punjab opioid dependence survey

Conducted forMinistry of Social Justice & Empowerment, Government of India

Supported byDepartment of Health, Government of Punjab

BRIEF REPORT

BackgroundIn recent years, there have been manyanecdotal reports suggesting a significantproblem of drug dependence in Punjab.' It isalso evident that most drug dependent peopleuse opioid group of drugs such' as heroin,

opium, doda, phukki, pharmaceutical opioidsetc.' However, there have been no credibleand reliable estimates of number of opioiddependent people in Punjab.' Such estimatesare essential for developing evidence-

informed policies and programmes in thestate.

Thus, a study was commissioned by theMinistry of Social Justice and Empowerment(MoSJE),Government of India to estimate the

numbers of opioid dependent individuals inPunjab. The "Punjab Opioid DependenceSurvey (PODS)"was conducted by Society forPromotion of Youth & Masses (SPYM)and ateam of researchers from National DrugDependence Treatment Centre (NDDTC),AIIMS, New Delhi in collaboration with

Department of Health and Family Welfare,Government of Punjab.

The study was aimed at (a) estimating the sizeof opioid dependent individuals in Punjab and(b) exploring the gaps in delivery of services

for opioid dependent individuals.

MethodologyFor conducting the size estimation of opioiddependent individuals,' the methodologyadopted was "Respondent Driven Sampling(RDS) with multiplier technique". Thisresearch method has been used earlier for thesimilar purpose in Punjab" as well as inneighbouring countries". This methodology is

particularly suitable for reaching out tohidden population groups such as people whouse illicit drugs. Additionally, an online surveyamong organizations and individualprofessionals involved in delivery oftreatment services to opioid dependentindividuals was also conducted."

The RDSstudy was carried out at 10 districts

in the state: Bathinda, Ferozepur, Gurdaspur,Hoshiarpur, Jalandhar, Kapurthala, Moga,Patiala, Sangrur, Tarn Taran. Together these

Punjab Opioid Dependence Survey: Brief Report

10 districts house about 60% of thepopulation of Punjab and are representativeof the entire state on many parameters(population, male:female ratio, urban:ruralratio, location at international or inter-stateborder, location in the different regions ofPunjab).

Two separate training programmes wereconducted to train the staff on data-collectionand data management. The RDS Study wasconducted between February and April 2015,at government de-addiction centres by the

trained counsellors under supervision of thepsychiatrists / nodal-officers working with theGovernment of Punjab. Informed consent wasobtained from all the respondents andclearance was obtained from the InstituteEthics Committee of AIIMS, New Delhi. Thedata was collected in the digital format andwas subsequently ana lysed by the researchersat AIIMS using special analytical techniques(RDSATand SPSS).

Findings

Profile of Opioid DependentIndividuals in PunjabThe data was collected from a total of 3620opioid dependent individuals across the 10

districts. Based upon the analysis of the data,about 76% opioid dependent individuals inPunjab are in the age group of 18 to 35 years.About 99% are males and 54% are married. Alarge majority (89%) are literate and havesome degree of formal education. Most ofthem are employed and their majoroccupations are: Unskilled worker / labourer(27%); Farmer (21%); clerical jobs /

Demographicprofile of OpioidDependentindividuals in Punjab:• Males:99%• Literateandeducated:89%• Married:54%• Employed:83%• Punjabiasmothertongue:99%

businessmen (15%); Transport worker (14%)and skilled worker (13%). About 56% of opioiddependent people in the state belong to ruralareas and almost all (99%) report Punjabi as

their mother tongue.

Most common opioid drug used by this groupis heroin (reported by 53%), followed by

opium / doda / phukki (reported by 33%). Rest(14%) report using a variety of pharmaceuticalopioids. About one-third take their opioiddrugs through injecting route and amongthem almost 90% (29% overall), inject heroin.

Among various reasons reported for startingthe use of opioid drugs, the most commonreason was 'peer-influence' (reported by

75%). On an average a heroin using individualspends about Rs. 1400/day on drugs while thisfigure is considerably lower for opium users(Rs. 340/day) and pharmaceutical-opioidusers (Rs. 265/day). A large majority reportsuffering from physical, mental or socialadverse consequences of their drugs use.While only a minority report having beenarrested and having been jailed, almosteveryone who had been to jail reportscontinuing drug use, while inside the jail.

