Is there an opioid epidemic in India?

The opioid epidemic in the United States has brought addiction-related issues into global consciousness. Does this epidemic extend beyond American shores? High opioid-related mortality rates are reported in many parts of the world1 including Canada,2 the UK,3 Australia4 and Mexico.5 This essay asks: Is India going through an opioid epidemic? Data for middle and low economic countries (LMICs) are generally considered to be less ‘reliable’ than in high-income countries. For instance, in India, the precise numbers of opioid-related overdose deaths are not available. Deaths particularly among the homeless are often registered as ‘cause unknown’ or as ‘death by exposure to cold’ or ‘heat’, depending on the season. There have been only two national surveys that have estimated the prevalence of opioid use and opioid use disorders in India, the first in 2004 and a second in 2019. The 2019 study6 showed that the prevalence of opioid use in India is three times the global average. About 2.1% of India’s population use opioids. There is considerable variation in the number of opioid users across Indian states. Uttar Pradesh has the highest number of people with opioid use problems, although in terms of percentage of population affected, the worst affected states are Mizoram and Nagaland. (Fig. 1) India still has lower figures than USA for opioid use prevalence. However, this may change in the future, as pharmaceutical companies begin to aggressively target developing world markets, and governments gradually widen the range of available opioids. India’s previously stringent Narcotic Drugs and Psychotropic Substances Act was amended in 2014, to allow easier access to some opioids labelled as ‘essential narcotics’, for treatment purposes. These ‘essential narcotics’ include fentanyl, oxycodone, codeine and hydrocodone, all of which are prominent within the American opioid epidemic. The amendment in the narcotics law has paved the way for easier access to these drugs in India, which may worsen opioid use problems in India. Top ten states: no. of people who need help for opioid related problems. Source: Ambekar A, Agrawal A, Rao R, et al. Magnitude of Substance Use in India. New Delhi: Ministry of Social Justice and Empowerment, Government of India; 2019. http://socialjustice.nic.in/writereaddata/UploadFile/Survey%20Report636935330086452652.pdf. Top ten states: no. of people who need help for opioid related problems. Source: Ambekar A, Agrawal A, Rao R, et al. Magnitude of Substance Use in India. New Delhi: Ministry of Social Justice and Empowerment, Government of India; 2019. http://socialjustice.nic.in/writereaddata/UploadFile/Survey%20Report636935330086452652.pdf. Thus, India may be said to be going through an opioid epidemic. However, the use of the generic term ‘epidemic’ in some ways obscures, the differences between and within nations, across neighbouring territories, and even between demographically similar, adjacent localities in urban and rural areas. Although retaining the basic premise of an emerging crisis, the essay focuses on the significance of these global and local variations in opioid use and abuse. In USA, UK and Canada, the opioid epidemic appears to be mainly due to prescription-opioids. In contrast, in India, as in some other Asian countries such as Pakistan, Afghanistan and Iran, presently, the epidemic is largely due to heroin addiction (Fig. 2). Even for people who inject drugs (PWIDs) in India, the opioid infused pharmaceutical cocktails they inject are a continuation of heroin-related addiction trajectories and not related to prescription drugs. The source of pharmaceutical opioids is the informal drug market, most often from pharmacies without a prescription.7 Prevalence rate (%) of Illicit drug use in general population. Prevalence rate (%) of Illicit drug use in general population. The 2019 national survey6 shows that some Indian states have a significantly higher prevalence of opioid use than others, even when compared to their neighbouring states. Even within states, there are significant local variations. In the course of ethnographic and clinical work in Delhi, a striking difference was noted between two proximate and demographically similar lower-income urban neighbourhoods, Trilokpuri and Sundernagri in East Delhi (Fig. 3). In these two areas national drug dependence treatment centre (NDDTC), All India Institute of Medical Sciences (AIIMS) runs community drug treatment clinics that offer opioid substitution therapy (OST).8 As most nashe baaz (the colloquial Hindi term for addicts—although the term ‘addict’ is usually not used in contemporary academic scholarship because of its pejorative implications, it is used here to retain the colloquial resonance of the Hindi term), describe it, there are three ways to ingest heroin. It can be smoked or chased (inhaled) by