WHO Biennium Project (2006-2007)

REPORT
DRUG ABUSE
MONITORING SYSTEM
SE/06/226877
&
SE/07/117746

Conducted by : National Drug Dependence Treatment

Centre, AIIMS, New Delhi
Sponsored by : World Health Organization, India
Joint activity : Ministry of Health and Family Welfare &
World Health Organization, India
 ACKNOWLEDGMENTS

The implementation of Drug Abuse Monitoring System at national level and its modest
success has been possible with the joint efforts of resource persons and institutions and we
gratefully acknowledge their valuable contributions. The foremost among them is the
participating centers and respective heads/ nodal officers who gave their kind consent and
collected drug abuse monitoring data on a voluntary basis ( see annexure ‘A’ of
participating centers ). We are equally thankful to the Consultants, Medical Officers and
Staff of these participating Centers, who collected information on new registered patients
during their busy clinical schedule. We are also thankful the Directors/Principals and
Medical Superintends of participating Medical institutions/ colleges and Civil Hospitals for
the necessary permission to participate in this program. We are thankful to the project staff,
Mr.Vijay Kumar and Ms. Tanu Duggal for data entry, correspondence and necessary help
in preparation of the final report.

Dr Rajat Ray
1. Introduction:

Substance abuse has emerged as a global phenomenon that is influenced by a wide array of
factors that span social, economic, political and psychosocial domains. The multiplicity of
factors associated with drug abuse and their inter-relatedness makes the problem a complex
one. The escalation of drug abuse over the last three to four decades, particularly among the
adolescents and young people, has created major public health and socioeconomic
problems and challenges. The development and delivery of effective and appropriate
interventions in countries experiencing drug abuse problems are very much dependent on
an understanding of trends, patterns of drug use and their relationships to health and social
problems.

During the last few decades, drug scene in the country has changed at a very rapid pace.
The changes are scene in terms of availability, choice of psycho-active substances, users
and their socio-demographic characteristics. The changing drug scenario has its own
implications on the socio-cultural fabric of the society, besides adverse public health
problems (Sharma, 2005). These developments in the field of substance abuse call for a
systematic monitoring to develop effective strategy on the part of health planners and
policy makers. There have been a number of methods to assess drug abuse problem at
national and regional levels and drug abuse monitoring system has emerged as one of the
cost effective methods.

Treatment monitoring systems are one of the information sources in the field of drug
epidemiology and demand reduction, which can give valuable information on the scale and
characteristics of the drugs phenomenon as well as on measures taken against these
problems. These data can be collected with limited financial effort within treatment
services, as information on treated persons is available and collected also for treatment
needs. Information can be rather complete, as experts such as social workers and therapists
fill in the relevant questionnaires.

Drug Abuse Monitoring System has been implemented in different countries to develop
data bases to plan treatment services for subjects with substance abuse disorder. These are
useful in determining the broad trends and characteristics of dependent drug users whom
come in contact with treatment agency(ies). The information collected helps in
identification and describing the current groups at risk, the emerging risk groups and also
efficacy of the existing efforts to treatment systems.

2. Drug Abuse Monitoring and Surveillance:

2.1: Global Experiences:

There has been a number of drug abuse monitoring program at global level. A few
successful programs are cited below:
(i) Drug Abuse Warning Network (DAWN) : Based on event reporting system,
DAWN, a federal program in USA, was initiated in 1972. The monitoring
system collects information through ‘episode’ reports on patients provided by
 selected hospital emergency rooms, crisis centers and medical practioners. The
program obtained two types of data from these sources; adverse reaction to
dependence producing drug use from emergency room in general hospitals and
information on drug dependence related deaths from county medical examiners
or county corners. To be eligible for inclusion in DAWN, the emergency room
must be open for 24 hours and should have at least 1000 patients visit in one
year. The information emerging from the DAWN system has been used by Drug
Enforcement Administration ( DEA) for enforcement and scheduling its control
activities. On the other hand, National Institute of Drug Abuse (NIDA) has used
the same data for developing prevention, treatment and rehabilitation project. In
spite of a few shortcomings, the feedback information is provided to health
agencies throughout USA.

