Rights to Health and Access to Treatment of Drug Addicted Patients in India

Received: 03-Jan-2024, Manuscript No. JDAR-24-125086 ; Editor assigned: 05-Jan-2024, Pre QC No. JDAR-24-125086 (PQ); Reviewed: 19-Jan-2024, QC No. JDAR-24-125086; Revised: 24-Jan-2024, Manuscript No. JDAR-24-125086 (R); Published: 31-Jan-2024, DOI: 10.4303/JDAR/236280

Introduction

Article 47 of the Indian Constitution mandates that the state should strive to enforce the prohibition of the consumption of intoxicating drinks and drugs harmful to health. Efforts to address drug-related issues in the country can be broadly categorized into supply reduction and demand reduction. Supply reduction, aimed at decreasing the availability of illicit drugs within the country, falls under the jurisdiction of the Narcotics Control Bureau (NCB) under the Ministry of Home Affairs (MHA) and the Department of Revenue, which administers the Narcotic Drugs and Psychotropic Substances (NDPS) Act, 1985, and the prevention of illicit traffic in Narcotic Drugs and Psychotropic Substances (NDPS) Act, 1988. Demand reduction activities, focusing on raising awareness and providing treatment and rehabilitation for drug users, are overseen by the Ministry of Social Justice and Empowerment as the primary coordinating ministry, with some involvement from the Ministry of Health and Family Welfare. India faces a mounting challenge in the form of a growing drug addiction crisis, demanding a dual commitment to effective treatment and the protection of fundamental rights for those grappling with addiction. This paper endeavors to shed light on the critical intersection of drug addiction and human rights in the Indian context, emphasizing the need for a paradigm shift in the current system to break the chains of stigma, discrimination, and violations of individual autonomy. In recent years, drug addiction in India has become a pressing issue, affecting individuals across diverse socio-economic strata. The consequences of this crisis extend beyond health, permeating various facets of society, including familial relationships, employment prospects, and overall community well-being. However, amid the urgency for effective treatment, it is imperative to recognize that the rights of drug-addicted patients are often compromised within the existing healthcare framework [1]. The core argument of this paper is rooted conin the assertion that the prevailing system frequently falls short, subjecting individuals to stigma, discrimination, and violations of their autonomy. Drawing upon international human rights frameworks and Indian legal statutes, the paper aims to delineate tangible reforms to ensure dignified and rights-based drug treatment in India. These reforms encompass crucial aspects such as access to evidence-based therapies, informed consent, privacy protection, and the implementation of holistic rehabilitation strategies addressing both social and psychological determinants of addiction. By prioritizing healing and humanity, this paper contends that India can construct a sustainable and empowering drug treatment system for its citizens. The proposed reforms align with global best practices while considering the nation’s unique sociocultural context. The subsequent sections will delve into the socio-economic profile of drug addicts, the challenges in the current system, human rights frameworks, proposed reforms, and recommendations for a more compassionate and effective approach to drug treatment in India.

Who are addicts?

The World Health Organization (WHO) defines addiction as a “chronic, relapsing brain disease,” requiring evidence- based treatment and long-term support. Yet, drug users in India often face stigma, discrimination, and denial of their fundamental rights. The Narcotic Drugs and Psychotropic Substances Act (NDPS Act) of 1985, while aiming to curb drug trafficking, has contributed to the criminalization of users, leading to forced detention and violations of due process [2]. This punitive approach not only fails to address the underlying causes of addiction but also further marginalizes individuals seeking help. Addicts are predominantly individuals hailing from rural backgrounds, with a significant proportion originating from agricultural households. The age distribution of drug addicts raises concerns, with a substantial 76% falling within the 14 years-35 years age group, and this figure rises to 93% for individuals aged between 14 years and 45 years. Alarmingly, around 5% of addicts-initiated substance use at a remarkably young age, between 7 years and 14 years. Notably, a considerable majority of addicts exhibit limited educational attainment, with the highest educational level often reaching only up to the senior secondary 12^th standard level [3].

Reasons behind drug addiction

• Social and economic factors: Poverty and unemployment, economic hardships, and lack of opportunities may drive individuals towards drug use as a coping mechanism. Social disparities in access to resources and opportunities contribute to drug abuse, particularly in marginalized communities.

