Proposal to the Indian Psychiatric Society for adopting a specialty section on addiction medicine (alcohol and other substance abuse)

Abstract

The Indian Psychiatric Society, laudably, has a few special subsections catering to the advance and development of certain areas of mental-health care. These are devoted to areas or disciplines which are special to the health of the people of India but for historical reasons have not received the attention they deserve and therefore require affirmative action and special nurturing. This document outlines the need to adopt a similar approach to persons with alcohol- and drug-related problems in India and to create a specialty section on Addiction Medicine, under the purview of the Indian Psychiatric Society. BACKGROUND Alcohol, tobacco and other substance abuse affects a disproportionately large section of people in India The current prevalence rates among male adults (i.e., subjects who had used within the last 1 month) according to the NHS are as follows: alcohol 21.4% [62.5 million]; cannabis 3.0% [8.7 million]; opiates 0.7% [2 million]; any illicit drug 3.6% [10.5 million]. These numbers, when applied to the total Indian population of 102.7 crores in 2001, provide prevalence rates of 60/1000, 8/1000 and 2/1000 population respectively.[1] Around 25% of current users were ‘dependent’ users. Dependent users as a proportion of current users were 17% for alcohol, 26% for cannabis and 22% for opiates. A meta-analysis by Reddy and Chandrashekar[2] revealed an overall prevalence of alcohol dependence to be 6.9/1000 for India, with urban and rural rates of 5.8/1000 and 7.3/1000 population. The rates among men and women were 11.9 and 1.7 respectively. It is also well recognized that the prevalence rates are not uniform and vary widely within the country. The prevalence rates for alcohol- and other substance-use disorders are much higher – for example, in some of the northeastern states (prevalence of alcohol use was above 65% among men and above 50% in Arunachal Pradesh).[1] The figures for prevalence of substance use may at first appear deceptively small, especially the figures for alcohol use, when compared to global estimates; but the absolute numbers are huge. Also, it is increasingly apparent that the health burden, as well as the social cost attributable to alcohol misuse, is due in greater measure to persons with hazardous use than to persons with dependent use. Hazardous use has been estimated at over 80 and 55% of all male and female users respectively.[3] There is no such comfort of ‘low prevalence’ as far as tobacco use is concerned. There are currently about 240 million tobacco users aged 15 years and above (195 million male users and 45 million female users) in India.[4] Prescription drug abuse, especially of sedatives/ hypnotics [0.3 million as per the NHSDAA, 2003], is a growing problem, which has gone largely unrecognized in India. Media reports suggest rising abuse of stimulants by students as awakening pills (for exams, etc.) or as recreational agents in ‘rave’ parties. Then there is the largely unstudied phenomenon of inhalant abuse, which is widely prevalent among ‘hidden populations’ such as street children. The prevalence is more than that of all severe mental disorders combined The gravity of the problem of substance-use disorders can be highlighted by comparing their prevalence with that of other psychiatric disorders. Recent studies have generated all-India prevalence rates for all severe mental disorders of 58/1000[2] to 73/1000.[5] The health burden attributable to substance misuse is inordinately high The impact of a health problem should not be gauged merely by its prevalence but by the health burden and social cost that it wreaks on society. Unfortunately, the focus of the professional community, as well as public scrutiny, has been primarily on the phenomenon of dependence or ‘addiction’ in the individual client. In this context, the excessive and problematic use of a drug that is hard for the individual to control becomes the target. The problems caused by, and associated with, substance use are far broader. They include problems partly or wholly caused by intoxication, such as injuries and some acute illnesses; long-term effects on health of a pattern of substance use that does not otherwise disrupt social functioning; acute and chronic health problems caused by unsafe ways of using drugs otherwise unrelated to pharmacological effects (e.g., using dirty needles); impacts on other people (e.g., secondhand smoke); and impacts of the criminal justice system on people engaging in illegal behavior. Alcohol- and tobacco-related problems in India Hospital admission rates due to the adverse effects of alcohol consumption are disproportionately high. Several studies indicate that nearly 20–30% of admissions/ consultations are due to alcohol-related problems (direct or indirect) in different health-care settings but are under-recognized by primary-care physicians.[67] Alcohol misuse has been implicated in over 20% of traumatic brain injuries[8] and 60% of all injuries reporting to emergency rooms.