(ii) The Client Oriented Data Acquisition Process (CODAP) is a case reporting
system developed and used in USA and provide information, on clients seeking
treatment to different agencies, their status at the time of discharge and their
progress reports with treatment. Under the CODAP System, it is compulsory for
all the treatment agencies funded by the Federal government for drug abuse
treatment and rehabilitation services, to provide such data on each client
admitted or discharged from the respective treatment agency. The information is
recorded on standard CODAP forms, which can be computer analyzed. The
advantage of CODAP monitoring system was that state and local level data were
utilized to determine utilization of available treatment resources, to identify drug
problems on continuous basis and the delivery of services to specific target
groups.

(iii) The National Mental Health Programme, Indonesia: The programme was
established at national level and spreads over to 35 mental health institutions
across the country. The information on all clients in treatment including alcohol
and drug disorders was collected on a 10 page multiple-choice questionnaire.
The programme helped the policy makers to monitor some of the dimensions of
drug dependence disorders in the country, including emergence of heroin and
morphine epidemics.

(iv) In Malaysia, the Anti-Narcotics Task force in the Prime Minister’s

Department was made the repository of all national data and information
pertaining to drug dependence disorder and abuse. Since the treatment and
Rehabilitation of an addict was compulsory, the situation and trend was well
monitored through this system. The information was collected from multiple
sources (clinical settings, prisons, schools, government departments, including
police and armed forces.)

(v) Case registers in UK: Under the Dangerous Drugs Regulations 1968, all
doctors were required to notify the Home Office of persons suspected of
 addiction to certain narcotics and cocaine. These led to creation of Addicts
index. It provided information on the characteristics of addicts and their clinic
attendance leading to defining the dependent’s profile cross-sectionally and
changes over a period of time. Although created on a smaller scale, the data base
has been able to report on estimates of numbers of users being seen by medical
practioners, psychiatrists and Drug Dependence Unit(s) and also information on
drug users, even ID Use.

(vi) Central Registry of Drug Addicts (CRDA) Hong Kong. In 1976, both
government and non-government agencies participated and data was collected
from 37000 addicts with in five years. The result was surprising as data showed
that individually finally cured from opiate addiction shifted to licit addiction like
alcohol. The outstanding feature of CRDA was sophisticated matching
procedure by computers to avoid duplicate.

Regional Network:

In the last two decades, efforts are on to develop a common monitoring and
surveillance network on regional basis i.e. European Union countries, African
countries and Caribbean countries. The overall objective of the program is to
strengthen the capacity of governments, technical entities and regional agencies to
respond to changing drug abuse patterns and trends and contribute to the abatement
of drug abuse in the region. The specific purpose of the project is to establish a
sound database and "early warning" surveillance system to assist national and
regional policy makers in demand reduction.

(i)European Monitoring Centre for Drugs and Drug Addiction (EMCDDA)

Over the last decades inside and outside of Europe, treatment-based data have been
used in epidemiological research on drugs and drug abuse. They offer information
on hidden populations. As this type of research can be done on rather low budgets,
there are long-term projects run in many countries. Experts from the national
systems in several EU member states have been working together to develop a
common standard on the basis of the Pompidou Group (PG) Definitive Protocol.
The items and basic definitions of the European Monitoring Centre for Drugs and
Drug Addiction (EMCDDA)/PG Treatment Demand Indicator Protocol are
described, which plays an important role in the process of harmonization of data (
Simon et al,1999).

More than twenty cities are using this protocol and many national systems are either
entirely (e.g. Ireland, Greece) or at least partly (e.g. The Czech Republic, Denmark,
Belgium) based on this protocol. For 1996, 22 cities from all over Europe
(Amsterdam, Athens, Bratislava, Bucharest, Budapest, Copenhagen, Cyprus,
Dublin, Gdansk, Geneva, Liège, Ljubljana, Malta, Orenburg, Prague, Rome, St.
Petersburg, Sofia, Szeged, Varna, Warsaw and Zagreb) provided their data on a
total of 29 000 treatment demands.
 In future it is planned to do a reliability and validity check on an international
multi-site basis to make sure, that the items used fulfill basic methodological
requirements.

