Contents Preface 10. Community-based Treatment of Substance Foreword Use Disorder Acknowledgements 11. Nicotine Dependence 12. Intervention with Treatment Non Seekers 1. Drug De-addiction Programmes in India 13. Role of Laboratory Services in Substance 2. Assessment and Diagnosis in Substance Use Use Disorder Disorder 14. Prevention of Substance Abuse in India 3. Epidemiology of Substance Use 15. Management of Substance Use Disorder in 4. Acute Effects of Alcohol, Opioid and Primary Care Cannabis Use 16. Comorbidity in Substance Use Disorder 5. Health Hazards of Long Term Alcohol, Opioid 17. Substance use disorder in Women and Cannabis Use 18. Adolescent Substance Abuse 6. Treatment Principles and Issues in Manage- 19. Legal Aspects of Drug Abuse in India ment of Substance Use Disorder – An Overview Appendix 1 Appendix 5 7. Pharmacotherapy of Substance Use Disorder Appendix 2 Appendix 6 8. Long-Term Treatment of Opioid Dependence Appendix 3 Appendix 7 Syndrome Appendix 4 Appendix 8 9. Psychosocial Treatment in Substance Use List of Contributors Disorder Glossary Preface It is indeed a pleasure to be associated with the task of compiling the manual for the World Health Organization (India) and the Ministry of Health and Family Welfare (Government of India). This manual is a product of intense deliberations and the felt need to revise the course materials for training of General Duty Medical Officers being conducted as a part of training programmes undertaken by the Ministry of Health and Family Welfare (Government of India) at various apex institutes across the country. It is intended to cover as many areas as can be envisaged. There may be some degree of overlap in the information given between chapters, which the editors have not deleted in order to maintain the coherence of individual chapters. Any suggestions for topics that have not been covered and are important may be informed so that they may be addressed in the revised version. Though intended to be used primarily by the GDMO’s, this manual may also be useful for others who are involved in the care of patients with substance use disorders. We look forward to any suggestions for improvement and changes. Rakesh Lal Ravindra Rao Indra Mohan October 2005 Foreword Substance Abuse is a complex problem having medical and social ramifications which impacts all social strata. It affects not only the user and their families but all sections of the society. Controlling substance abuse by way of demand reduction, provision of treatment services etc. has been a matter of priority for the Ministry of Health and Family Welfare for many years now. Recognizing that there is a paucity of experts in this field, the Ministry has made efforts so that in each State and Central Government Health Institutions, General Physicians are sensitized and trained to combat the problem. The task of managing this training was entrusted to the National Drug Dependence Treatment Centre, AIIMS which has been conducting regular courses for medical officers on the subject of Substance Abuse for the past 15 years. A Manual had been developed to assist the GDMO’s undergoing training in 1999. Due to the rapid advancements in this field, a need to revise the existing manual became neces- sary. I congratulate the National Drud Dependence Treatment Centre, AIIMS for bringing out this new edition of the training manual. I am sure it will be a useful tool for all persons con- cerned with the treatment and care of patients of Substance Use Disorder. Rita Teaotia Joint Secretary Ministry of Health and Family Welfare Acknowledgements In the road to putting this manual together there were a number of persons and agencies that helped. At the outset I would like to gratefully acknowledge the funds provided by the World Health Organization (India). I would like to especially thank Dr Cherian Varghese at the WHO (I) who has been a guiding force all through. Thanks are also due to the Drug Abuse Cell at the Ministry of Health and Family Welfare (Government of India) for the support and encourage- ment. Special mention must be made of the Joint Secretary, Ms. Rita Teaotia and Director, Mr Rajesh Bhushan. Acknowledgemnts are due to the Director as well as to the Dean, All India Institute of Medical Sciences for permission to carry out the work. Professor Rajat Ray, Chief, National Drug Dependence Treatment Centre deserves special grati- tude for being the constant guide and critic and without his tireless assistance this work would not have been possible. Acknowledgements are also due to the participants of the National Workshop where the course materials revision was discussed and finalized. This work would just not have been possible without the timely help of the contributors and special thanks are due to each and every one of them. My associate editors, Dr. Ravindra Rao and