[9] It has a disproportionately high association with deliberate self-harm,[10] high-risk sexual behavior,[11] HIV infection, tuberculosis,[12] esophageal cancer,[13] liver disease[14] and duodenal ulcer.[15] A recent estimate from surveillance of major noncommunicable diseases in India placed the burden due to alcohol as the numero uno among all noncommunicable disorders.[16] There are 700,000 deaths per year due to smoking and 800,000 to 900,000 per year due to all forms of tobacco use/ exposure in India. For the next 20 years, there will be a faster trajectory of rise in tobacco-related deaths. Many of the deaths (>50%) will occur below 70 years of age.[17] The social cost due to alcohol- and tobacco-related problems is prohibitively high. Alcohol misuse wreaks a high social cost. In addition to the health costs, there are indirect costs linked to a wide variety of social implications (family disruption, marital disharmony, impact on development of children, deprivation of the family, absenteeism and industrial loss, crime and violence, etc.).[18–20] The social cost attributable to alcohol use, extrapolated to the entire country, was estimated at Rs. 244 billion for the year 2003–04; whereas the total excise revenues generated from alcohol manufacture and sales was Rs. 216 billion.[20] An earlier study from Karnataka estimated that monetizable direct and indirect costs attributable to people with alcohol dependence alone were more than three times the profits from alcohol taxation and several times more than the annual health budget of that state.[21] The cost of tobacco-attributable burden of just three groups of diseases – cancer, heart disease and lung disease – was estimated at Rs. 308.33 billion in 2002-2003.[17] Alcohol and substance dependence/ abuse is very often comorbid with other communicable and noncommunicable disorders Axis 1 psychiatric disorders (psychosis, mood disorders, anxiety disorders) and substance abuse co-occur more frequently than can be explained by chance alone. Patients with schizophrenia are 4.6 times more likely to have substance-use disorders than persons without mental illness (3 times higher for alcohol, 6 times higher for other illicit drugs).[22] While it has been previously commonly held that substance-use comorbidity in schizophrenia represents self-medication, an attempt by patients to alleviate adverse positive and negative symptoms, cognitive impairment or medication side effects; recent advances suggest that increased vulnerability to addictive behavior may reflect the impact of the neuropathology of schizophrenia on the neural circuitry mediating drug reward and reinforcement. Thus, schizophrenic patients may have a predilection for addictive behavior as a primary disease symptom in parallel to, and in many cases independent from, their other symptoms. There is also early evidence that the pathology in the neurobiological substrates that underlie mood and anxiety disorders also subserves the predisposition to substance-use problems.[23] Substance abuse, especially of alcohol and tobacco, and a spectrum of high-risk behaviors, which often go together, are common risk factors for most of the noncommunicable disorders (like hypertension, diabetes, heart disease, cancer), which are assuming increasingly larger proportions of the health burden on the Indian society.[3] Drug abuse and addiction also have tremendous implications for the health of the public, since drug use, directly or indirectly, is now seen as a major vector for the transmission of many serious infectious diseases, particularly HIV/ AIDS, hepatitis and tuberculosis; and is instrumental in one of the largest sources of mortality and morbidity in India, namely, road traffic accidents and violence.[20] Substance use disorders, especially involving alcohol and tobacco, are grave public health problems It obviously follows from the above statements that substance-use disorders need to be recognized as public health problems and that there is urgency for psychiatrists to liaise with other medical specialties, the public health delivery system, as well as organizations working in the area of development. As specialists in bio-behavioral disorders, psychiatrists are in an ideal position to do so, and the problem requires the involvement of diverse medical professionals. Here, one needs to exercise caution and steer clear of the ‘me-too’ syndrome, wherein one creates a specialized discipline which clamors for an independent share of limited health-care resources. It would be prudent for the psychiatrist community to work in tandem with, and to juxtapose its strength and skill-sets with, the existing networks and delivery systems for communicable and noncommunicable disorders. Addiction medication is an area where the psychiatrist can fruitfully work in tandem with other medical specialists, and in some ways this will be a good medium to get psychiatry into the mainstream. So the advantage can be mutual. Alcohol and tobacco use are also strongly affected by the economic and political compulsions of the day. One needs to only look at the recent imbroglio over the issue of scary pictures of consequences of tobacco use on cigarette packs and the subsequent backtracking by the Ministry of Health in the face of pressure from the tobacco lobby.