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

1. Deaddiction programmes in
India
Dr. Raghavendra Huchchannavar
Junior Resident,
Deptt. of 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 19th 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
USE
ABUSE
ADDICTION
DEPENDENCE

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

13. 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.

14. “Golden Crescent” and “Golden Triangle”

15. 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)

16. Factors influencing
substance abuse and
dependance

17. 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.

19. 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.

20. 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.

21. 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.

22. 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.

23. 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.

24. 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.

25. 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.

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

27. 5. To promote collective initiatives and self-help endeavours
among individuals and groups vulnerable to addiction.
6. To establish appropriate linkages between voluntary agencies,
working in the field of addiction and government
organisations.
7. 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

28. • 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

29. • 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

30. 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.

31. • 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

32. 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.

33. 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.

34. 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.

35. Treatment-cum-Rehabilitation
Centre, Rohtak

36. 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

37. Awareness activity: Painting
competition

38. 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

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

40. 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.

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

42. 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.

43. 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.

44. 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.

45. 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.

46. 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.

47. 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

49. 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.

51. 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

52. 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)

53. 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.

54. 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.

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

56. 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

57. 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

58. 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.

59. 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%

60. 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

61. 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

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

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

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

65. 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.

66. 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.

67. 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

68. 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

69.  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

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