heating on a tin foil (panni),9 which costs approximately Rs. 250 (£2.50) a ‘piece’. One ‘piece’ can produce 22 ‘lines’. A panni typically requires at least two lines. A third method, considered more extreme even by the most hardened users, is by injection. An injector’s ‘set’ consists of a ‘sui’ (needle and syringe) and ‘sheeshi’ (small glass bottles with buprenorphine and chlorpheniramine), which are available from ‘secretly’ known chemist shops for Rs. 50 (50 pence) or less, one-fifth the price of a smoker or chaser’s habit. As most addicts assert, ‘a chaser’s life is ten years long, an injector’s life is two years at most’. The increased risks faced by injectors are well known in public health scholarship, in particular the risk of contracting HIV or Hepatitis B through shared needles, with mortality rates up to 10 times higher than the general population.10 Data were collected by the authors based on repeat clinical interviews (in many cases following patient trajectories over five or more years), patient files and ethnographic immersion in both neighbourhoods with treatment seekers, addicts, residents and through household surveys. A stark difference in the mode of heroin consumption was identified between these two proximate neighbourhoods. Trilokpuri had no injectors; in contrast, in Sundernagri, injector groups and the detritus of used injections were commonplace in neighbourhood spaces such as parks. Neighbourhoods (Delhi, India). Neighbourhoods (Delhi, India). Specifically, in Trilokpuri out of the 3138 drug users attending the clinic only 4 patients (0.1%) were former injecting drug users (IDUs) and 6 patients (0.2%) were HIV positive. In contrast, in Sundernagri out of 1773 patients, 300 patients (17%) were current IDUs and 137 patients (7%) were HIV positive. National data show a higher rate of HIV among IDUs than female sex workers, who are often assumed to be the cause for the spread of HIV.11 These ‘local’ differences would be obscured in an undifferentiated picture of a global or national epidemic. A further question, somewhat beyond the scope of this present essay, would be: what causes such differences, between otherwise similar neighbourhoods and local ecologies? A possible explanation in this case would be differences of caste and occupational status between these two neighbourhoods: a mainly salaried economy of government-employed sanitation workers in Trilokpuri who can afford the more expensive chasing smack as opposed to the more unstable informal economy of Sundernagri where they can only afford the cheaper option of injecting. Although the local economies are a possible factor a second, more qualitatively observed factor would be the distinct ‘cultures of death’12 that emerged within these two neighbourhoods, which restricted the rise of an injector culture in Trilokpuri. As the ‘chaska’ (craze) for drug injecting first emerged in Delhi in the early 2000s, a series of sudden deaths among neophyte injectors in Trilokpuri led to a distrust of this mode of consumption. Gangs of addicts, some of whom were linked to local political leaders, began to police collective spaces to root out injectors from the neighbourhood. In contrast, in Sundernagri, which witnessed a significantly higher level of mortality among IDUs, this became a form of ‘death without weeping’13 and did not result in the emergence of anti-injector sentiment. The injector culture therefore took root and grew within this more unstable local economy. Such local variations between seemingly similar demographic areas can also have a wider significance. For instance, in USA, more recent opioid related research tracks neighbourhood level variation,14 as well as significant rural–urban and regional differences between the American South, Northeast and the Midwest in patterns of opioid abuse15 and mortality rates.16 These differences are significant enough to ask the questions of whether or not this is an entirely physician induced ‘iatrogenic’ epidemic even within a US context.17 Some argue that the American opioid epidemic is better understood as a series of three distinct waves,18 marked by different types of opioids and diverse geographical, temporal and socio-demographic patterns of mortality. A deeper understanding of such variations within seemingly similar regions could have a significant impact on improved treatment and appropriate interventions. A third key factor in understanding the opioid epidemic in India is a sharp gender gap, in ways that are complementary and distinct from other analyses of the mental health gender-gap in India. Women report significantly higher levels of mental distress than men.19 In contrast (or perhaps not as a contrast, but rather as a gendered variation in the experience of distress), those with heroin addiction are overwhelmingly male. The national survey, 2019, reported the prevalence of