Psychoactive drug use and substance-induced psychosis: Emerging challenges in a low-middle-income country

Plain language summary

The Ministry of Home Affairs, Nepal, “The National Master Plan on Prevention and Control of Narcotic Drugs 2012-2019″ reports that cannabis accounts for the highest prevalence of initial narcotic drug use (80.4%), followed by diazepam (9.4%). Narcotic drug users increased by 5.06% annually over the seven-year period, with most users initiating use below the age of 19, posing a significant challenge for drug-induced psychosis. Health policies also influence the use of psychoactive agents. With growing calls for cannabis legalisation in Nepal, policymakers must carefully consider evidence from high-income countries, including the associated public health and mental health consequences. The 12-directive Mandamus issued by the Supreme Court of Nepal for individuals with mental health conditions represents a pivotal step in strengthening mental health in Nepal. It focuses on upholding mental health rights under the constitution and aligning national policies and regulations with international human rights treaties. Effective mental health care requires multidisciplinary teams comprising psychiatrists, psychologists, psychiatric nurses, psychotherapists, and pharmacists.

The prevalence of drug-induced disorders (DUD) and psychosis is growing in the context of low- and middle-income countries (LMICs), as the conditions further exacerbate because of the lack of knowledge and scarce research regarding the utilization of psychoactive agents and the development of DUD. ¹ One such LMIC where the conditions of such psychoactive agents are vivid with an increased utilization is Nepal, a South Asian Nation. This is evident through the report issued by the Ministry of Home Affairs, Nepal where “The National Master Plan on Prevention and Control of Narcotic Drugs 2012-2019” shows the prevalence of initial users of narcotic drugs with cannabis (80.4%) as the highest followed by diazepam (9.4%), opiates (4.7%), tramadol (1.9%), pregabalin (1.9%), inhalants (1.8%), hallucinogens (0.5%) and the lowest as stimulants (0.1%). ² Notably, narcotic drug users have increased 5.06% annually, with most initiating use below 19 years of age. ²

The use of such psychoactive agents, along with the development of mental health conditions, is also hugely affected by policy changes in a Nation or its states. Legalization of medical use of cannabis is observed heavily in countries such as the USA, Canada, and Uruguay; as such, these changes in policies affect the utilization of psychoactive agents, as they can have both favorable and adverse outcomes. ³ While Nepal cannot be directly compared to high-income settings, evidence from Florida, USA, which has the world’s largest cannabis program, is instructive: legalisation of smokable cannabis was associated with a significant increase in dispensed THC, exceeding recommended doses and raising patient safety concerns. This highlights that even in well-resourced settings with established regulatory frameworks, cannabis policy changes carry substantial risks, suggesting that Nepal must exercise particular caution given its limited regulatory capacity and healthcare infrastructure. ⁴ With proponents for cannabis legalization in the context of Nepal, too, policymakers must think about the evidence from high-income countries along with the public health consequences associated with it. ³ A national STEPS survey (Nepal, 2019; n>6,000) reported 17% prevalence of current smoking and 7% harmful alcohol use. ⁵ A cross-sectional study at a Nepali primary healthcare facility (n≈700) found 30.8% prevalence of Alcohol Use Disorder, with 5.4% in alcohol dependence. ⁶

The recent 12 directives order Mandamus issued by the Supreme Court of Nepal on April 25th, 2025, for individuals affected with mental health conditions, acts as one of the pivotal moments for strengthening Nepalese mental health conditions. ⁷ The directives specifically focus on implementing mental health rights as per the constitution, along with harmonizing all policies and rules with international human rights treaties. ⁷ Multidisciplinary teams involving psychiatrists, psychologists, psychiatric nurses, psychotherapists, and pharmacists are definitely needed to improve patient health quality. The government must prioritize the execution of the Supreme Court’s mandamus by expanding mental health services, increasing the number of trained personnel, and strengthening DUD treatment capacity. Relevant ministries should coordinate to reduce illicit use of psychoactive agents, and policymakers must draw on evidence from contexts comparable to Nepal before considering any regulatory change.

ORCID iDs

Nabin Pathak https://orcid.org/0000-0002-1952-642X

Sunil Shrestha https://orcid.org/0000-0002-9174-7120

Ethical considerations

Ethics board approval was not required for this study, as it is a letter to the editor and does not involve clinical patients.