Punjab drug addiction: 16% or 0.06%?

Out of the 2.77 crore population of the state, only 0.06 percent was found abusing drugs, which is the lowest percentage across the nation,” said Punjab Deputy Chief Minister Sukhbir Singh Badal in February 2016, citing a 2015 study as he criticised Delhi Chief Minister Arvind Kejriwal for projecting Punjab as a drug haven.

But Badal’s response misquotes the 2015 study (conducted by the Society for Promotion of Youth & Masses, an NGO, in collaboration with the National Drug Dependence Treatment Centre, All India Institute of Medical Sciences(AIIMS).

The 2015 study “was not about all drugs, but just one type of drug - opioids, which means products of the opium plant, such as heroin and morphine, or synthetic drugs, which affect the body like opium”, said lead investigator Atul Ambekar, additional professor, National Drug Dependence Treatment Centre and Department of Psychiatry, AIIMS. “The WHO describes the following categories of drugs other than opioids (and tobacco and alcohol) that may cause dependence: cannabis, sedatives, hallucinogens, cocaine, and amphetamine-type stimulants, and inhalants.”

The study interviewed a sample of 3,620 opioid-dependent people to estimate that Punjab has 232,000 opioid-dependents. It also said there may be up to 860,000 opioid users in the state though this was not a stated aim.

The AIIMS finding translates to 837 opioid-dependents per 100,000 people in Punjab or 0.84 percent of the state’s 28 million population. This alone is more than three times as much as the corresponding all-India figure for all types of drug dependents, based on a Ministry of Social Justice & Empowerment estimate of three million drug dependents nationwide, which is 250 per 100,000, or 0.25 percent of the Indian population.

Drug use in Punjab has been estimated through surveys of selected sample groups, as scientific studies tend to be. There has never been a state-wide census-type survey.

“Over 16 percent (of Punjab’s) population is addicted to hard drugs,” said an affidavit submitted by Harjit Singh, secretary of the state’s Department of Social Security and Women and Child Development, citing a departmental survey in reply to a petition filed by some drug rehabilitation centres before the Punjab and Haryana High Court in May 2009.

Punjab: the opioid consumption capital of India, but how many use more damaging drugs? Estimating the extent of the drug problem in Punjab based on opioid-pharmaceutical drugs or opium-dependency made sense because that is the flavour of the user market, although the last such - and still widely quoted - the report is 12 years old.

Punjab was home to 56 percent of Indian opium users, said a 2004 United Nations Office on Drugs and Crime (UNODC) report, followed at a distance by Rajasthan (11 percent) and Haryana (six percent). Punjab was one of only three states reporting the abuse of propoxyphene, a narcotic opiate pain reliever used as an injectable substance, the others being Nagaland and Mizoram, as per the UN report, based on the Drug Abuse Monitoring System data from 203 participating centres nationwide.

The affidavit submitted by Harjit Singh appeared to second this finding.

 It said: “Opiates, their derivatives, and synthetic opiate drugs are used by 70 percent of the addicts, followed by a combination of opiate and other sedatives, including morphine.”

Lead investigator of the AIIMS study, Ambekar believes one of their findings validates the decision to focus on opioids. The study involved asking psychiatrists and agencies offering de-addiction services in Punjab about their case load; 80 individuals and 80 agencies participated.

“One in four patients seen by the participating professionals and agencies was opioid-dependent,” said Amedkar. “Clearly, opioid dependency is putting a disproportionate burden on mental health services.”

But the study showed a shift from opium or pharmaceutical opioids to heroin, a highly processed, more addictive form of opium. “Whereas earlier studies have reported that opium or pharmaceutical opioids are largely used in the state, we found heroin is the drug of choice of opioid addicts,” said Ambekar.

Defining drugs as including alcohol and tobacco as well as narcotics, as many studies examining the extent of drug use do, yields a much higher prevalence of drug use in Punjab. As we said, the affidavit we cited quoted a survey from the secretary of the social security department to say that two-thirds of rural households in Punjab have at least one drug addict. IndiaSpend has cited this data to convey the extent of Punjab’s drug problem, in a June 2015 report.

A cocktail of demand, supply and ample currency to trade have created Punjab’s drug problem. Punjab and other parts of north India have a culture of consuming “afeem” for recreational and other purposes, informs Pramod Kumar, Director, Institute for Development and Communication (IDC), Chandigarh, who led a 2001 study on drug user profiles that was tabled in the Punjab State Assembly in 2008.

 It may be recalled that in 2007, expelled Bharatiya Janata Party leader Jaswant Singh was reported to have distributed a poppy-based drink to guests at an event in his native village Jasol in Rajasthan.

Contrary to the image of an idle Punjabi taking to drugs, only 16 percent of the IDC’s sample of drug users was unemployed.

 “24 percent of drug users were farmers and 25 percent were labourers, mostly migrants from Bihar and Uttar Pradesh put on drugs to extract maximum work out of them,” according to Kumar. Supply is easy because heroin from Afghanistan is smuggled across the border into Punjab for onward transit to the West. Opium, poppy husk, charas, and ganja, among other drugs, enter the state from Himachal Pradesh, Madhya Pradesh, Rajasthan, etc. Chemists and other peddlers supply prescription drugs.

In 1979, a study published in the British Journal of Addiction found 19 percent of a sample of southeastern Chhajli town's population using opium, mostly as dependent users; six percent used barbiturates and two percent cannabis.

A 2011 study of the same village published in the Delhi Psychiatry Journal found only 3.4 percent of the sample was addicted to opium, marking an 82 percent fall in the use of opium, attributable “to the efforts of post graduate students from Government Medical College, Patiala, to sensitise the villagers to the problem of drug use and encourage them to seek treatment”, said Dr Balwant Singh Sidhu,Professor and Head, Psychiatry, Rajendra Hospital, Government Medical College, Patiala and the study co-author.

One of the biggest findings of the AIIMS study is that while four in five patients had tried to kick the habit, just over one in three had received any kind of support. One in six patients had received some kind of medical treatment and only one in 10 opioid-dependents had received Opioid Substitution Therapy (OST), de-addiction treatment that involves an opioid medication to help patients with long-term withdrawal.

“This is because the existing rules have been misinterpreted in the state. OST is being allowed only for the licensed in-patient centres,” said Ambekar. “Punjab must integrate OST into out-patient, clinic-based health services for better results. Restricting such treatment only to addicts admitted to de-addiction centres is severely limiting the number of patients who can be helped.”

In April 2012, the deputyChief Minister consulted psychiatrists from the Postgraduate Institute of Medical Education and Research, Chandigarh, to draw up a strategy to reduce addiction.

The recommendations of the consultation with psychiatrists required Badal’s administration to create five model de-addiction centres (in Amritsar, Faridkot, Patiala, Jalandhar, and Bathinda) and 25 intermediate-level de-addiction centres, train medical professionals and make available essential drugs for running the services.

Badal would do better to share an update on the implementation of these recommendations.