[24] Similarly, the pursuit of a rational alcohol policy has been vitiated by economic compulsions of the states and the misdirected coercion of market economics. Thus, there is very little debate on the recent active moves of the grape-growers' lobby to have the Finance Ministry re-designate wine as an agricultural product. Macro-level interventions in these domains are likely to be more effective and cost-effective. Intensive advocacy at several levels should therefore be a part of any endeavor in this area. The Framework Convention on Tobacco Control (FCTC) is a classic example and could provide the template for such initiatives at the national/ international level. The negative economics of addictions (e.g., the social costs of alcohol and tobacco overshadowing tax revenues from these commodities) must be carefully articulated as these are potent advocacy tools. It is also necessary to examine and publicize the cost-effectiveness of interventions to control substance abuse. The role of the industry and its vested interests (e.g., the powerful liquor and tobacco lobbies), as well as the complicity of medical professionals and pharmacists (as in benzodiazepine and other over-the-counter–medication misuse), should also be a focus of any remedial strategies. The psychiatric community is specially equipped to provide leadership to such activities and bring to bear the valuable experiences gained from the successes and mistakes of the community psychiatry movement in India. Substance-use disorders constitute a large proportion of the clinical load in both private and public-health psychiatric practice Substance-use disorders already form more than 20% of the case load of psychiatric practitioners, often, as noted above, inextricably associated with mood, anxiety and psychotic disorders. However, as a recent piquant exchange on a popular Indian psychiatrists' bulletin board revealed, many psychiatrists are loath to take on clients with substance-use disorders, preferring to refer them on to a very short list of colleagues who will see them. This is often related to a feeling of helplessness and frustration faced with the usual picture of recidivism that typifies the natural history of persons with alcohol and drug disorders. Practitioners have an attitude of therapeutic nihilism towards addiction medicine and the addicted patient These experiences translate into an attitude of therapeutic nihilism, which unfortunately is widely prevalent across the medical community. There are several factors which appear to contribute to this way of thinking: Lack of education about alcohol and substance abuse: Only a very small portion of the undergraduate medical syllabus, and even the postgraduate psychiatry syllabus, is devoted to this area, and it is limited only to the medical complications of alcoholism. Negative attitudes about alcoholism: Physicians and psychiatrists in training often see late-stage alcoholics, who often evoke feelings of aversion, hostility and helplessness. Some physicians tend to see alcoholics and drug addicts as bad or morally weak. Discomfort with related social issues: Since alcoholism involves not just medical issues but significant psycho-social issues also, many physicians are uncomfortable dealing with it. Pessimism about treatment: There are many physicians who feel that addiction is not treatable. Part of the helplessness and pessimism occurs because of the experience with late-stage problem drinkers, where the treatment is not always successful. The physician must remember that early detection of, and intervention to resolve, alcohol-, tobacco- and other substance-related problems offers the best results. It is not surprising, then, that the field of addiction psychiatry currently suffers the same pariah status that psychiatry was once ‘favored’ with among other medical professionals. The drug rehabilitation centers of the early 21st century often serve the same function that the leprosaria and asylums of the early 20th century did: seclusion and restraint! Leadership in the field of advocacy and policy making or legislation has been ceded to nonmedical, nonpsychiatric bodies To a large extent, this pessimism also arises from the fact that till lately, there have not been too many effective treatments. Here one must invoke the late Abraham Maslow, who famously said: “If your only tool is a hammer, all your problems look like nails!” For far too long, treatment strategies have been limited by a single-hammer model dominated by an abstinence paradigm and equipped with limited behavioral-change strategies. Unconscionably, physicians in frustration have attempted to curb the uncontrollable behaviors of persons with drug and alcohol problems with antipsychotics and electroconvulsive therapies. This has only served to alienate them from this client group. One has only to attend a survivors' group meeting to realize the hostility that psychiatrists in general are viewed with. Not surprisingly, the onus of treating these clients has shifted either to survivor groups like the Alcoholics Anonymous and Narcotics Anonymous; or to nonmedical, nonpsychiatric rehabilitation agencies. Unsurprisingly, the leadership