NAMS task force report on Alcohol, substance use disorders, and behavioral addictions in India

Current situation in the country

Alcohol and other substance use and behavioral addictions constitute an important public health issue all around the world, including India. Several research endeavors have estimated the prevalence of substance use and substance use disorders in India. In this section, we present the magnitude of the problem based on reports from India.

The National Survey on Magnitude of Substance Use in India (2019), conducted by the National Drug Dependence Treatment Centre (NDDTC), All India Institute of Medical Sciences (AIIMS), New Delhi, has estimated the national and state-wise prevalence of substance use in the country.¹ The survey has reported that alcohol is the most common psychoactive substance used by the Indian population. Nearly 15% of the population aged between 10 and 75 years consume alcohol. Converting these to absolute numbers, about 16 crore persons consume alcohol in India. The prevalence rate of alcohol use is much higher among men (about 27.3%) as compared to women (1.6%). The states with the highest prevalence of alcohol use, as per this survey, are Chhattisgarh, Tripura, Punjab, Arunachal Pradesh, and Goa. The types of alcohol commonly consumed in India include both country liquor and Indian-made foreign liquor. Among the 16 crore alcohol users, about 5.7 crore individuals were found to be problem users (i.e., experiencing some problems with the use of substances), and about 2.9 crore individuals were identified as dependent users [Figures 2 and 3]. This suggests that there are a large number of individuals with alcohol use disorders.

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Figure 2:

Alcohol use in India.

(Source: Magnitude of substance use in India. New Delhi: Ministry of Social Justice and Empowerment, Government of India. 2019.)

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Figure 3:

Alcohol use in different population subgroups.

(Source: Magnitude of substance use in India. New Delhi: Ministry of Social Justice and Empowerment, Government of India. 2019.)

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Cannabis use was reported by about 2.8% of the population. This translates to about 3.1 crore individuals reporting cannabis use in India. Different forms of cannabis used have also been assessed in this survey. About 2% of the population uses bhang (translating to about 2.2 crore individuals), and 1.2% of the population uses ganja and charas (translating to about 1.3 crore individuals). The states with the highest reported prevalence of cannabis use were Uttar Pradesh, Punjab, Sikkim, Chhattisgarh, and Delhi. There were about 72 lakh problem users and 25 lakh dependent users of cannabis across the country [Figure 4].

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Figure 4:

Cannabis use in India.

(Source: Magnitude of substance use in India. New Delhi: Ministry of Social Justice and Empowerment, Government of India. 2019.)

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Opioids were the next common substance of use. About 2.26 crore individuals, translating to about 2.1% of the country’s population, consume opioids. Heroin (1.14%), followed by pharmaceutical opioids (0.96%) and raw opium (0.52%), were the commonest opioids being used in India. The states with the highest prevalence of opioid use were Sikkim, Arunachal Pradesh, Nagaland, Manipur, and Mizoram (the prevalence of use in the general population was more than 10%). It was estimated that there were 77 lakh problem users of opioids, and about 28 lakh dependent users [Figure 5].

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Figure 5:

Opioid use in India.

(Source: Magnitude of substance use in India. New Delhi: Ministry of Social Justice and Empowerment, Government of India. 2019.)

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The survey estimated 1.08% of the population (translating to about 1.18 crore people) as current users of nonmedical and nonprescription sedatives. Sikkim, Nagaland, Manipur, and Mizoram have the highest prevalence of such sedative usage. Inhalant use was more common among children and adolescents (1.17%) than adults (0.58%). Other categories of drugs, such as cocaine (0.10%), amphetamine-type stimulants (0.18%), and hallucinogens (0.12%), were reported to be used by a smaller proportion of the population.

The National Mental Health Survey of India conducted in the years 2015–2016 has also presented the data on harmful and dependent use of alcohol and other substances.⁴ The prevalence of alcohol use disorders was found to be 4.7%, and the prevalence of other substance use disorders (apart from tobacco) was found to be 0.6%. The prevalence of tobacco use disorders was 20.9%. These findings also suggest a high prevalence of substance use disorders in the country.

The rates of tobacco use according to National Family Health Survey - 5 was found to be 38.0% among men and 8.9% among women, though this survey did not present the prevalence of tobacco use disorders per se.³ Similarly, the prevalence rate of alcohol use among men and women was reported to be 18.3% and 1.3%, respectively.

