Treatment of substance use disorders through the government health facilities: Developments in the “Drug De-addiction Programme” of Ministry of Health and Family Welfare, Government of India

Abstract

Substance use disorder (SUD) is a major problem worldwide, including in India, and contributes significantly to morbidity and mortality. The Ministry of Social Justice and Empowerment, Government of India, addresses the prevention and rehabilitation aspect of substance use through the establishment of “rehabilitation centers” run by nongovernmental organizations. The Drug De-addiction Programme (DDAP) was initiated in 1988 under the Ministry of Health and Family Welfare, Government of India, and was mandated with provision of treatment for SUDs. Through the DDAP, de-addiction centers (DACs) have been established in government hospitals by providing a one-time financial grant by the central government, with the recurring expenses to be borne by the state governments. In addition, some premier institutions as well as DACs from Northeastern region are provided annual recurring grants for their functioning. Capacity building has been a major focus area of DDAP in which nonspecialist medical officers working in government hospitals have been trained, and various training materials have been developed. Another major area of work is the development of “drug abuse monitoring system” to track the pattern of drug use and profile among individuals seeking treatment in the DACs. Monitoring and evaluation exercises carried out show that the existing model of inpatient treatment and of shared responsibility between central and state governments is partially successful. The establishment of drug treatment clinics on pilot basis with a focus on outpatient treatment and direct support from the DDAP for staff as well as for medicines is showing encouraging results.

INTRODUCTION

Substance use disorder (SUD) is a global public health issue. It was estimated that globally, 246 million people (1 out of 20) aged between 15 and 64 years used an illicit drug in 2013, out of whom about 27 million people are problem drug users. Almost half of the illicit problem drug users inject drugs and an estimated 1.65 million of those who inject drugs were living with human immunodeficiency virus (HIV).[1] Similarly, a large proportion of the population (around 38%) consume alcohol globally, among whom, about 16% engage in heavy episodic drinking. In 2012, about 5.9% of all global deaths were attributable to alcohol consumption.[2] The global disease burden attributable to illicit drugs and alcohol use disorders was estimated to be 10.9% and 9.6% of disability-adjusted life years caused by mental illness and SUD.[3] In India, the National Household Survey reported alcohol (21.4%) as the primary substance used followed by cannabis (3.0%) and opioids (0.7%). The survey estimated that more than one crore people in the country were suffering from alcohol or drug dependence.[4] SUDs are associated with various health hazards which place a heavy burden on public health systems in terms of the prevention, treatment, and care of SUDs and their health consequences.

ADDRESSING THE DRUG USE PROBLEM IN INDIA: THE ARRANGEMENTS

In India, different government departments and ministries work to address the problem of drug use. Like elsewhere in the world, three broad approaches are followed to address the issue of drug use – “supply reduction,” “demand reduction,” and “harm reduction.” The “supply reduction” sector of the government works toward reducing the availability of illicit drugs through implementing the relevant drug laws and policies and is managed largely by the Department of Revenue, Ministry of Finance, the Narcotics Control Bureau, Ministry of Home Affairs, Government of India and a variety of other agencies in the central or state governments. The “demand reduction” sector, on the other hand, deals with reducing the demand for drugs in the population through prevention, treatment, and rehabilitation. The Ministry of Social Justice and Empowerment (MoSJE), Government of India, is the nodal ministry for demand reduction and has a “Scheme for Prevention of Alcoholism and Substance (Drugs) Abuse” in place since 1985–86.[5] This scheme of the MoSJE is implemented by the nongovernmental organizations (NGOs), who run “Integrated Rehabilitation Centre for Addicts” for treatment and rehabilitation of people with SUD. The health sector of the country also plays a very important role in drug demand reduction by treatment of SUDs through government health-care facilities, which is the focus of this article. “Harm reduction” in India is primarily seen as prevention of HIV among people who inject drugs and various strategies for this are implemented by the National AIDS Control Organization, Ministry of Health and Family Welfare (MoHFW).[6]