(ii) Another regional surveillance network — Caribbean Drug Information

Network (CARIDIN) has been established with a series of sustainable activities to
inform this network (CARIDIN, 2001). The UNDCP, within its Global Assessment
Programme (GAP), has been assisting countries in the region to conduct studies
aimed at improving the understanding of the patterns and causes of drug abuse.
CICAD has developed a system, the Inter-American Uniform Drug Use
System(SIDUC), to improve the collection of comparable statistical information on
the consumption of psychoactive substances within the region. The principal
activities to be carried out, in all beneficiary countries (Total 15), surround network
capacity building, the implementation of school surveys and conducting of focused
assessments in high-risk groups. Other activities will include data collection from
emergency rooms, treatment centers & prisons.

(iii)TheSoutn African Community Epidemiological Network on Drug

Abuse(SACENDU)
Project is an alcohol and other drug (AOD)sentinel surveillance system now
operational in 8 provinces in South Africa: Western Cape (WC: Cape Town),
KwaZulu-Natal (KZN: Durban, Pietermaritzburg), Eastern Cape (EC), Mpumalanga
(MP), Gauteng (GT: Johannesburg, Pretoria), Free State (FS), Northern Cape (NC),
and Northwest (NW).

The last 3 provinces form part of what is termed the Central Region (CR) and
provided data from 2006b. The system, operational since 1996, monitors trends in
AOD use and associated consequences on a six-monthly basis from specialist AOD
treatment program. Plans are underway to expand the surveillance system to all
provinces during 2007 and to increase the spread of treatment centers included in
WC, GT and KZN. This report will focus on data on treatment admissions from the
8770 patients seen across the 73 centers/program in the 2nd half of 2006.

The experience gained from these monitoring systems eliciting information from
treatment seekers in the field of substance abuse is that with comprehensive guidelines
and not too complicated instruments, useful data can be elicited on trends and profiles
at national and regional levels.

2.2 Indian Experiences:

(i) Indian Council of Medical Research Collaborative study: The viability of

Drug Abuse Monitoring System has been seen for first time through a Task
 force project of Indian Council of Medical Research. The study was conducted
at Delhi, Jodhpur and Lucknow and information was elicited from more than
10,000 respondents registered at governmental and non-governmental
organizations from 1990 to 1992data. ( Ray and associates,1992).The cost of
such an exercise was minimal and data generated over 3 years provided very
meaningful insight for resource allocation, re appropriation and over all program
implementation

(ii) Community Based Pilot Project: There was also DAMS component in a
multi-centered community-based pilot project at three sites ( Barabanki,
Mandsuar and Thobal), implemented by All India Institute of Medical Sciences
on behalf on Ministry of Health & Family Welfare( Ray and associates,1998)

(iii) In 1999, the Ministry of Social Justice and Empowerment and United
Nations International Drug Control Program, ROSA office, New Delhi
sponsored a DAMS study and a total of 203 agencies (NGO’s, private
psychiatrists and governmental organizations participated in this exercise. The
study spread over to 23 states and 2 union territories and National Capital
Territory was able to elicit information from more than 16000 respondents in
three months and provided information on socio-demographic profiles of
treatment seekers, drug pattern and trends and high risk behavior (DAMS
Monograph, 2002).

3 Objectives and Methods

3.1 Rationale:
It became clear from the above description that such types of studies are sustainable and
remain a relatively inexpensive method to get wide sources of information from
registered patients at a treatment facility. However, drug scene change rapidly and
require data on continuous basis on parameters like use of licit and illicit drugs, socio-
demographic profiles of treatment seekers, injectable drug use if any, risk behaviors,
sexually transmitted infections including HIV and long term maintenance plan. The
information collected as a routine procedure helps in planning, management and even
evaluation of drug treatment program at national level. The Drug Abuse Monitoring
component of WHO Biennium Project (2006-07) is an effort in this direction at national
level. The main advantage of this exercise would be the initiation and evolvement of
drug abuse monitoring at national level. The earlier studies were restricted to a few
centers or cities.