Of late, behavioral addictions have emerged as an important consideration in India as well.¹⁰ Among them, Internet addiction has drawn research attention across the different states of India.⁶ It has been estimated that about 20% to 40% of college students in India are at risk of Internet addiction. Similarly, gambling-related problems have been studied in the Indian context and there is evidence to suggest that 7.4% of college students indulged in problem gambling.⁵ Thus, behavioral addictions also need to be addressed from a policy and healthcare perspective in India. However, the literature on behavioral addiction has been limited, and representative national surveys are yet to be conducted on behavioral addictions.

Substance use disorders and behavioral addictions cause adverse health consequences, which result in disability and death. Ramalingam et al. (2022)⁸ showed that alcoholic liver disease led to more than 8,000 deaths in the National Capital Territory of Delhi in a single year starting in March 2017.⁸ The health-related expenditure due to alcohol was estimated to be about two times the revenue generated due to the sale of alcohol. Similarly, the Bangalore study suggests that alcohol use was associated with several familial and social adverse consequences, and the costs incurred due to alcohol use exceeded the revenue generated from alcohol.^2,11

Taken together, there seems to be a high prevalence of substance use and substance use disorders in the country.¹² Problematic substance use not only affects the person from a health perspective but also causes a burden to the family and society. Substance use can cause both direct and indirect harm to individuals and communities.

Current infrastructure, facilities, technologies, policies, programs, etc., in the country in the context of the problem/health issue

Care of people with substance use disorders can be at various levels, including primary, secondary, and tertiary care [Figure 6]. Primary care has the widest approach and is most easily accessible to individuals with substance use disorders.

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Figure 6:

Care levels for people with substance use and behavioral problems.

(Source: Magnitude of substance use in India. New Delhi: Ministry of Social Justice and Empowerment, Government of India. 2019.)

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A larger number of individuals can be helped at a lower level of care. As the severity of problems increases, the individual may need to be referred to a higher level of care.

Brief interventions at the primary care level can be of much use to elicit problematic substance use and to use the medical/clinical encounter for suggesting behavioral change and discussing methods of reducing or ceasing substance use.¹³ For example, a clinical encounter in the medicine/emergency department with a medical health problem can provide an opportunity to discuss cessation of alcohol use, which has led to gastritis/accident. Screening, brief intervention, and referral to treatment (SBIRT) can be utilized to screen and refer patients with more severe substance use disorders to the secondary level of care, and patients with complex needs can be referred to the tertiary levels of care.

Provisions of care can be through various approaches and settings:^14-18

• Public institutions – There is a wide array of medical and mental health services at primary, secondary, and tertiary care. Generally, patients with substance use disorders and behavioral addictions would have closer access to primary care. Much of the treatment of patients with substance use disorders, especially screening and identification, can be conducted in primary care.¹⁹

• There are also specialized center and psychiatry departments in medical colleges for helping people with substance use disorders and behavioral addictions. NDDTC Ghaziabad, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh; National Institute of Dr. RML Mental Health and Neurosciences (NIMHANS), Bengaluru; RML Hospital, New Delhi; AIIMS, Bhubaneswar; and Central Institute of Psychiatry (CIP), Ranchi, are among the centrally supported institutions. Apart from that, there are several drug treatment clinics (DTCs) and addiction treatment facilities (ATFs) across the country. Medical colleges (centrally supported or supported through state governments) also provide care.

• Private medical facilities – Many private medical facilities (both inpatient and outpatient) provide care for patients with substance use disorders. These facilities may be dedicated mental health facilities or general medical facilities. Counseling is also provided by independent practitioners from across the country. Alcohol, tobacco, and other substance-related harms may make individuals visit general healthcare facilities, and this can be an opportune moment to discuss cessation/reduction of substance use.

• Nongovernmental organization (NGO) and not-for-profit sector – This sector also aims to reach out to patients with substance use disorders and provide care for them. There are a range of models of providing care, and these services tend to provide low-threshold services in the community. NGO and not-for-profit sectors provide a wide range of services varying from outpatient counseling services to long-term residential rehabilitation services. In addition, Alcoholics Anonymous and Narcotics Anonymous also provide mutual self-help 12-step facilitation among substance users.

• Traditional and alternative systems of medicine – Many patients with substance use disorders approach traditional and alternative systems of medicine as well. Several interventions, like yoga, have demonstrated efficacy for patients with substance use disorders.