THE “DRUG DE-ADDICTION PROGRAMME”: EVOLUTION

The decade of 1980s witnessed some very important developments in India, in response to the rising problems of drugs use. Along with the scheme of MoSJE (mentioned earlier), there was a felt need among the experts and policy makers to address the medical treatment of SUDs through the health-care systems of the country, involving the MoHFW, Government of India. It was envisaged that treatment provision will be the mandate of MoHFW, while prevention and rehabilitation will be the mandate of the MoSJE. Following the recommendations of a Cabinet subcommittee, the “Drug De-addiction Programme (DDAP)” was launched in 1988. The program envisaged establishing 30-bedded “de-addiction centers” (DACs) (The term “de-addiction” continues to be used in the official communications of the Government health sector, and hence, it is being used here. It should not be seen as an endorsement of this term by the authors) in each of the six premier hospitals/institutions in the country for providing inpatient treatment for patients with SUD. Within next few years, the program was further expanded in 1992–93 under a scheme for establishment of DACs in medical colleges/district hospitals in various states. Through a collaboration between the central and state governments, the one-time expenses for establishment of DACs were borne by the central government, while the recurring cost of running the DAC services was envisaged to be borne by the state governments. The arrangement between the central and state government was made taking into consideration that “health” subject is a shared mandate between the union and state governments under the Constitution of India. Thus, the central government assistance was largely limited to provision of one-time grant for infrastructure, while staff, supplies, and other recurring expenses were to be borne by the respective state governments. For the northeastern states, however, there was a provision of an additional recurring assistance of up to Rs. 200,000 per year per center by the central government. Under the scheme, about 122 DACs have been established by the MoHFW, of which 43 are in the northeastern states. Besides, the DACs in the northeastern states, few others were also supported by the MoHFW through provision of one-time infrastructure support as well as almost 100% of recurring expenses for staff and supplies. These were located in the following central government institutes: All India Institute of Medical Sciences (AIIMS), New Delhi; Postgraduate Institute of Medical Education and Research, Chandigarh; National Institute of Mental Health and Neurosciences, Bengaluru; Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry; and Ram Manohar Lohia Hospital, New Delhi. Out of these, the DAC at AIIMS, New Delhi, was designated as the “National Drug Dependence Treatment Centre” (NDDTC) in 2002, with an expanded mandate of working as a national level resource center. Apart from the clinical, academic, and training activities, NDDTC has been tasked with the responsibility of playing an advisory role to the DDAP, MoH, and FW as well as coordination of several activities on behalf of the Ministry.[7,8]

The “DDAP” is a modest-sized program coordinated by the MoHFW through a “section” in the Ministry where the day-to-day affairs are managed by a Director, DDAP, who in turn, reports to a Joint Secretary. In most of the state governments, there are no state-level counterparts for DDAP. There is also provision of an additional staff in the form of an assistant program officer/under-secretary. However, none of the senior administrative officials are responsible exclusively for this program and they have many other responsibilities as well. Thus, there is no senior official at the Union Health Ministry in Government of India, tasked exclusively with looking after the addiction treatment issues. The budget allocated to the DDAP is also modest; the approved budget outlay for 5 years in the 12^th 5-year plan from 2012 to 17 was Rupees one hundred and fifty-one crores.[9]

MAJOR FOCUS AREA OF DRUG DE-ADDICTION PROGRAMME: CAPACITY BUILDING

Since the direct provision of services through the MoHFW was very limited in scope and scale, an important area identified by the DDAP from its very inception was building the capacities of service providers for providing addiction treatment services. Considering the burden and magnitude of SUD and the shortage of specialist medical professionals (i.e., psychiatrists) in India, the strategy was t provide short-term, in-service training to the nonspecialist cadre of general duty medical officers (GDMOs), who were employed by the state government health services. Through national level workshops of experts in 1988 and 2003, training curricula were developed to train the GDMOs. While initially, the training courses were of three-week duration, over the years, the duration has been reduced to 14 days, 10 days, and then 7 days on receiving feedback from the training participants. NDDTC, along with other collaborating medical institutes, has conducted several training courses through which cumulatively more than 1000 doctors have been trained in management of SUDs in general health-care settings.

Some important experiences were gathered through these training programs. In general, these programs were perceived as very useful by the trainees. This is understandable, since at the level of graduate medical course (MBBS), there is hardly any exposure or training on substance use issues.[10] Thus, most trainees reported a significant enhancement of their knowledge, which has been corroborated objectively through comparison of their scores on the pre- and post-training tests. Another useful insight gained has been that the training programs are more effective when lecture/discussion formats are supplemented with clinical exposure through live case demonstrations and trainees joining the resource persons (faculty members) in the outpatient clinics or ward rounds. A major challenge has been in getting nominations of in-service doctors from their respective state governments for the training program due to their clinical responsibilities and competing health priorities. However, there is no clear indication whether the training gets translated in enhancement of service delivery at the hospitals.

Along with medical professionals, efforts have been made to train paramedical and paraclinical professionals too though at a much smaller scale. Along with the development of training curricula and conducting training programs, a very important capacity-building initiative of DDAP has been development of resource materials such as manuals and handbooks for physicians, nurses, and paramedical staff on brief interventions, pharmacotherapy, and psychosocial interventions. Most of the resource materials are available for download free-of-cost from the NDDTC website at www.aiims.edu.

DRUG ABUSE MONITORING SYSTEM

Yet, another demand reduction area in which the MoHFW has taken the lead is the establishment of “Drug Abuse Monitoring System” (DAMS) to track the pattern of drug use and profile of treatment seekers as well as to assess any change in trends among treatment seekers at the government DACs. This system, developed by NDDTC for DDAP, is based on data collection from all the government DACs on an annual basis and is continuing from the year 2007 onward till date.[11] Data on clinical and demographic profile for all the “new” treatment seekers at each DAC are collected through a one-page performa and are collated and analyzed by NDDTC and shared with the DDAP. However, compliance of the DACs with this system is far from adequate; analysis of the DAMS data conducted from the year 2007 to 2013 showed that 57% DACs participated in the activity; only 39% DACs had transmitted the data periodically. The most striking feature was the variable patient load across the centers. On an average, each participating center reported catering to few new patients. In other words, while there is a dearth of treatment services in the country, existing services in the government hospitals are attracting very few patients.