• Psychological factors: Mental health disorders, Individuals with mental health issues may turn to drugs as a form of self-medication to alleviate symptoms. Stress and trauma exposure to chronic stress or traumatic events can increase vulnerability to substance abuse. Peer influence and social environment. Peer pressure influence from friends and social circles can play a significant role in initiating drug use. Dysfunctional family environments or a lack of parental support may contribute to susceptibility to drug abuse [4].

• Biological factors: Genetic predisposition genetic factors can contribute to an individual’s susceptibility to developing a substance use disorder. Neurological factors, brain chemistry, and structure may influence the rewarding effects of drugs and the development of addiction.

• Accessibility and availability of drugs: Drug availability and easy access to drugs and their availability in the community can contribute to increased usage rates.

• Cultural and societal influences: Cultural acceptance societal norms and cultural attitudes toward drug use can impact an individual’s likelihood of engaging in substance abuse. Media Influence media portrayal of drug use may influence perceptions and behaviours related to substance abuse. Lack of education and Limited knowledge about the risks associated with drug use may contribute to experimentation and subsequent abuse.

Legal framework in India related to drug-addicted patients

The cultivation of opium in India has a history dating back to the 10^th century. During the colonial era, efforts to regulate opium were made through the Opium Acts of 1867 and 1878, focusing on controlling cultivation and manufacturing rather than consumption. In the 1920s, responding to nationalist pressures, several provincial governments implemented laws to regulate opium consumption. The dangerous drugs act of 1930 aimed to oversee the cultivation, manufacture, sale, possession, trade, and transactions related to drugs, particularly those derived from plants like poppy, hemp, and coca. Notably, cannabis/drug consumption had no associated offenses under this act. The control was primarily exerted through licensing and penalizing unlicensed activities. Subsequently, in 1940, the drugs and cosmetics act, was introduced to regulate medicines, encompassing those developed from cannabis and opium as well.

Criminal offences: The Narcotic drugs and psychotropic substances act criminalizes the production, manufacture, possession, sale, purchase, transport, warehousing, use, consumption, import inter-state, export inter-state, import into India, export from India or transhipment of narcotic drugs and psychotropic substances, except for medical or scientific purposes and in the manner and to the extent provided by the provisions of this act. Over the years, there has been a continuous increase in crime rates associated with drug and intoxicant influence, despite the repeated enactment of fines and legislation. India is a signatory to three United Nations drug conventions: The 1961 single coninvention on narcotic drugs, the 1971 convention on psychotropic substances, and the 1988 convention against illicit traffic in narcotic drugs and psychotropic substances. The Dangerous act of 1930 was introduced to regulate the use, production, possession, manufacture, and sale of drugs like coca and cannabis. Subsequently, in 1940, the drugs and cosmetics act was implemented to oversee the production and sale of medicines, including cannabis and opium. The formation of the Indian constitution in 1950 introduced a new perspective through Article 47, emphasizing the state’s obligation to prohibit the use of drugs unless for therapeutic purposes. In 1985, the Indian Parliament approved the Narcotic Drugs and Psychotropic Substances Act (NDPS Act), replacing the drugs and cosmetics act. Amendments were made to the NDPS Act in 1989, 2001, and 2014. The 2014 amendment introduced new clauses, becoming effective on May 1, 2014. Despite these legislative efforts, the challenges associated with drug abuse and related crimes persist.

Rehabilitation and treatment: While the focus of the act is on controlling drug-related offenses, there is an increasing recognition of the need for rehabilitation and treatment of drug addicts. The mental healthcare act, of 2017 also addresses issues related to mental health, which includes substance use disorders. The Mental Healthcare Act (MHCA) of 2017 incorporates Substance Use Disorders (SUDs) within the definition of mental illness [5]. The legislation has garnered praise for its rights-centered approach, particularly in safeguarding individuals with addiction from cruel treatment at mental health establishments. This protection is ensured through mandatory registration of mental health establishments and regular assessments conducted by state mental health review boards. Additionally, the inclusion of SUDs underscores the perspective that these disorders are health issues rather than solely law and order concerns. Despite these positive changes, certain limitations exist in the MHCA concerning SUDs. The use of outdated terms like “abuse” is noted, which diverges from current classification systems. The act treats SUDs as a singular entity, lacking clarity on the specific substance categories included and the severity levels of SUDs. Moreover, the MHCA of 2017 establishes various human rights for individuals with mental illnesses, emphasizing protection from inhuman and degrading treatment. This aspect holds significance, especially considering the frequent reports of human rights violations occurring under the guise of SUD treatment [6].