Dr. Indra Mohan deserve special mention of grati- tude for their tireless support and help in putting this case-book together. Rakesh Lal Drug De-addiction Programmes in India 1 Rajesh Bhushan I. The context 1.3 In the area of Drug De-addiction and drug trafficking, the control on illicit drug 1.1 The constitution of India under Article trafficking and its production in India as 47, enjoins that the state shall endeavor well as coordination with international to bring about prohibition of the con- agencies is the responsibility of Ministry sumption, except for medical purposes, of Home Affairs. Rehabilitation of addicts of intoxicating drinks and of drugs which as well as their counseling is the responsi- are injurious to health. The various drug bility of Ministry of Social Justice & Em- de-addiction programmes of Government powerment. Demand reduction by way of India have to be seen in this light. The of treatment and after care is the concern Government of India, Ministry of Health of Ministry of Health & Family Welfare. and Family Welfare in 1976 appointed a The Drug De-addiction Programme of the high powered committee to examine the Ministry of Health & Family Welfare was problem of Drug De-Addiction and sug- started in 1987-88, which was modified gest future guidelines. The report of this in 1992-93 as a scheme under Central high powered committee was submitted sector assistance to States. in 1977 and was laid on the floor of the Parliament. The Planning Commission 1.4 The role of Ministry of Health & Family and the Central Council of Health Min- Welfare in the area of Drug De-addiction isters reviewed this report in 1979. The is demand reduction by way of providing recommendations of the report empha- treatment services. Under the scheme a sized the need to evolve appropriate strat- one time grant in aid of Rs. 8.00 lakhs is egies and to bring about better coordina- given for construction of Drug De-addic- tion among different Ministries and De- tion Centres and a recurring grant of Rs. partments working in this area. The Plan- 2.00 lakhs is given to Drug De-addiction ning Commission and the Central Coun- Centres established in North Eastern cil of Health Ministers accepted this. Regions. At present 122 such Centres have 1.2 Drug addiction entails high cost to hu- been established across the country man health, social fabric and economy. including centres in Central Government In addition, Drug addiction has come to hospitals and institutions. 43 such Cen- represent yet another danger over the past tres have been established in the North decades. This comes from the role which Eastern Region. The six Drug-addiction drug use plays in the spread of HIV/AIDS. Centres established in Central Govern- It was in this context that the Drug De- ment hospitals and institutions are at All addiction Programme in the Ministry of India Institute of Medical Sciences, New Health & Family Welfare was started in Delhi, Dr. RML Hospital, New Delhi, the year 1987-88. Lady Hardinge Medical College, New 1 Drug De-addiction Programmes in India Delhi, PGI, Chandigarh, JIPMER, of Rs. 5.10 crores and currently houses Pondicherry and NIMHANS, Bangalore. 30 in patient beds. The centre conducts A national nodal centre has been estab- therapeutic group sessions for both inpa- lished under the All India Institute of tients and outpatients. Medical Sciences (AIIMS), New Delhi. 4.2 The De-addiction Centre caters to more This is located in Ghaziabad and has been than 50% of the patients seeking treat- designated as “National Drug Dependence ment for substance abuse problems in the Treatment Centre.” city of Bangalore. The Centre also treats II. National Drug Dependence Treatment patients from different parts of Karnataka, Centre, AIIMS Andhra Pradesh, Tamil Nadu and Kerala. Referrals are also received from other states 2.1 National Drug Dependence Treatment of the country including the North-East- Centre, AIIMS was established during ern States. Recently there have been sev- the year 1987-88 and was functioning at eral referrals from countries in the SAARC Deen Dayal Upadhyay Hospital, Hari region and other countries as well. Nagar.This has subsequently been shifted to its own building constructed at CGO V. Convergence: Complex, Kamala Nehru Nagar, 5.1 In a meeting held on 6.10.04 in the Ghaziabad. It started outdoor facilities chamber of Joint Secretary, Ministry of from 14.04.03 and indoor facilities on Social Justice & Empowerment, it was 2.12.03. A Community Clinic was estab- decided that an effective linkage between lished at Trilokpuri and this started func- the rehabilitation centres managed by tioning from 1.8.2003. Apart from ren- NGOs funded by the Ministry of Social dering patient-care services, the centre is Justice could be established with the treat- engaged in a number of research projects.