• Digital and tele services – In the recent past, telephone and digital platforms have expanded in India. These offer an opportunity of reducing costs and make care more easily and immediately available. mHealth-based applications can be used through smartphones and can help in the reduction of substance use. Similarly, quitlines can provide counseling for the cessation of tobacco.

Figure 7 summarizes the range of services available for substance use disorders and behavioral addictions.

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Figure 7:

Treatment service provisions.

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Apart from services, prevention forms an important component of the approach to substance use and substance use disorders at the community level.^20-25 Prevention aims at both educating the younger population about harms associated with substance use and emphasizing the measures available for addressing substance use. Other approaches for prevention rely on improving prosocial behaviors in the school setting, which has been shown to reduce substance use initiation. Workplace-based interventions have also shown promise for reducing substance use. Prevention measures can be universal, selective, or indicated, though universal approaches may have a wider reach and show greater impact. Prevention approaches that have shown a reduction in substance use among adolescents and young adults include increasing taxes on alcohol, brief alcohol screening, and intervention for college students, and workplace interventions.

Supply control measures may also have an impact on the use of substances like alcohol. Restrictions on the sale below a certain age, prohibition of the sale of alcohol in a particular area, control on the number of outlets, and taxation may also limit the consumption of alcohol, and hence the consequent harms.

Current policies:

National Policy on Narcotic Drugs and Psychotropic Substances

Current programs:

• Drug De-Addiction Program under the Ministry of Health and Family Welfare, Government of India.

• National Action Plan for Drug Demand Reduction under the Ministry of Social Justice and Empowerment, Government of India.

• Nasha Mukt Bharat Abhiyaan under the Ministry of Social Justice and Empowerment, Government of India.

Current Budget

Ministry of Health & Family Welfare is running a National “Drug De-Addiction Program (DDAP)” with the objective of providing affordable, easily accessible, and evidence-based treatment for all substance use disorders through the government healthcare facilities and of building the capacities of healthcare staff in recognition and management of substance use disorders. The program is implemented through the health institutions under the Ministry of Health and Family Welfare (MoH&FW), viz., AIIMS, Dr.RML New Delhi; PGIMER, Chandigarh; NIMHANS, Bengaluru; RML Hospital, New Delhi; AIIMS, Bhubaneswar; and CIP, Ranchi. Out of these six, the center at AIIMS, New Delhi (NDDTC), is functioning as the National/Nodal center. The Ministry of Health and Family Welfare (MoHFW) has released the “Standard Treatment Guidelines for the Management of Substance Use Disorders and Behavioral Addictions”.¹⁸ The average annual budget of Rs. 45–53 crores has been allotted for DDAP Program for these above-cited DDAP Institutes in the last three years.

Ministry of Social Justice and Empowerment (MoSJE) implements the National Action Plan for Drug Demand Reduction (NAPDDR), which is an umbrella scheme under which financial assistance is provided to:

1. ‘State governments/union territory (UT) administrations for preventive education and awareness generation, capacity building, skill development, vocational training, and livelihood support of ex-drug addicts, programs for drug demand reduction by states/UT, etc.’

2. “Non-Government-Organizations/Voluntary Organizations for running and maintenance of Integrated Rehabilitation Centers for Addicts (IRCAs), Community-based peer Led Intervention (CPLI) for early Drug Use Prevention among Adolescents and Outreach and Drop In Centers (ODIC) and Addiction treatment facilities (ATFs) in Government Hospitals”.

Key issues/gaps identified in the current infrastructure, facilities, technologies, policies, programs, etc., in the country in the context of the problem/health issue

Key gaps in the current infrastructure, facilities, technologies, policies, and programs include:

1. Lack of adequate facilities and evidence-based treatment available to provide treatment for substance use disorder.

2. Lack of knowledge and skills in medical personnel to address substance use disorder

3. Different agencies to deal with different aspects of substance use disorders

4. Non uniform policies on alcohol

5. Lack of awareness regarding available treatment for substance use disorders and behavioral addiction

6. Lack of community support for treatment, support, and aftercare for people with substance use disorders

7. Lack of regulation of some centers that cater to people with substance use disorders resulting in the mistreatment of people with substance use disorders

8. Lack of due emphasis/focus on substance use disorders at the state level (which is responsible for health) in the midst of competing priorities.

