Dealing with the epidemic of drug use

Extent of the drug use problem

The World Drug Report of 2023¹ states that one in 17 people aged 15–64 yr had used one or the other drug over the past 12 months. The estimated number of users has reportedly grown from 240 million in 2011 to 296 million in 2021 (roughly 5.8 % of the global adult population aged, 15–64 yr). Cannabis was found to be the most used drug with an estimated 219 million users (roughly 4.3% of the global adult population aged, 15-64 yr). Other common drugs of abuse reportedly include amphetamines (36 million), cocaine (22 million) and ecstasy type substances (20 million). There were 13.2 million injection drug users (IDUs) in 2021, 18 per cent higher than in 2020 (11.2 million). Twenty three per cent of the new hepatitis C infections are reportedly attributable to unsafe drug injections. The Centers for Disease Control and Prevention (CDC) estimates that >105,000 deaths that occurred in the United States due to overdose of opioid group of drugs in the 12 months ending in October 2021 matched the number of deaths caused by the COVID pandemic, with the opioid crisis subsequently being designated as an epidemic².

Shifting the focus from the illicit drugs to two socially sanctioned psychoactive substances, alcohol and tobacco, the two are no less associated with harmful effects on health. According to the World Health Organization (WHO) report on the Global Tobacco Epidemic 2021³, tobacco accounts for >8 million deaths and costs the global economy roughly US$ 1.4 trillion each year. In 2020, 22.3 per cent of the world’s population (36.7% of men and 7.8% of women) reportedly used tobacco. Around 80 per cent of the world’s 1.3 billion tobacco users live in low- and middle- income countries⁴. In light of the morbidity and mortality associated with the opioid and tobacco use, these have been identified as epidemics. Alcohol use disorders are another major contributor to the addiction related morbidity and mortality. Worldwide, 3 million deaths each year reportedly result from harmful use of alcohol, accounting for 5.3 per cent of all deaths⁵. Alcohol use is the leading risk factor for mortality among males aged 15–49 yr, the most productive years of life with an overall 5.1 per cent of the global injury and disease burden attributable to alcohol. Harmful use of alcohol is also a causal factor in >200 disease and injury conditions⁵.

Since continuing public awareness activities have been successful in bringing some decline in the cigarette sales, the tobacco companies have come out with electronic nicotine delivery systems (ENDS)³ including new products like heated-tobacco products and e-cigarettes, which are equally addicting.

Drug use in India

Drug use is equally prevalent in India, as in other parts of the world. A nationwide study⁶ on the magnitude of substance use in India, conducted during 2017-18, reported prevalence of problematic and dependent alcohol use in 5.2 and 2.7 per cent of the population, respectively. Cannabis and opioid use were reported in 2.8 and 2.1 per cent of the population, respectively, whereas problematic use (harmful use or dependence) of cannabis and opioid was found in 0.66 and 0.7 per cent of the population, respectively. Furthermore, 850,000 individuals have reported using drugs (heroin or pharmaceutical opioids) by the injection route. Cocaine, amphetamine type substances and hallucinogens were much less frequent. The Global Adult Tobacco Survey-2 (GATS-2)⁷ of 2016-17 estimated the prevalence of smoking at 10.7 per cent and of smokeless tobacco use at 21.4 per cent in the adults in India. Tobacco use is also a major cause of mortality and disease in India, accounting for nearly 1.35 million deaths each year. As a result of sustained public health initiatives under the National Tobacco Control Programme, there has been a decline in the prevalence of tobacco use from 34.6 per cent as estimated in the GATS-1 in 2009-10 to 28.6 per cent in GATS-2 in 2016-17 in adults, and from 10 to 4 per cent in the age group of 15-17 yr⁷.It is however, important to note that the use of smokeless tobacco by one in five of the adult population is an alarming figure.

