS) Drug Abuse Monitoring System ( DAMS) Rapid Assessment Survey of Drug Abuse (RAS) and

52. Data collection Data was collected between March 2000 and November 2001. National Household Survey of Drug and Alcohol Abuse (NHS): The NHS was carried out on a nationally representative sample that was randomly selected across the country . Was done to estimate the extent of substance abuse Drug Abuse Monitoring System (DAMS ): Data was obtained from consecutive new patients seeking help in various treatment centres funded by the Ministry of Social Justice and Empowerment, the Ministry of Health and Family Welfare and private psychiatrists Was done to develop a format for collecting information on a regular basis

53. Data collection Rapid Assessment Survey of Drug Abuse (RAS ): Collected information on drug use through in-depth interviews of identified drug users (non-random sample), key informants and focus group discussion from 14 urban sites. Was done to know the demographic characteristics , drug use patterns, risk behaviour, adverse health and social consequences of drug users

54. Results Major highlights of these studies were Alcohol, cannabis and opiates were the commonest drugs of abuse except in the RAS where the proportion of opiate users was higher . Sharing needles among IDUs was common and on average with three partners per person Several health hazards like weakness, cough, loss of body weight, chest infection, fever and tuberculosis were common across studies. Depression and anxiety were the most commonly reported psychological symptoms.

55. Results The current prevalence rates (i.e., subjects who had used within the last one month) according to the NHS are as follows: Alcohol 21.4%, Cannabis 3.0%, Opiates 0.7%, Any illicit drug 3.6%

56. Results Data from treatment centres Drug Abuse Monitoring System (DAMS) revealed that The primary drug of abuse among these subjects was: alcohol (43.9 percent), followed by opiates (26.0 percent of which heroin was 11.1%, opium was 8.6%, other opiates were 3.7% and propoxyphene 2.6%, cannabis (11.6 percent), stimulants (1.8 percent) and others (16.7 percent). Most (70%) were between 21-40 years Largely (97%) males Most (77%) were married A few (16%) were illiterate Some (20%) were unemployed

57. Results Among those interviewed in the RAS, about 25 percent were homeless Drugs of Abuse Across Sites Cannabis-Mostly in Bangalore , Shillong , Thiruvananthapuram, Hyderabad and Goa Heroin-Mostly in Imphal , Thiruvananthapuram, Ahmedabad, Chennai , Mumbai and Delhi Buprenorphine – Mostly in Jamshedpur, Chennai and Kolkata

58. Supply reduction Supply reduction approaches: Regulation by prohibition ( Total/ partial) Regulation by Taxation Restricting access: Age limit for legal access to alcohol

59. Status of prohibition across Indian states (1991 to 2010)

60. Proportional revenues from excise on alcohol (% of total revenue ) 2003-04 Thehindubusinessline.com

61. Demand reduction Govt. of India has a three-pronged strategy for demand reduction consisting of : Building awareness and educating people about ill effects of drug abuse . Dealing with the addicts through programme of motivational counselling , treatment, follow-up and social-reintegration of recovered addicts. To impart drug abuse prevention/rehabilitation training to volunteers with a view to build up an educated cadre of service providers .

62. Legal measures The Government of India, enacted a very stringent and comprehensive law, the Narcotic Drugs and Psychotropic Substances Act, 1985 , under which a minimum punishment of 10 years rigorous imprisonment and a fine of Rs. 1 lakh which may go up to Rs. 3 lakhs can be imposed. Moreover, the courts have been empowered to impose fines exceeding these limits for reasons to be recorded in their judgements. The Narcotic Drugs and Psychotropic Substances Act, 1985 was amended in December, 1988 to impose a stringent punishment for financing illicit traffic and harbouring offenders, including death penalty for perpetrations of this crime. It also prescribes forfeiture of property derived from or used in illicit traffic.

63. NATIONAL TOBACCO CONTROL PROGRAMME (NTCP) The Ministry of Health and Family Welfare launched the pilot phase of the National Tobacco Control Programme in 2007-08 in 9 states of the country covering 18 districts In 2008, it has been upscaled to 42 districts across 21 states . 67

64. MAIN COMPONENTS OF THE NTCP Setting up of State Tobacco Control Cells District tobacco control programme: Training and capacity building of enforcement officials Monitoring and implementation of tobacco control laws Launching an IEC/media campaign Cessation centres at district levels School health and awareness programmes 68

65. National level mass awareness campaigns Establishment of tobacco product testing labs Research and training Monitoring and evaluation, including Adult Tobacco Survey (ATS) Setting up of National Regulatory Authority (NRA) 69 MAIN COMPONENTS OF THE NTCP

66. International Day against Drug Abuse and Illicit Trafficking June 26 th

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