Almost 80% report that they have tried togive-up drug use in the past but just about35% have received any kind of help ortreatment. The medical treatment (whichinvolves using medicines for treatment ofwithdrawal symptoms) has been received by

just about 16% of opioid dependentindividuals, 'ever'. Medicines which arerequired to be taken on a long term basis(also known as Opioid Substitution Therapy -OST), have been received by less than 10% of

Drug-useprofile of OpioidDependentindividuals in Punjab:• Mostcommonopioiddrug:Heroin(53%)• Usingdrugsthroughinjectingroute:33%• Mostcommonreasonfor startingopioiduse:

Peer-influence(75%)• Evertriedtoquit?:80%• Everreceivedanyhelpforquitting?:35%


opioid dependent individuals, 'ever'. Withinpast one year, just about 8% individualsreceived in-patient treatment / admission to ade-addiction centre.

Estimated size of opioid dependentpopulation in PunjabFor estimating the sizeof opioid dependentpopulation, as per the "multiplier technique"the following formula was used:

ANo. of OpioidDependent Patientsactually admitted toDe-addiction centre inthe year 2014

x

BReverse of Proportionof the samplereporting that theywere admitted to thesame centre in theyear 2014

Review of records of de-addiction centres inthe 10 surveyed districts revealed that a totalof 2414 opioid dependent individual wereadmitted to these 10 centres in the year 2014(column A). Among the overall sample ofsurveyed individuals, 1.8% reported that they

were admitted to the same de-addictioncentre in 2014 (column B). Upon multiplyingthese figures the estimated number of opioiddependent people is 1,34,111 (in the 10surveyed districts).

After projecting these figures to the totalpopulation of state, the estimated size ofopioid dependent population in Punjab is2,32,856. The range for this estimate is: lowerbound = 1,74,642 and upper bound =

3,22,416.

Estimated number of opioid dependentindividuals in Punjab

1,74,642Lowerbound

estimate

2,32,856 3,22,416Upperbound

estimate

Data from the service providersRequests for participating in the online surveywere sent to all the de-addiction centres aswell as individual psychiatrists providingaddiction treatment services in Punjab,accompanied with a communicationaddressed to them from the department ofhealth, Government of Punjab. About 80organizations and 80 individuals participated

in the survey.

Among the 80 organizations (which belongedto all the 22 districts of Punjab), almost all thevariety of organizations participated in thesurvey including Government, private or NGOde-addiction centres, private nursing homes,Government OST centres, NGOs providingneedle-syringe services, rehabilitation centresetc. Out of 80 organizations, about 35reported that they have the facility forproviding in-patient treatment; on an averageabout 333 opioid dependent patients wereadmitted per centre, in the year 2014.

Among 80 individuals who participated in thesurvey about two-thirds were medical doctorsamong whom majority were psychiatrists(representing all the districts of Punjab). Thissurvey revealed that majority of case-load ofpsychiatrists in Punjab is composed ofpatients with drug addiction problems.Among addictions too, more than half of thecases belong to the opioid related disorders.

Thus, almost one third of clientele of surveyedmental health professionals is comprised ofopioid-related problems; rest of the clienteleinclude all the other mental health and drug-use problems. Among all the patients seekingtreatment for opioid dependence, majority

use heroin (more than 50%).

Among both the types of respondents -organizations and individual professionals - amajority opined that the best treatment ofopioid dependence is "Iong term agonistmedicines i.e. OST."


Discussion and ImplicationsThis is the first ever study of its kind in Punjabwhich provides an estimation of size of opioiddependent population in the entire state,using a scientifically valid and time-testedmethodology. What makes this study uniqueis its large scope (data from 10 out of 22districts, covering almost 60% of population)and the collaborative manner in which the

entire exercise was conducted.

The important take-home points from the

study are:

• Punjab has a sizable population ofopioid dependent people

This study estimates that there about 2.3 lakhopioid dependent people in Punjab. For thesake of comparison, the National Survey(conducted nationwide, in 2001, with adifferent methodology) estimated the entirecountry's opioid dependent population to be5 lakhs.' Clearly, a fresh, methodologically-robust survey at the national level is urgentlyrequired.