Key issues/gaps identified in current financial inputs, etc., in the country in the context of the problem/health issue

While financial inputs are being provided for the treatment of substance use disorders, there needs to be a greater emphasis. Some of the further measures could be:

• Dedicated outlays for evidence-based preventive measures

• Greater government expenditure for sustaining services in the government sector

• Dedicated budget for substance use disorders through telemedicine

• Financial incentive for the provision of care to patients with substance use disorder in the NGO sector

• Dedicated funds for incentivizing capacity development – trained primary care physicians, medical professionals, counselors, nurses, and other health professionals.

• Funds for research need to be earmarked to find contextual solutions to the problems of substance use and behavioral addictions in India

Suggested policy activities and advocacy for policy makers

• Working further toward a national alcohol policy in line with the WHO Global Strategy to reduce the harmful use of alcohol.

• Relocation of all health-related activities for tobacco, alcohol, drugs, and behavioral addictions within the Ministry of Health and Family Welfare.

• Framing policies to divert patients with substance use disorders with small quantities of recovered substances toward medical care in lieu of criminal proceedings and incarceration.

• Sensitizing important stakeholders, including law enforcement authorities, and judiciary, on the need to distinguish drug users from drug dealers.

• Telemedicine rules and guidelines should also facilitate the treatment of substance use disorders.

• Enabling provisions to ensure the physical safety of healthcare providers at the workplace.

• Advocating with policymakers on the need to ease the availability of medicines that are otherwise regulated under the Narcotic Drugs and Psychotropic Substances (NDPS) Act of 1985 and the need to protect the medical fraternity from inadvertent lapses in following processes/procedures in prescribing and dispensing medicines. This includes benzodiazepines that are needed for patients with mental illnesses.

• Fund policy-related research activities on existing policies on substance use disorders and behavioral addiction, for example, the impact of banning alcohol in some regions/states, whether criminalization/decriminalization of some substances is the way forward, etc.

Recommendations for health/medical professionals

• Training medical professionals and other healthcare providers about substance use disorders to enable screening and detection of substance use disorders and behavioral addictions at the primary/emergency care level.

• Every patient who visits any health center or tertiary care center and has any of the above listed addiction habits should be counseled by the doctor at first instance and necessary referral should be provided by a psychiatrist in case a need arises.

• Greater utilization of brief intervention and referral to the treatment of patients encountered in the medical setting who have problematic substance use at the primary level of care.

• Optimum utilization of online training mechanisms for the training of medical professionals about substance use disorders and behavioral addictions. As a long-term goal, incorporate the Ministry of Health and Family Welfare-approved addiction psychiatry curriculum at the MBBS level.

• Enable provision of basic treatment of substance use disorders and behavioral addictions at the primary care level.

• Making a basket of services available to cater to the different needs of the population.

• Greater access to treatment services like opioid substitution treatment for those who need such treatment.

• Integrate psychosocial rehabilitation with medical treatment of patients with substance use disorders.

• Training about addictive disorders at postgraduate levels in mental health and allied disciplines.

Suggestions to create awareness among general public, NGOs, and community stakeholders

• Enhancing the awareness about substance use and the harms associated with it at the school and college levels. This includes not only medical harms and health deterioration but also mental health concerns and social consequences of substance use disorders.

• Strengthening, implementation and monitoring of “Nasha Mukt Bharat Abhiyaan” could hold promise in preventive aspects.

• Initiate workplace interventions for substance use problems in the workforce.

• Sensitizing teachers in educational institutions about substance use for early identification and referral.

• Target school and college students toward enhancing prosocial behaviors, to reduce substance use experimentation.

The key thrusts at policy, professional, and awareness levels are given in Figure 9.

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Figure 9:

Key thrusts at policy, professional, and awareness levels.

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The implementation plan would need more thorough deliberations with not only medical experts but also a multi-stakeholder approach, including individuals with substance use disorders, those with programmatic and administrative experience, financial experts, and others. The choice of strategies to be prioritized should be based on the evidence base and also the unique cultural, social, economic, and political landscape of the country. Social marketing should be considered while planning and implementing programs that address substance-related problems and behavioral addictions (Tiwari, 1998). The strategies selected should be linked to measurable outcomes evaluated on a suitable time frame basis. The objectives being defined by being specific, measurable, achievable, reliable, and time-bound would help to know whether the strategies have the intended effects. This would be beneficial in directing resources and better utilization of the inputs.

Further implementation plan is given in Figure 10.

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Figure 10:

Further implementation plan.

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