Monitoring of substance abuse in India--initiatives & experiences.

Substance use is ubiquitous with a range of substances being abused the world over. Their abuse and associated harm have been of international concern since early 1980s and the WHO highlighted the importance of monitoring the drug abuse situation and trends1. Monitoring thus assumes importance which must be timely and sensitive to the trends which are dynamic and vary according to population and geographic region.

Several modalities can be used to monitor data. Epidemiological surveys provide information on prevalence and trends of drug use among general population. It is important to draw a distinction between population survey carried out on national probability sample and those carried out as regional and/or local surveys which may also be unique in a time series data. Survey methods hold promise in monitoring trend data but have their limitations which include large sample sizes and are resource intensive2. On the other hand, data from treatment centres provide information on drug consumption patterns and trends from people entering treatment. Such a method is cost-effective as data can be collected with limited financial effort. In addition, organization profile and available treatment facilities can also be obtained3.

International efforts

There are national reporting systems in place in several countries. The United States has systems like the Drug and Alcohol Services Information System (DASIS)4; Treatment Episode Demand System(TEDS)5 a component of DASIS and Drug Abuse Warning Network (DAWN)6. Some of these systems are episode-based, while others draw information directly from patients’ records and provide characteristics and drug history information of individuals admitted to treatment facility including contact with emergency departments (DAWN).

Treatment registries and monitoring data for 30 countries under EU and Member States are being compiled by the European Monitoring Centre for Drugs and Drugs Addictions (EMCDDA)7. Some EU countries maintain centralized systems of referral, treatment, monitoring and reporting while others have de-centralized systems with minimal reporting requirements.

Guidelines for establishing and managing systems for the collection of treatment data are also available. Other monitoring modalities include the ‘Pulse Check’ in the US which reports on national trends and provides timely information on illicit drug abuse and drug markets gathered from telephone conversations with ethnographers, epidemiologists, law enforcement officials and treatment providers from 25 sites across USA8. Thus, documentation of changing drug use trends requires multiple methods.

In the article by Basu et al9 in the current issue, the authors demonstrate that the information collected as a routine procedure in a treatment centre can provide a relatively inexpensive method of monitoring changing trends of drug use in a community. It is important to compare these retrospective data from a single treatment against the national trend, if available.

Monitoring drug use - India

Data on drug use have been recorded through several general population surveys in 1970s and 1980s10. Cannabis, tranquilizers and alcohol use in 1980s among general population and heroin use was established in early 1980s9. However, all these studies have been district/ regional surveys and do not project the national picture10. Thus, changing trends through population survey in India are not available.

The viability of a Drug Abuse Monitoring System in the country was examined for the first time through a Task force project (ICMR) conducted at Delhi, Jodhpur and Lucknow in 1990 and provided one year data among 10,321 persons11. A large scale exercise as a sub-component of the National survey on drug abuse documented information on treatment seekers (N=16942) from government organizations, non government organizations (NGOs) and private sectors (NHS, 2004, data obtained in 2001-2002) over a three month period12. This attempt at monitoring though of a shorter duration, provided a baseline for establishing large scale efforts.

Prospective data (Drug Abuse Monitoring System-DAMS) have been collected by the National Drug Dependence Treatment Centre (NDDTC) at the All India Institute of Medical Sciences (AIIMS), New Delhi, with the support of the WHO-India office, but have not been published and are available as reports with the Drug De-Addiction Programme, Ministry of Health and Family Welfare, (DDAP, MoHFW, NDDTC and WHO, unpublished data). The proforma uses 19 items. The data have been obtained from persons seeking help at 122 treatment centres supported by the DDAP, the effort started in January 2006 and is ongoing. However, only about 45 per cent of the centres (out of 122) contributed data over these three years (DAMS, 2007-2009). Thus data from treatment centres as a part of a national effort to document changing trends are available over several years. Despite this inadequacy, the information has been useful to policymakers and helped DDAP/ NACO (National AIDS Control Organization) to develop harm reduction programme and Oral Substitution Treatment (OST).

The data across several of these studies (1988-2009) are presented in the Table. Two of the studies reflect national data (NHS, 2004 and DAMS, 2007-2009) and show that increasing number of subjects are seeking treatment for opiate dependence in later years; other variables have remained largely unchanged. It is obvious from this effort that the participating government treatment centres do not give priority to this task and there is inadequate record keeping. Chronic under reporting leads to inaccurate national picture with regard to consumption of various drugs in India.

Table

Comparison of data on select variables across different studies

The current paper9 reflects certain changes in substance above pattern over three decades and most encouraging sign is that increasing number of persons has come forward for treatment. With regard to pattern of drug abuse, most obvious change is report of abuse of inhalants and pharmaceuticals. This is quite in keeping with the general perception in India including north India13.

To conclude, it can be stated unambiguously that India requires a robust national Drug Abuse Monitoring System and efforts must be made to improve compliance and streamline the process of data collection. Even online submission of data should be explored. The DAMS at present is in its infancy in terms of its potential benefit to the government. But continued support and persuasion should show long-term stability it will and grow to be in a position where it achieves a ‘motherhood’ stature.