Ideas and Action for a Better India
By Dwip Rachchh
After the initial stream of denials by the government and administration, there seems to be a tacit agreement that the drug problem in Punjab has turned into a full blown crisis. The 2015 Punjab Opioid Dependency Survey, conducted by AIIMS, roughly put the number of Opioid dependants at 232,856. It also estimates the total number of opioid users to be 860,000. Most of these users were male and in the age group of 18-35.
The primary response to this has been increased policing and emphasis on in patient de-addiction centres. The National Crimes Records Bureau indicates an increased year on year drug related arrests. The health and family welfare minister has inaugurated new hospitals/de-addiction centres. However those arrested are mostly drug users which does nothing to curb the supply or deincentivise drug trade. The scant hospitals/de-addiction centres cannot keep up with the burgeoning demand. According to the same survey only 8% of the dependant individuals had access to de-addiction centres. Predictably this has further exacerbated the problem with an increased user base and overwhelmed health service providers
Switzerland grappled with the same problem in the 70’s. Their success in solving this crisis has garnered appreciation among drug policy practioners globally. While Punjab and Switzerland cannot be held in the same stead socio-economically, the Swiss response and methodology can certainly shed light on what we’re doing wrong and what we can do to curb this situation.
Commonality with Swiss situation
With the rise of the counter-culture movement in Europe, Switzerland too experienced a drastic increase in drug use. The earliest onset of heroin can be traced back to the 70’s, assisted partially by the transit points at US military bases in neighbouring Italy. The next two decades witnessed consistent increase in user base despite efforts to the contrary. At its peak thousands would descend on to Platzspitz Park, a small spit of land between two rivers, to consume narcotics. A survey conducted in this park in 1990 showed a user base ranging from young people to older working and professional adults. Predictably this lead to unwanted externalities like increased rate of HIV and low-level crimes. As of 1988-89, half of all new cases of HIV transmission were linked to the injection of drugs.
Several parallels can be drawn with the Swiss situation of the 80’s and 90’s. Punjab too is grappling with an opioid crisis partly fuelled by heroin from external sources. This epidemic too has mostly afflicted men ranging from 18 year olds to middle aged working professionals. HIV transmission is very common among drug users. Drug related crimes are on the rise, especially with the arrest of drug users in a bid to alleviate the problem. The situation has steadily declined in spite of sustained efforts.
Commonality with previous approach
What makes this comparison interesting is the commonality in initial effort and its result therein. As with the entire world, the Swiss believed that the solution lay in increased policing and harsher sentencing for drug users. The federal drug law of 1975 defined rigorous criminal sanctions on drug use and sale. This resulted in significant increase in arrests and registration of drug users and sellers by the police. The law further promoted an abstinence only approach. Public health measures like distribution of clean syringes and prescription of methadone to curb heroin users were made more onerous. It was believed that such methods would legitimize drug use and encourage more people to try drugs. Many health and social professionals underscored that traditional methods of drug dependency treatment which included long periods of in-patient care were obsolete. This approach did little to stem the growth of drug use in the country.
Those familiar with Punjab’s story can recognize the parallels between the two cases. Our National Policy on Narcotics Drugs and Psychotropic Substances presupposes that “If any NGO or person is allowed to promote harm reduction, then there is a greater risk of it being used as a cover to actually push drugs or promote them” such myopic and outdated policy stances cost Switzerland dearly in the 80’s and continues to plague Punjab till date. According to the same POD survey, 80% of the surveyed users tried to quit and received little help, In-patient care which is the mainstay of our current policy was made available to only 8% of the users many of whom relapsed. Lack of sterile syringes has led to an increases in transmitted diseases particularly HIV. All evidence points to the failure of the current system in rehabilitating drug users and in ensuring their health and wellbeing.
New Swiss policy and what we can learn from it
The new Swiss model of drug use prevention was based on four pillars. These were prevention of drug use, therapy for drug dependence, harm reduction and law enforcement/policing. While prevention and policing are common to most systems, therapy for dependence and harm reduction is what distinguishes good policies from bad. One of the first steps to helping drug users is to decriminalize small quantities of drugs. This helps distinguish drug dealers from users and ensures that those in need of help are diverted to medical centres instead of prison. Drug users are also more likely to come forward to receive help if it’s guaranteed that they will not be prosecuted. Further, countering drug dependence is a multi-step process that cannot be straitjacketed into in patient care/ de addiction centres. Low threshold admission for methadone prescription is one of the most effective methods to counter drug dependency. While there were talks of initiating a Methadone Maintenance Treatment (MMT) program in India, no such initiative has been rolled across the state to counter opioid dependence. Another signature initiative of the Swiss policy was to introduce Heroin Assisted Treatment (HAT) for addicts that would ensure that addicts were given access to clean heroin and under medical supervision. This ensures that over time these doses can be stabilized and gradually reduced to wean people off heroin. This move when implemented was plagued with a lot of fears and misinformation. However after studying the effects of rigorous implementation researchers were able to establish that HAT does not initiate heroin use among non-users, there is a serious improvement in the health and well-being of the addicts and it is effective in helping people wean off heroin in the long term. Other associated benefits included lack of criminal activities among regular users to purchase illicit heroin, reduction in availability of illicit heroin in the black market as addicts peddling drugs to get their own fix disappeared. These findings were later also endorsed by a WHO report in 1999. The Swiss model was quick in recognizing that emphasis on in-patient care was not enough to treat the prevailing drug dependence in the country. The result was low threshold acceptance to out-patient care for drug dependence where programs like HAT and opioid substitution therapy (OST) were implemented. Punjab too is hard pressed to provide in-patient care to all of its drug dependants. It must consider out-patient care for them which would involve similar programs along with counselling and necessary training. This would ensure better utilization of meagre resources.
Another irreplaceable aspect of an effective drug policy is harm reduction. Motivated Swiss medical and social practioners after years of struggle were able to convince the government and the general citizenry about the benefits of harm reduction. Harm reduction techniques like providing clean syringes and raising awareness about safe drug use helped Switzerland transition from the highest incidence of HIV transmission in Europe to one of the lowest. Eradicating or even controlling drug dependence is a long process and to ensure the health and well-being of users while they consume drugs is the duty of the state. As mentioned earlier our national policy believes that setting up of injection rooms for safe consumption or provide clean syringes is akin to encouraging drug use. Not only is this theory outdated but there also exists empirical evidence in abundance that refutes this claim. Today all major European countries consider harm reduction to be a human right and have made provisions of injection rooms and needle exchange programs.
Outcome and conclusion
The success of the Swiss policy can be gauged by the following numbers. The number of new heroin users dropped from 850 in 1990 to 150 in 2002. Between 1991 and 2004 drug related deaths decreased by more than 50%. The country witnessed a 90% reduction in crime committed by drug users. Moreover the country with highest rates of HIV transmission in Western Europe is now among the lowest. The way to achieve this favourable outcome is by recognizing that current policies are flawed and make an effort to change them. Central to this is recognizing that drug dependence is a health issue and not criminal deviance. It is also important to recognize that the drug user is a person who is entitles to all human rights, primarily his health, well-being and dignity.
A shortened version of this article appeared in The Indian Economist
(The author is an Associate Fellow at Observer Research Foundation Mumbai where he works on issues of law and policy)
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