Ambekar 24 aug - opioid policy and legal issues
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Transcript of Ambekar 24 aug - opioid policy and legal issues
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24 August, 2014, Ludhiana
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• Is it working ?
International Drug
regulatory framework
• Implications for mental health professionals
The Indian Scene
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» About 1 in 20 persons between the ages of 15 and 64 uses an illicit drug at least once a year ˃ Large majority of them use CANNABIS
» Fewer than 1 in 160 are “problem drug users”
» Overall value of the illicit drug market: about $320 billion (0.9 % of global GDP)
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AlcoholTobacco
Illicit Drugs
35%
25%
2.50%
Global Prevalence of 'past month' use
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» Today’s ‘narcotics’ have had a long history of use throughout the world
» Plants have been major source of drugs: ˃ Opioids
˃ Cannabis
˃ Cocaine
» Drugs have been used as medicines, for recreation and as part of social / cultural rituals
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19th Century: Indian Opium exports to China
1909: Shanghai Opium Commission
1912: Hague Convention
UN Conventions: 1961, 1971, 1988
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International Drug treaties
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Opiates Cocaine Cannabis
12.9 13.4
147.4
17.35 17
160
Number of users in millions 1998 2008
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"Sadly, the illicit
manufacture and
illicit consumption
of drugs occur
everywhere.”
Yury Fedotov, Executive Director, UNODC, 2012
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Pettus, 2014
“Evil” reflects influence of missionaries in early prohibition policy”
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» The stated intention behind the establishment of the global drug prohibition regime was to protect the world from the dangers of drugs.
» At different points in history, drug production, use and supply have all been presented as threats to security:
˃ human,
˃ national or
˃ international security.
“Menace” “Social evil”
“Existential threat”
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Creation of a criminal black
market
Policy displacement
Geographical displacement
Substance displacement
Marginalization of drug users from social mainstream
UNODC 2008
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Decrease
from 14.1 % in
2001 to
10.6 % in 2006
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http://www.globalcommissionondrugs.org/
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“The war on drugs has failed”
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» Drug policies must be based on scientific evidence human rights and public health principles ..
» …legal regulation of drugs …
» …evidence-based prevention ... treatment and care for drug dependence..
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Supply reduction
• Department of Revenue, Ministry of Finance
• Narcotics Control Bureau, Ministry of Home
• Central Bureau of Narcotics, Ministry of Finance
Demand reduction
• Prevention and Rehabilitation: Ministry of Social Justice and Empowerment NGOs
• Medical Treatment: DDAP, Ministry of Health and Family Welfare Govt. Hospitals
Harm reduction (IDU)
• National AIDS Control Organisation (NACO), MoH&FW NGOs and Govt. Hospitals
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Major ‘players’
Additionally, ‘Alternate approaches’: AA, spiritual / religious groups etc.
Availability of treatment services in India
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» 124 in number
» Established by the Union MOHFW (DDAP division)
» Attached with district hospitals and medical colleges (Department of Psychiatry)
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Only a few get recurring grant from the central government
Rest, dependent on the state governments
Drug dependence treatment is often seen as a low priority area by the local state governments
At some places, buildings meant for De-addiction centers are being used for other purposes!
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» ‘Minimum standards of care’ exist
» No structured, regular system for M & E
˃ DAMS for new patients
» Capacity Building: Through institutions located regionally
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» Supported by the MSJE
» About 450 in number
» Get funding from the ministry ˃ Mainly residential (in-patient) treatment
˃ Stand alone services – not a part of general health care
» Recent revision of guidelines / scheme
» Functioning status?
» Capacity Building – through RRTCs
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» Number: unknown
» Qualifications of service providers: unknown ˃ ranges from MD Psychiatry to no professional
qualification (just an experience of having gone through the treatment)
» Whether follow some standards / norms: unknown
» Highly variable status for evaluation / functioning
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Gaps in service demand and service provision » Conservative
estimate of number of Alcohol / drug dependent individuals
= 1 crore (10000000)
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» Conservative estimate of number of Alcohol / drug dependent individuals
= 1 crore (10000000)
» Liberal estimates of Number of beds available for drug treatment
NGO sector 400 X 15 6000
Government sector 100 X 10 1000
Private sector --- 5000
Total 12000
Assuming minimum duration of acute-phase treatment = 1 month
144000
10000000
144000
Gaps in service demand and service provision
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10000000 versus
Gaps in service demand and service provision
144000
Clearly, reliance only on the existing number of services and the in-patient, ‘de-addiction’ model is not enough!