current opioid use to be 4% in males and 0.2% in females. Studying substance abuse among women in India20,21 is more difficult, partly because of under-reporting.22 Women rarely attend drug treatment centres, often coming for only one visit. According to available data, including data from our household surveys and ethnographic work, the most common substances for women include gutka (smokeless tobacco), non-opioid analgesics, alcohol and benzodiazepines. And yet, this does not mean that the opioid epidemic is a primarily ‘male’ experience. In ethnographic and clinical work carried out by the authors, findings suggest that heroin addicts in India, almost always continue to live within households. Their primary caregivers are overwhelmingly female. The addicts who survive often do so because of the consistent and continued care by a mother, sister or wife. This is illustrated by the difference in the two neighbourhoods discussed above. In Trilokpuri, with significantly lower opioid-related mortality, clinic visits with families is significantly higher (Fig. 4). Further, in a quirk of the informal economy, drug dealers in the north of India, for example, in Delhi are predominantly women, often with film noir and folklore-infused epithets like Vidhwa (the widow), Gudiya (the doll) and Budiya (the old woman). These dealers are often the widows of former gang leaders and addicts, who are able to broker deals with the local police station and maintain stability between rival gangs. Trilokpuri versus Sundarnagri. Comparison of family members accompanying patients during clinic visits. Source: A mixed method (anthropological and psychological) study to examine and compare neighborhood characteristics in determining high risk behavior and treatment outcomes in relation to opioid use in two Resettlement Colonies in East Delhi (Tallied for January–December 2018). Trilokpuri versus Sundarnagri. Comparison of family members accompanying patients during clinic visits. Source: A mixed method (anthropological and psychological) study to examine and compare neighborhood characteristics in determining high risk behavior and treatment outcomes in relation to opioid use in two Resettlement Colonies in East Delhi (Tallied for January–December 2018). With these gendered divisions of labour and care, it is important to consider the opioid epidemic in India as not solely related to males but to consider the varied burdens that addiction places on households (in particular in households where women become the primary or sole income-earners, as a result of addiction-related issues), rather than only on individuals. The abruptly announced COVID-19 lockdown in India caused major upheaval among labour migrants and the urban poor.22 In the dire economic circumstances of the pandemic, it is important to consider the impact on care and access to heroin and OST treatments. The NDDTC community drug treatment clinics in these neighbourhoods continued to work throughout the lockdown period in 2020. Our research team undertook three rounds of telephone household surveys (between June and October 2020), on a small sample of 10 households in both neighbourhoods, drawn from the initial sample of 200 households in our neighbourhoods based study. The survey designed by Clara Han (Johns Hopkins University) and Veena Das (Johns Hopkins University), as part of a multi-country study on household responses to the COVID-19 pandemic, aimed to track household income and expenditure, illness experiences, distress events and social networks, to which supplementary questions on dietary adjustments, hunger and mental health and addiction issues within households were included by our team. The results provided some information on household income and expenditure (Fig. 5). As is often the case with household data, income may be under-reported and expenditure over-reported. However, data on the approximate duration of the stopping and resumption of income and the extent to which households were drawing on savings during these months, as well as the timing and frequency of ‘distress’ events such as the sudden sale of household items, liquidation of assets and adverse health events was collected (Fig. 6). HH financial situation. Source: Study -Implementation of COVID-19 related policies: Implications for household inequalities across five countries among low income households survey interviews undertaken by Ms Shivani Poornima (June–October 2020). HH financial situation. Source: Study -Implementation of COVID-19 related policies: Implications for household inequalities across five countries among low income households survey interviews undertaken by Ms Shivani Poornima (June–October 2020). HH distress events during survey period. HH distress events during survey period. Given the severe constraints and at times absence of any income and (partial) spatial mobility in Indian