Another noteworthy point is that this study

estimates the size of opioid DEPENDENTpeople. In any society, the numbers of USERSof a drug are far more than the numbers ofpeople who are DEPENDENTon drugs. TheNational survey of 2001 estimated that about27% of opioid users are dependent. If the

same proportion holds true even today, theestimates for opioid USERSin Punjab could bearound 8.6 lakh (though estimating thenumber of 'users' was not the main focus ofthe study).

Male youth in Punjab are disproportionatelyaffected by opioid dependence. Data suggeststhat among 18-35 years old men in Punjab,about 4 in 100 are opioid dependent and

about 15 in 100 could be opioid users.

• Opioid dependence has spread acrossthe state

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Findings show that opioid dependence is nolonger concentrated only in some, urbanareas. In all the surveyed districts, estimatesof opioid dependent people run intothousands. In fact, across the state, about55% of opioid dependent population belongsto rural areas. The typical profile of the opioiddependent population is: male, young,Punjabi-speaking, from a lower-middle classbackground.

• Heroin is the most widely used opioid inPunjab among dependent individuals

A distinct shift in the pattern of drug use isvisible in the state whereby heroin emerges asthe most common opioid used by opioiddependent people. The previous studiesreported pharmaceutical products as the drugof choice among people who inject drugs. 4,8

Our study also indicates existence of a largepopulation of people who inject drugs (about75,000 injecting drug users as opposed toabout 25,000, which is the existing estimate").This has serious implications for the HIV/AIDSprogramme of the state.

• Opioid dependence poses significantburden .

A large majority of opioid dependentindividuals perceived physical/social /psychological complications. Though only aminority report having been to jail, those whohad experienced a jail-term, reported thatthey continued to use drugs while inside thejail.

Findings also indicate that there is a huge

illegal market of opioid drugs in Punjab. Studyprovides data on average expenditure onopioid drugs incurred by the opioiddependent persons per day. After multiplyingthe figures on expenditure with the estimatednumber of dependent users in the state, wecan project that opioid dependent people arespending around 20 crore rupees per day onopioid drugs. This amounts to an annual


expenditure on opioid drugs to be about Rs.

7,575 Crores per year.

• There is a huge gap in the availability oftreatment services for opioid dependentindividuals - despite significant demand

This study indicates that while as many as 80%of opioid dependent individuals have tried togive-up, only about 35% have received anyhelp. Evidence-based, effective treatment hasbeen received by a miniscule proportion."Admission to a de-addiction centre" - whichappears to be the most focused-uponaddiction-treatment strategy in the state" - isreported by just about 8% individuals in lastyear. If the treatment strategies remainfocused on only a single modality oftreatment (i.e. "Admission to a de-addictioncentre"), it will take about 10 years to

provide a single episode of treatment to theentire opioid dependent population in thestate.

• Evidence-based and preferred treatmentoption is not widely available

Opioid Substitution Therapy (OST, whichinvolves providing an opioid medication likebuprenorphine to the patients on a long-termbasis) is the most evidence-based treatmentmodality which has been endorsed by UnitedNations and World Health Organization aswell as the Indian Psychiatric Society. InPunjab, less than 10% of patients have

Opioid Dependence in Punjab: HighlightsA huge population affected by opioiddrugs: about 2.3 lakh dependentindividuals and'probable 8.6lakh opioidusersYoung males disproportionately affectedHeroin is the most widely used opioidSignificant burden on societyEstimated annual expenditure on opioiddrugs by dependent individuals: Rs.7,500 crores.Availability and access to evidence-based treatment services is grosslyinadequate.

received OST 'ever'. If there are concernsabout availability of this treatment resulting inaddiction on these medications, the concernseems to be unfounded; less than 1% ofopioid dependent people report usingbuprenorphine (as a drug of dependence).