The Rights of Persons with Disabilities (RPWD) Act of 2016, replacing the Persons with Disabilities (PWD) Act of 1995, aligns with the United Nations Convention on the Rights of Persons with Disabilities (UNCRPD). Emphasizing a rights-based approach, the RPWD Act ensures the dignity of individuals with disabilities. The act allows disability certification for those diagnosed with “mental illness,” inclusive of Substance Use Disorders (SUDs) as per the Mental Healthcare Act of 2017. Despite debates among psychiatrists due to stigma, the act aims to overcome attitudinal barriers [7]. Recognizing substance use as a significant global health risk, both acts emphasize a non-discriminatory and humane approach towards individuals with SUDs, acknowledging the importance of disability irrespective of the diagnosis. Challenges remain in quantifying disability, certification, and benefit provision for SUDs [8].

National program related to drug use

National mental health program, 1982: The National Mental Health Program (NMHP) was initiated in 1982 to provide accessible mental healthcare services, promote community participation, and translate existing knowledge for social development. A key aspect of the program is the District Mental Health Program, established in 1996. While the World Health Organization (WHO) recommends increased resources for substance use disorders through the mhGAP action program, criticism has been directed at the NMHP for overlooking SUDs during its implementation [9]. Notably, the list of drugs recommended for availability at Primary Health Centers (PHC) lacks medications for treating SUDs, except for lorazepam [10,11]. The recent Health and Wellness Clinics (HWCs) initiative introduced by the Government of India in 2018 aims to integrate SUD management into primary care. The operational guidelines cover the basic management of SUDs, incorporating medications such as naltrexone, naloxone, and thiamine [12]. However, the effectiveness of integrating SUD management in PHCs in both the short and long term remains to be seen. To enhance the implementation of NMHP, it is suggested that, instead of treating the entire spectrum of mental illnesses as a single entity, a more segmented approach, such as addressing psychotic spectrum disorders and SUDs separately, would ensure a fair distribution of resources and service delivery [13].

Central sector scheme for prevention of alcoholism and substance (drug) abuse, 1985

Since 1985-1986, the Ministry of Social Justice and Empowerment has implemented a central sector scheme to address alcoholism and substance abuse. The scheme focuses on the identification, counselling, treatment, and rehabilitation of individuals with addiction, facilitated through voluntary and eligible organizations. In 2008, it was consolidated with a social services scheme under a unified umbrella scheme. Financial assistance is provided to organizations for activities such as operating Integrated Rehabilitation Centres for Addicts (IRCA). Recently, the scheme has been incorporated into the overarching framework of the National Action Plan for Drug Demand Reduction (NAPDDR) 2018.

National action plan for drug demand reduction, 2018

Section 71 of the Narcotic Drugs and Psychotropic Substances (NDPS) Act, 1985, empowers the government to establish centers for identifying and treating addicts, as well as supplying narcotic drugs and psychotropic substances. The provision allows the government to set conditions for such centers, and supply is permitted for medical necessity to registered addicts and others. To effectively implement the NDPS Act and the NDPS Policy 2012, the National Action Plan for Drug Demand Reduction (NAPDDR) has been formulated. Recognizing the need for a comprehensive approach, the Ministry of Social Justice and Empowerment provides financial support for the establishment of “District De-Addiction Centres” in vulnerable districts, aligning with a multipronged strategy to reduce drug use prevalence in the country.

Government initiatives

The government may also undertake various initiatives to address the issue of drug addiction, including awareness programs, treatment facilities, and counseling services.