EVALUATION AND MONITORING OF SERVICES

While there is no ongoing program of monitoring the functioning of DACs, on a few occasions, monitoring and evaluation exercises have been carried out by DDAP, MoHFW through NDDTC. In the first instance (2002), information was obtained from 104 DACs through postal questionnaire and/or through onsite visits. It was seen that most hospitals with DACs were providing some treatment services although only few DACs were functioning optimally. Subsequently, DACs in five states (Himachal Pradesh, Punjab, Nagaland, Manipur, and Maharashtra) were visited in 2006–07 and interactions with officer-in-charge of the DACs were held. Some of the constraints in the functioning of DACs noted in these evaluation exercises included:

• There was mostly no provision of funding for providing services through the state governments for the DACs (except for northeastern states that were receiving recurring grant from the central government)

• Low priority was accorded to drug dependence treatment services by the hospital authorities. Trained doctors were not available in many of the centers, neither was there any dedicated support staff (nurses/counselors)

• Very few patients were accessing services and even those accessing services were not retained in treatment. Record maintenance was inadequate. Most of the medicines required for treatment were usually not available. Psychosocial interventions were often not provided. Community-based activities were lacking.

Subsequently, in one more evaluation conducted in 2007 that focused on assessment of outcome of treatment at the DACs, outcome data for 3 years were collected through postal questionnaires and through visits from a total of 44 centers that had seen more than 100 new patients in the previous year. This exercise also confirmed the findings of the previous evaluations.

Thus, these evaluation exercises demonstrated that the model of service delivery – based on an inpatient setting of care with infrastructure support by the central government and which was dependent on state government support for continuation of services – was met with only partial success. Hence, there was an urgent need of strengthening the DDAP of MoHFW in India.

STRENGTHENING THE DRUG DE-ADDICTION PROGRAMME IN INDIA

The provision of treatment services through DDAP has focused heavily on inpatient treatment services. However, with accumulating experience in India and globally, it is now understood that a large number of patients can be treated on an outpatient basis and only some may require inpatient services. Based on this, a scheme was developed by NDDTC, AIIMS, titled “Strengthening DDAP: Establishment of Drug Treatment Clinics (DTCs)”. The scheme was subsequently approved by the Expenditure Finance Committee of the MoHFW for the 12^th 5-year plan period (2012-17). Through this initiative, it was proposed that the DTC should be made functional in government health-care facilities (i.e., medical colleges and civil hospitals/district hospitals), largely utilizing the existing infrastructure. The DTC would be part of the general hospital and dedicated to provide outpatient services for patients with substance use problems. Some patients who need admission would be hospitalized in the established DAC ward/psychiatry ward/medicine ward. Apart from emphasis on outpatient treatment, the most important departure from the existing system includes direct funding from the central government for the staff salaries and procurement of medications (routed through NDDTC, AIIMS). A nodal officer identified from the hospital and three dedicated contractual staff (doctor, nurse, and counselor recruited for this purpose) are responsible for provision of services. The treatment services include psychosocial as well as pharmacological interventions. All the DTCs provide free-of-cost medication for short-term treatment of withdrawals and long-term pharmacotherapy (including opioid agonists, opioid antagonists, and anti-craving and deterrent medications for treatment of alcohol use disorder). Those patients requiring ancillary services are referred to other departments of the hospital and to NGOs for social needs. DTCs also follow uniform system of record keeping of key activities and services, with periodic reporting to the regional resource centers established in select psychiatry departments of medical colleges. The entire system is based on intensive capacity building, monitoring, and mentoring of the staff, coordinated by the NDDTC and other regional resource centers. As on December 2016, 14 such DTCs are functional in government hospitals in Delhi, Haryana, Maharashtra, Manipur, Punjab, Rajasthan, and Uttar Pradesh. The scheme is on a scale-up mode and it is proposed that by the end of 2017, there will be 25–30 DTCs across the country. The learning from this phase will be used to expand the network of DTCs so that there are at least 100 government hospitals providing free-of-cost, outpatient treatment for SUDs across the country. The initial experiences with the scheme are highly encouraging. This initiative has been awarded the prestigious British Medical Journal South Asia Award for the year 2016 under the category “Noncommunicable Disease Initiative of the Year.”

CONCLUSIONS

The DDAP of MoHFW has succeeded in (a) establishing addiction treatment as a health issue and (b) creating systems for capacity building of health professionals in the country in this area. The resource institutions created by DDAP have evolved as leaders in the area of addiction treatment at national and international levels. However, the scale and scope of services under this program have been limited. The initially planned strategy – one-time infrastructure support from the central government and the recurring expenditure by the state governments – has met with only limited success. The recent development – scheme of establishing DTCs – is likely to be much more successful since it is based almost entirely upon funding support from the central government, with mentoring provided by the academic institutions. Eventually, issues regarding sustainability of this initiative will have to be considered. There is a need to continuously monitor the implementation and ensure ongoing support and nurturance to the scheme. It is high time that addiction treatment gets mainstreamed into general health care.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.