Conclusion andRecommendationsData provides clear evidence that the statehas a sizable burden of opioid dependence. To

deal with this, it would require:

A healthy mix of Short-term and Long-

term strategies

Inter-sectoral coordination amongvarious stakeholders

A spirit of 'helping affected people' (asopposed to 'punishing the people who

are guilty of using drugs')

Among short term strategies it would becrucial to strengthen the treatment servicesfor opioid dependent people. Relying on thesingular approach of de-addiction centres isunlikely to be helpful, since opioiddependence is known to be a chronic,relapsing disorder. In this respect, thiscondition is much similar to diabetes or highblood pressure (which require long-termmanagement) as opposed to malaria or

typhoid (which can be managed by shortbouts of treatment).

Thus, the state needs a judicious combinationof multiple strategies that includes (a)providing both short-term (detoxification) andlong-term treatment (such as OST), and (b)

providing treatment at both outpatient aswell as inpatient settings. Consequently, itwould be imperative to shift the focus from'de-addiction centres' (providing in-patientservices) and to expand the basket of servicesby establishing 'Drug Dependence Treatment


Clinics• that provide long-term outpatient

treatment. The treatment available at thesecentres and clinics must follow certainminimum standards and guidelines.

The most evidence-based and effectivetreatment for opioid dependence - OST- isscarcely available to the affected patients inPunjab. Primarily, the injecting drug users arereceiving OST as a part of the National AIDSControl Programme." The legal and policy

road blocks to OST must be looked into inorder to ensure that these medicines are

accessible to all the needy patients throughtheir service providers. It would be necessaryto enhance the capacity of service providersalong with continuous monitoring, to ensurethat this treatment (OST) is provided in ajudicious, scientific and standard manner with

minimum risk of harm to the patients.

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In the long term, it would be necessary toensure coordination between sectors involvedin Supply reduction, Demand reduction andHarm reduction. All three approaches havetheir distinct role to play and over-relying onanyone of the three approaches (at the costof other approaches) is likely to bedetrimental to any society.

AcknowledgmentWe acknowledge the support provided by the

Ministry of Social Justice and Empowerment,

Government of India; Department of Health and

Family Welfare, Government of Punjab; staff of allthe de-addiction centers and NGOs involved in data

collection and above all, all the respondents who

participated in the study. Thanks are also due to

the administration of AIIMS, New Delhi for

necessary permissions and clearances.

PODSTeamSPYM, New Delhi

Dr. Rajesh KumarMr. Manish Kumar

[email protected]

NDDTC, AIIMS, New DelhiDr. Atul AmbekarDr. Ravindra RaoDr. Alok AgrawalDr. Ashwani Mishra

[email protected]

References

1 DNA, 31 Dec 2014.2014: "Drug menace reaches alarming proportions in Punjab". Accessed athttp://www.dnaindia.com/i ndia/report -2014-d rug-menace-reaches-a larm ing-proportions- in-pu njab-20483822 DNA, 4 Jan 2015. "Maximum drug patients in Punjab users of opium, poppy husk, smack". Accessed athttp://www.dnaindia.com/india/report-maximum-drug-patients-in-punjab-users-of-opium-poppy-husk-smack-20495943 Outlook, 12 Oct 2012. "What percentage of Punjab Youth is addicted to drugs?" Accessed athttp://www.outlookindia.com/b Iogs/post/wh at -percentage-of -p unjab-youth -is-ad dicted -to-d rugs/28 73/314 Ambekar & Tripathi (2008). Size estimation of injecting drug use in Punjab, Haryana and Chandigarh.UNAIDS, New Delhi.5 UNODC (2012). National Drug Use Survey - Maldives.6 https://punjabsurvey.wordpress.com/7 MoSJE and UNODC (2004): The extent pattern and trends of drug abuse in India: National Survey.8 Ambekar A (2012), Association of Drug Use Pattern with vulnerabilitv and service uptake among IDUs. UnitedNations Office on Drugs and Crime (UNODC), and National AIDS Control Organisation, New Delhi9 Rao R, Kumar M, Singh M.(2013. Evolution of Targeted Intervention Program for High Risk Groups in Punjabunder National AIDS Control Program-III: A documentary. Punjab State AIDS Control Society, Chandigarh andSociety for Promotion of Youth and Masses, New Delhi10 "De Addiction Efforts of Punjab Government", Accessed at: http://pbhealth.gov.in/deefforts.html


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