3.2 Objectives:
(i) To develop and establish a national monitoring system to collect information on
continuous basis on drug use, profile and risk behaviour from treatment seekers
registered at drug dependence treatment centres.
(ii) To develop practical and cost efficient methods of collecting and assessing data on
licit and illicit drugs.

3.3 Methods:

3.3.1 Universe of the Study:

All new patients, i.e. registering for the first time for treatment to any of Drug
Dependence Treatment Centre sponsored/ strengthened by the Ministry of Health &
Family Welfare. The Ministry has established 122 Drug De-addiction Centers in
Central Governmental Hospitals/ Institutions, State civil/district hospitals all over the
country by 2005.Treatment stands for any or combination of detoxification and psycho-
social therapies. To keep uniformity in recording of information for DAMS, patient will
be the sole informant on various items and information provided by him/her would not
be validated from other sources.

3.3.2 Instruction Manual: A manual was developed to provide a comprehensive

document for the participating agencies to fill the necessary information in simple and
objective manner. The uniform data collected would help in developing a broad-based
data can be gathered at national level on a continuous basis. In this manual, efforts have
been made to provide definitions and instructions in filling of each item and relevant
codes. There is a reference for who should be included under DAMS, proper
completion of form and submission.

3.3.3 Data Collection Instrument: A simple pre-coded monitoring tool was developed
for collecting data. All treatment centers covered under Ministry of Health & Family
Welfare to gather data for a period of twelve months from all their new patients
registered from 1st September, 2006 onwards. The form was filled out on the first day of
contact with the client though it could be subsequently revised if the person remained in
contact for a longer duration. The person In charge of treatment facility/ centre was then
asked to send the completed questionnaires to the Coordinating office at National Drug
Dependence Treatment Centre at All India Institute of Medical sciences, New Delhi on
quarterly basis.
 The DAMS instrument included questions on the following:
User Profile-Age, Sex, Education, Marital and Employment Status and Current
living arrangement
Drug Profile - The Profile of Abuse of Various Drug Types “Use within 30 days”
and “life time use” Inject able Drug Use practice, physical complications, viz.
Sexually Transmitted Infections, Jaundice, HIV Screening & Status, Concurrent
Psychiatric and Medical illness and previous treatment.

There were altogether nineteen items in the DAMS instrument. These were:
Demographic parameters (8 items)
Drug use history (1item), ID Use (2 items), Physical complications (3items),
Concurrent illness (2 items) and Previous treatment (2 items)

3.3.4 Consent & familiarization:

Since, unit of participations for DAMS component were spread over to all over India, a
postal contact was initiated and a detail was provided about aims and objectives, the
nature of participation and mechanism of co-ordination in the month of June, 2006. The
centers were also informed that it is a voluntary participation and a small grant would
be sent to them for expenditure incurred on photocopying of instrument, postal
expenses and other incidental charges. As the consent of participation came gradually,
second and third reminders were sent. The DAMS co-coordinator’s office maintained
separate record of participation status of each centre. Once, the consent of participation
received from a centre, the DAMS Instrument, instruction manual and a contingency
amount were sent to them. A total of 60 centers consent for participation came and data
collection was started by these centers from 1st Sept, 2006

3.3.5 Data collection and scrutiny of proforma:

To keep the uniformity, data collection period was divided into four quarters (Sept to
Nov.,06, Dec.,06 to Feb.,07, March to May,07 and June to August,07). The Center’s
data received on quarterly basis was scrutinized by the co-coordinating office and
discrepancy, if any was intimated. A close co-ordination was maintained with the
participating centers during data collection phase. This helped in filling of complete
proforma/information and maintains internal consistency.

The data was collected from 1st of September 2006 to August 2007.

4 Results:

At country level out of 122 De-addiction centers, 60 gave consented for participation for
Monitoring. However, 9 centers could not sent data either on account of patients not getting
registered for treatment or non- functioning of a Centre due to administrative/ other
problems. A total sample of 11775 new patients, registered at 51 De-addiction centers
during 1st Sept, 2006 to 31st Aug, 2007 was covered under Monitoring System. The results
presented here are divided into three parts : Socio-demographic profile, drug use pattern
including Injectable Drug use and Physical and Mental Health problems and attempts for
treatment.