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Do our laws and policies facilitate treatment of opioid dependence ?
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» Principle of regulatory framework:
“Balance between:
curbing misuse
and
ensuring access for medical and scientific purpose”
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» Principle of regulatory framework:
“Balance between:
curbing misuse
and
ensuring access for medical and scientific purpose”
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» Drug Use a criminal act
» Provision for treatment in lieu of jail term for Drug Users ˃ Onus on accused to prove that s/he is a
drug user; not a trafficker !
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» Three amendments: 1988, 2001, 2014
» 1988 amendment ˃ Stringent punishment for harboring offenders and
financing illicit traffic including death
˃ Forfeiture of property derived from/ used in illicit traffic
» 2001 amendment ˃ Punishment based on quantity found
˃ Further strengthened powers to trace and seize illegally acquired properties
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2014 amendment
» ‘Essential Narcotic Drugs’ for medical use
» Subject to central rules; state licenses not needed
» Government to recognize and approve treatment centres to regulate illegal / unethical practices
» Punishment for users & traffickers increased!
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» 28 July 2014: National Workshop on drafting NDPS rules
» All stakeholders welcomed the proposals: ˃ A uniform national set of regulations (as opposed to
state-specific rules)
˃ Recognition that easy access and availability of medications as important as stringent regulations
˃ ENDs – indicated for both – Pain relief and treatment of Opioid Dependence
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» National Narcotic Drugs and Psychotropic Substances (NDPS) Policy (2012)
˃ Talks about a combination of supply, demand and “Harm Reduction” approaches
˃ Harm reduction – reluctantly endorsed; Only for IDUs
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»National Drug and Alcohol Demand Reduction Policy (DRAFT) ˃ (Was) Being Developed by the MSJE
˃? Draft under the process of review and refinement
˃No clear stand on evidence-based pharmacological treatment of opioid addiction
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Methadone
Buprenorphine
Buprenorphine+naloxone
Morphine
Tramadol
Non Opioids (Clonidine; Naltrexone etc.)
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Methadone
Buprenorphine
Buprenorphine+naloxone
Morphine
Tramadol
1961 convention
1971 convention
1971 convention
1961 convention
Not under control*
International Control
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Methadone
Buprenorphine
Buprenorphine+naloxone
Morphine
(Essential) Narcotic
Psychotropic
Psychotropic
(Essential) Narcotic
Indian Law
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Methadone
Buprenorphine
Buprenorphine+naloxone
Morphine
?
Schedule H1
Schedule H1
Schedule K
Indian Scheduling and regulations
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“The preparation shall be supplied only to the designated de-addiction centres set up by the Govt. of India funded by the Ministry of Health and Ministry of Social Justice and Empowerment and Hospitals with De-addiction facilities and a list of the centres to whom the supply of the drug is made should be made to this Directorate periodically indicating the quantities supplied to each centre.”
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» The Punjab chaos spreads to other parts of the country. Some over-zealous official proposes to totally ban Buprenorphine
» Methadone and Morphine get listed as ENDs (and become available easily, even with prescription). Buprenorphine remains tightly regulated.
» Buprenorphine becomes de-regulated and starts being available in the pharmacy shops. Soon, it becomes OTC (like practically everything else) and we see a fresh epidemic.
» The ideal scenario
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» Buprenorphine or Methadone are not available in pharmacies.
» They are available only through licensed and accredited facilities:
˃ Drug Treatment centres / Clinics (Govt. / NGO / Private)
˃ Prescribed by specifically trained doctors
˃ Records are maintained; M & E framework exists
» Methadone and plain Buprenorphine available only as DOTS
» Buprenorphine + Naloxone available as ‘take-home’ option (with standard procedures, and an upper limit)
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Conceptual basis for a ‘rational drug policy’
» Prevention
» Supply reduction
» Treatment and harm reduction
» Criminal sanctions and decriminalisation
» Control of the legal market through prescription drug regimes
Drug policy and the public good, Babor et al, 2010
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Is there something we can do?
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» Ensuring only evidence-based practice
» Advocacy
˃Realizing that our role goes much beyond the service provision
˃Making our presence felt as professional bodies
˃Generating the discourse on policy reforms
˃Pressurizing our governments to take right stand in the International forums
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Acknowledgement:
Dr. Sathya Prakash Senior Resident,
AIIMS, New Delhi