Nasha Mukt Bharat Abhiyan: The Ministry of Social Justice and Empowerment serves as the central ministry overseeing Drug Demand Reduction efforts in the country. Within its purview, the ministry coordinates implements, and monitors various interventions, including prevention, assessing the extent of the problem, treatment, rehabilitation, aftercare, information dissemination, and community awareness initiatives. To gauge the scale of substance use in India, a national survey titled “National Survey on Extant and Pattern of Substance Use” was conducted. In a concerted effort to combat Substance Abuse and with a vision to achieve a Drug-Free India, the Nasha Mukt Bharat Abhiyaan (NMBA) was launched on August 15, 2020. This initiative targets 272 districts identified as most vulnerable to drug usage based on findings from the Comprehensive National Survey and insights provided by the Narcotics Control Bureau (NCB) [14]. There are 355 drug rehabilitation centers known as “Integrated Rehabilitation Centre for Addicts” receiving funding and support from the Ministry of Social Justice and Empowerment. These centers offer treatment, rehabilitation services, and comprehensive recovery support for individuals struggling with addiction. Over the past five years, a total of 594,754 beneficiaries have received de-addiction treatment at these facilities [15]. Additionally, the Ministry supports 53 Community-based Peer-led Intervention (CPLI) Centers. These CPLIs specifically target vulnerable and at-risk children and adolescents. Within this initiative, peer educators engage with children to raise awareness and conduct life-skill activities [16].

Nasha Mukt Bharat Abhiyaan (NMBA) was launched on 15^th August 2020 and presently is being implemented in 372 identified most vulnerable districts. The State/UT-wise number of districts, in which Nasha Mukt Bharat Abhiyaan (NMBA) is operational at present, are as shown in Table 1 [17].

Table 1: State/UT-wise number of districts, in which Nasha Mukt Bharat Abhiyaan (NMBA) is operational at present

Drug de-addiction program of India, 1988: The Ministry of Social Justice and Empowerment, Government of India, addresses the prevention and rehabilitation aspects of substance use by establishing “rehabilitation centers” operated by non-governmental organizations. The Drug De-Addiction Programme (DDAP) was launched in 1988 under the Ministry of Health and Family Welfare, Government of India, with a mandate to provide treatment for substance use disorders. Through DDAP, De-addiction Centers (DACs) have been set up in government hospitals, supported by a one-time financial grant from the central government, while the recurring expenses are covered by state governments. Some premier institutions and DACs in the North-eastern region receive annual recurring grants for their operation. Capacity building is a key focus of DDAP, involving the training of non-specialist medical officers in government hospitals, along with the development of various training materials. The DDAP also works on establishing a “drug abuse monitoring system” to track the drug use patterns and profiles among individuals seeking treatment in DACs. Monitoring and evaluation exercises indicate that the current inpatient treatment model, with shared responsibilities between central and state governments, has achieved partial success. As part of ongoing efforts, establishing drug treatment clinics on a pilot basis, emphasizing outpatient treatment and direct support from DDAP for staff and medicines, is yielding positive results [18].

The updated list of Drug Treatment Clinics (DTCs) under NDDTC, AIIMS, New Delhi under the DTC Scheme given in Table 2 [19].

Table 2: Updated list of Drug Treatment Clinics (DTCs) under NDDTC, AIIMS, New Delhi under the DTC Scheme

Gaps and violations in the current system

The reduction of psychoactive substance demand in India falls under the purview of the Ministry of Social Justice and Empowerment and the Ministry of Health and Family Welfare offers financial support to Non-Governmental Organizations (NGOs) to establish and operate Integrated Rehabilitation Centers for Addicts [20]. Currently, the Ministry supports over 400 Integrated Rehabilitation Centers for Addicts (IRCAs). The Ministry of Health and Family Welfare’s initiative, the “Drug De-addiction Programme (DDAP),” has set up over 120 De-addiction Centres (DACs) for inpatient treatment of drug addicts in various medical colleges and district hospitals. Additionally, privately operated facilities are present, run by individuals ranging from highly qualified psychiatrists to those who have successfully recovered from drug addiction [21].

The existing drug treatment system in India faces various challenges:

1. Limited availability of evidence-based care: Numerous centers rely on outdated abstinence-only approaches, overlooking proven therapies such as medication-assisted treatment [22].