in the field of advocacy and policy making or legislation in the area has also been ceded to nonmedical, nonpsychiatric bodies. One needs to mention here that the standards of treatment of clients with addictive disorders are variable, at best. The various agencies involved differ widely in the methods they utilize and in a mostly unregulated there are of clients to which are at and often and It is the of the to use their to bring some and of into the by A good to from is the on treatment that the has previously as well as the generated by the of Health and and disorders are bio-behavioral disorders which are strongly by economic and political However, one needs to here that because of their training as bio-behavioral specialists, are best to the of this of these and are recognized to be a of the of substance use with a neurobiological by Recent studies have that have in brain areas for reward and due to a This may in a of system as a spectrum of behaviors by high or increased to a to more attention to and long-term when making to and a for social This is associated with from alcohol and drugs with early of A significant portion of this has of In then, drug in large may be the of, or a of, a which has been to to mood anxiety and may be and even or their to This is to for far too long, the to the medical and model of alcohol and other substance have been to from the prevalent social which drug users the of the model as – who are too to and who deserve they Also, the growing on the to exposure to of abuse is to the neuropathology that rise to the which for the and of the these advances from the are into in and pharmacological strategies for more There are recent reports on the of pharmacological agents and of individual and interventions which are more than earlier A special and is to and document these interventions and them at the same them into public the community of psychiatrists is well to these at the study of the bio-behavioral of this of disorders and the from into Addiction medicine is a and active in most international psychiatric bodies It is to look at the status of addiction within the of other international psychiatric bodies. In the for example, on addiction medicine are medical specialists who focus on addictive disease and have had special study and training on the and treatment of such There are to in the addiction one a psychiatric and the other of The of Addiction that of its are the has received medical training in other The above the need for the Indian Psychiatric to constitute a specialty section devoted to Addiction Medicine, within its The specialty section on Addiction will be and advance the to the and practice of Addiction in all its different the of the health of persons directly or by alcohol- and other substance-related problems and treatment and of all alcohol- and other substance-related as well as which constitute high risk for and alcohol-related This involves and of the to and treatment strategies and This with other but not limited to, agencies social justice and and agencies involved in direct of persons with substance abuse, as well as agencies are by problems directly or indirectly, their and other medical and primary health-care This also requires the of of the and other professionals involved in diverse such as mental drug disease to just a in advocacy in to policy making and in that substance-use disorders and their consequences constitute a grave public health which an severe burden on the health and of the people of India. above requires and of on the social and health costs of substance abuse to the Indian and on the evidence of of There is that the risk factors and consequences of substance-use disorders are often common to, and frequently the development and of a of medical disorders and social with other above, in of will to both in of intervention impact as well as the to will also the and from parallel agencies working towards similar which limited of and and the of the for and standards of treatment and rehabilitation of persons or affected directly or by substance-use disorders. In it will be necessary to for and for the education and training of medical and involved in the the of psychiatrists and professionals in the practice of Addiction in India and standards in the practice of Addiction in and in the field of addiction with a focus on the of to the and the use of interventions in the delivery of mental-health care. A linked to the of the Indian Psychiatric Society, which will of to the practice of Addiction in India, with direct and indirect to or treatment treatment and for education and to the of the and practice of Addiction Medicine, with special on areas like the northeastern and and position on the impact of substance abuse in India, with a to public with organizations to such as the to and primary health and emergency for early detection and the of working to and physicians and pharmacists to drug abuse, especially for the the of a using The to constitute a specialty section on Addiction was first by at the at in It was by Reddy and received by the This document is in of that and the to the document the to the necessary that the may debate and in the to substance to this