cities, it was expected that the already precarious health status, ill health and tootan (the Hindi word for withdrawal symptoms) would pose a major problem for those with opioid-dependency in these neighbourhoods. However, data from bi-weekly clinic-based conversations and records appeared to suggest that this was not the case, at least in terms of verifiably increased illness or mortality among heroin dependent individuals during the pandemic period in 2020. This may have been because during the lockdown, community drug treatment clinics in these neighbourhoods continued to remain open and the numbers attending and forms of drug use remained relatively stable. Chemist shops remained open so IDUs could still purchase the occasional ‘set’. For reasons harder to discern, the price of heroin only rose marginally during the pandemic, and smack dealer’s supply did not dry up. ‘Hotspots’ (a public health term that has made it into vernacular addiction slang) were remapped, with heroin user groups congregating not in public parks but in abandoned bathrooms and construction sites, as was also partly the case in pre-pandemic times. Those in desperate circumstances consumed what is considered a ‘poor man’s weed’, the wild bhang (cannabis) leaf, which when rubbed produces a handmade mix of dirt and herb called hatto, which can be smoked. It appears that the COVID-19 pandemic, in 2020, was a period of constraint rather than catastrophe. The availability of outpatient, evidence-based treatment of opioid dependence such as OST is at a relatively fledgling stage in India. It is estimated that not more than 2% of those with opioid dependence receive OST in India.23 With the paucity of OST, a worrying trend is the mushrooming, across Indian cities, of private nashamukti kendra (‘de-addiction’ centres), advertised on walls and public spaces, often with just a mobile phone number. These centres are mostly unregulated places of incarceration, usually not requiring any patient consent and charging prohibitively high monthly fees, paid by the family members of heroin addicts. Although data on these clinics are not yet available, patient and caregiver narratives included alarm over reports of sudden deaths within these centres, with unclear post-mortem information shared with families, cruel forms of discipline, absence of regulation and possibly increased risks of post-discharge relapse and overdose-related fatalities. This could also lead to a situation where growing numbers of the opioid using population in India find themselves trapped in cycles of debt, opioid addiction and potential incarceration in private or state institutions without appropriate treatment facilities. This is an aspect of the opioid epidemic that needs urgent investigation and appropriate intervention. As in neighbouring parts of South Asia, India has already seen a major shift in the type of opioids being used by its population. The 2004 national survey showed opium, in its non-synthetic form, being the most common opioid used in India. The 2019 national survey6 shows heroin, the semi-synthetic form of opioids, as the most common opioid used in India, followed by pharmaceutical opioids. It is a cause for worry that the next decade may see an even sharper shift towards synthetic forms of opioids, with chemist shops as a hub of informal markets for opioids. India has a large and relatively successful pharmaceutical industry. The shift of focus of transnational big pharma towards LMICs such as India may also add to a next wave of a pharmaceutical opioid epidemic in India. This essay has attempted to outline both macro and micro perspectives through an overview drawn from quantitative and qualitative work undertaken on how the opioid epidemic in India is unfolding across regions, genders and within particular low-income urban neighbourhoods in Delhi. This essay has highlighted the need for appropriate and accessible care including outpatient treatment facilities that need to be urgently expanded. It also outlines the research required to further explore the variations in the Indian opioid epidemic that the essay has described and consider possible measures to control this burgeoning epidemic in India. Dr Singh wishes to acknowledge funding provided by the Wenner-Gren Foundation for Anthropological Research, American Institute for Indian Studies, Center for Contemporary South Asia (Brown University) and Wissenschaftskolleg zu Berlin (Institute for Advanced Study Berlin) for long-term ethnographic and survey work based in the two neighborhood community clinics in Delhi. Dr Rao does not have any funding to declare. Oxford-India Sustainable Centre, Somerville College, University of Oxford. Bhrigupati Singh, Associate Professor (Anthropology & Sociology, Ashoka University), Visiting Associate Professor of Psychiatry, Brown University Ravindra Rao, Additional Professor