2. Coercion and involuntary treatment: The association of addiction with criminality often results in involuntary detention and treatment, infringing upon informed consent and personal autonomy [23].

3. Stigma and discrimination: Deep-seated societal biases and a lack of awareness persistently marginalize drug users, impeding their access to healthcare, employment, and social integration [24].

4. Privacy breaches: Poor protection of data related to a patient’s drug use history raises the risk of discrimination and potential misuse [25].

5. Insufficient psychosocial support: Emphasis on detoxification and abstinence overlooks the emotional and social aspects of recovery, contributing to elevated relapse rates [26].

Absence of fundamental amenities

Many regulations and laws, such as the Mental Healthcare Act (MHCA) of 2017, emphasize the minimum standards of care for individuals with substance use disorders [27]. MHCA (Sec 20) asserts the rights to privacy, a safe and hygienic environment, and recreational facilities for those undergoing treatment in mental health establishments [28]. State rules, like the Minimum Standards of Care for Centres Providing Substance Use Disorder Treatment and Rehabilitation, 2018 for NCT of Delhi, also stress on basic facilities like access to wholesome food. Despite these regulations, our study highlights that numerous private addiction treatment facilities neglect these standards. Inmates from a de-addiction center in Ludhiana, Punjab, instances of poor conditions. To ensure adequate care, treatment institutions must base their philosophy on a robust ethical foundation. Operating within an ethical framework requires adherence to national laws regarding facility registration, licensing, staffing according to minimum care standards, and preventing human rights violations [29].

Unfortunately, our study suggests that many treatment facilities, particularly privately owned ones, have transformed into places of mistreatment rather than healing [30]. The crisis is compounded by the lack of attention from relevant government bodies, insufficient regulation in the addiction profession, and to some extent, a lack of awareness among service users. Strengthening the Indian de-addiction treatment system demands not only evidence-based treatment but, more importantly, interventions rooted in rights and compassion.

Conclusion

India has proactively undertaken prompt measures to tackle drug-related issues. Despite possessing a comprehensive plan, a dedicated workforce, and numerous specialized programs and policies, there exists a necessity for enhancing existing initiatives to meet unaddressed needs. It is crucial to establish a cohesive collaboration between Ministries to ensure policy uniformity, make informed decisions based on scientific insights, and bolster the chains involved in reducing the supply of drugs. The Government of India has achieved significant advancements in the control of drug-related issues and the reduction of demand.

The introduction and evolution of various programs, acts, and statutes have played a crucial role in alleviating the overall mental health burden in the country. These policies are interconnected, exhibiting diverse implementation and coverage across different regions of the nation. Primary care physicians, mental health professionals, and stakeholders at both state and national levels must be well-informed about these policies to enhance healthcare services for individuals. Additionally, there is a need to conduct a comparative analysis of India’s drug use policies with those of other countries, offering a comprehensive perspective on the strengths and weaknesses of the current Indian approaches.

Recommendations for reform

• Promoting informed consent and voluntary treatment: Patients must have access to comprehensive information about different treatment options and the right to choose freely.

• Combating stigma and discrimination: Public awareness campaigns and educational programs can challenge negative stereotypes and promote understanding of addiction as a health issue.

• Increase knowledge of drug abuse problems and effective interventions: Use the tools of communications technology to achieve better transfer and use of information flows rapidly around the world. The process of knowledge assessment and transfer provides an opportunity to improve international and community responses to substance-related problems. Drug abuse prevention has not sufficiently exploited communication tools. New uses of electronic information transfer are needed. Policy problems facing countries and international organizations are increasing faster than their capacity to deal with them, and information technology can help increase the effectiveness of response measures.

• Increase international collaboration on drug abuse: International agencies have a wealth of expertise on drug problems, and their combined experience gives a unique opportunity to tackle complex problems. A mechanism of collaboration is needed to focus the cooperation of international agencies on selected drug abuse problems

• Strengthening data privacy protections: Robust legal and technical safeguards are needed to ensure the confidentiality of patient information.

• Integrating psychosocial support services: Alongside medical treatment, providing individual and group therapy, vocational training, and peer support can enhance long-term recovery prospects.

Acknowledgement

None.

Conflict Of Interest

Authors have no conflict of interest to declare.

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