Meeting the challenge

Addiction imposes a huge challenge to the public health with substantial morbidity and mortality as well as association of drugs with crime. There is, however, a large treatment gap with only one out of five drug users seeking treatment¹. In low- and middle- income countries, the figure of the individuals remaining untreated reaches nearly 90 per cent. The National Mental Health Survey of India⁸ has reported a treatment gap of 91.8 and 86.3 per cent for tobacco and alcohol use disorders, respectively. The National Survey on Magnitude of Substance Use in India⁶ reports that only one in four persons using drugs receives treatment. Reasons for a large untreated population include absence of adequate treatment facilities in the community as well as a lack of awareness on part of the users as well as their family members, and also the community.

Widening the scope of treatment by creating treatment facilities in the community, raising awareness about the problem and sustained efforts towards prevention remain the core strategies for managing the problem of substance use⁹. A public health model of primary, secondary and tertiary prevention can be adopted. Primary prevention needs to be aimed at raising community awareness about the drugs, correcting myths and misconceptions, and early identification and treatment. A common myth that drug use is not just a habit but an illness needing medical intervention also needs to be corrected. Preventive efforts should focus on the use of gateway substances, such as tobacco, alcohol and cannabis. Since use of these substances starts among adolescents, the preventive strategies should target this population. Secondary prevention involves providing treatment to the affected population. In case of addictions, this would include creating treatment facilities, which are easily accessible to the affected individuals. Tertiary prevention focusses on rehabilitation of the treated population in the community and relapse prevention. There also needs to be a focus on demand reduction, harm reduction and supply reduction which needs policy initiatives at the level of multiple stakeholders. There is also a need to completely ban the surrogate advertisements in the media and sponsorship of sports events by the alcohol and tobacco industry. In the recent years, increased digital interconnectivity has brought about innovative methods of drugs supply, making supply chains shorter, increasing accessibility and reducing costs¹, a new challenge to the drug law enforcement agencies. WHO’s 2023 report on the global tobacco epidemic succinctly summarizes effective tobacco control measures as mPOWER¹⁰. Furthermore, several countries across the world have taken initiatives in this direction.

Since initiation of drug use often occurs during late childhood or early adolescence, incorporation of the ill effects of drug use in the life skills programmes in school curriculum can be an important step. Students need to be sensitized about the harms of drugs from an early age and taught refusal skills ‘how to say no, if offered a drug’. Approaches should be participatory, based on peer learning rather than didactic or prescriptive in nature. School teachers need to be sensitized about identifying children and adolescents at risk of developing drug use and referring them to a school counsellor. Parent-teacher meetings should also focus on this issue to sensitize the parents about the risk of drug use.

Initiatives taken in India

India with a population of more than 1.4 billion¹¹ is no less affected by the problem of drug use, both illicit as well as the licit, compared to other parts of the world. In the background of rising cases of opioid dependence in 1980s, the Government of India took three major initiatives in form of the enactment of the Narcotic Drugs and Psychotropic Substances Act, 1985, establishment of the Narcotics Control Bureau in 1986 and the launch of the Drug De-addiction Programme in 1988. Subsequently, deaddiction centres have been established all over the country. In the recent past, emphasis has been on setting up of satellite clinics in the community, named drug treatment clinics and addiction treatment facilities by the Ministry of Health and Family Welfare and the Ministry of Social Justice and Empowerment (MSJE), respectively of the Government of India. The MSJE also launched Nasha Mukt Bharat Abhiyan¹² (Drug Free India Programme) in 2019 and has undertaken many community level initiatives under this programme. The National Tobacco Control Programme, launched in 2007, has been another important initiative taken by the Government of India to deal with this problem of tobacco use. Under this programme, a nationwide helpline (Quit Line) has been established and a network of tobacco cessation clinics has been established at district level. Recently, in the background of rising use of the ENDS, the Government of India has come up with a law, “The Prohibition of Electronic Cigarettes (Production, Manufacture, Import, Export, Transport, Sale, Distribution, Storage and Advertisement) Act, 2019” to prevent its use in India.

Overall, it is time to recognize the enormous problem of addictions which is taking the shape of an epidemic. There is a need to take effective preventive measures to control the harms caused by addiction as well as raise community awareness about the problem and develop community-based treatment facilities. An aggressive and coordinated public health approach having collaborations with international agencies like the WHO and the UNODC and learning from success stories can go a long way in dealing with this problem.