Part-I Socio- demographic profile of treatment seekers:-

Sex Wise Distribution (Table1)

A majority of them were men (99.1). There were 117 women, almost one percent of sample
covered who seek treatment for substance abuse disorder at these facilities for the first time
during the study period.

Age Wise Distribution (Table 2)

Among men patients, one –third of treatment seekers (35.5%) were in the age group of 26-
35 years, followed by the next higher group 36-45 (28.7%). The youth/adolescent group
had also a fair representation; more than 18% of the sample covered was below the age of
25 years.
The same trend was reflected among 117 women treatment seekers. About 25% were below
the age of 25 years. The maximum were in the age group of 26-35 years (29.9%), followed
by the age group of 36-45 years (28.2%)

Martial status of the Samples (Table 3)

Among men, a large majority were married (72.6%) and 23% were unmarried. A small
section of samples covered in the category of separation/ widower (3.2%). There were 138
men (1.2%), who reported separation on account of substance abuse behavior.

A different trend emerged among women treatment seekers in respect of marital status.
Among them half of them were married and 15% had never married status. The broken
marriage and separation was seen among 20% of women subjects and 15% reported widow
status. These figures clearly indicate family dysfunction and social burden among women
drug users.

Education wise distribution (Table 4)

About One-fifth men treatment seekers (19.2%) among men were illiterate or just could
read and write where as primary/middle education was reported by 35% registered patients.
An equal proportion had education up to 10th/12th classes (higher secondary level). The
higher studies (graduation and above) was stated by one-tenth of men respondents.
Among women registered patients, 40% were illiterate or just can read and write, 30% were
primary/ middle and 18.8% reported 10th /12th class education level. The graduation and
above education was indicated by one –tenth of women users, almost competing with that
of men users in the study.
Distribution according to Employment Status (Table 5)
About one-third of male patients (29.3%) reported non- employment status at the time of
registration. From employment perspective, one-third were self employed (33.0%) followed
by full time employment (22.5%) and part- time employment (9.2%). The student
constituted 2% of the sample covered under monitoring system.

The women users registered under drug abuse monitoring system had a different trend in
employment. One- fourth (23.1%) were engaged in household work, while more than one-
third (33.4%) were self or part-time employed. The full time employment was confined to
just 7% of the sample covered.

Distribution according to Living Arrangement (Table 6)

Contrary to the belief, a large majority of patients under monitoring system was staying
within the institution of family. Among men 55% reported staying in nuclear family,
whereas 40% were living within the joint set up, i.e. parents, siblings and offspring. The
rest reported staying alone (2.5%) with friends and (1.0%) and other living arrangement,
mostly on the street/ homeless was seen among a very small percentage (1.6).
Among women treatment seekers, again nuclear family unit was the arrangement for a large
majority (60%), followed by joint family (29%) whereas 5% were staying alone. Six cases
were staying outside the family (with acquaintance/ street).

Part-II Drug Use Pattern:

Drug use pattern among the patients registered under DAMS (Table 7)

Drug use pattern was assessed from the treatment seekers on the basis of use of one or more
substances during 30 days of registration (current use) and during their life time (Ever use).

Among men, most commonly used substances were alcohol (65%) and tobacco (68%).
Opium and its derivatives (heroin, other opioids) emerged as second preferred drug
category as 40% men reported its use (14% each for opium and heroin and 12% other
opoids mainly Proxyvon, Spasmoproxyvon, fortwin and norphine etc.). Cannabinoids
(bhang, ganja) was reported by one-tenth (9.6%) of these registered patients). Sedatives/
Hypnotics, part of ploy drug abuse scene were reported by 6.5% of these men. Use of
Volatile solvents (toluene etc. mainly in the form of whitener) was reported by 109 of the
subjects.
Among women subjects, tobacco, alcohol was reported by 56.4% and 51.3% respectively.
Again 40% of women registered patients reported use of opium, heroin, other opioids; a
trend almost close to men’s drug use pattern. Sedatives/ Hypnotics were choice of 8.5%.
Cannabis use was reported just by 2 patients.

Distribution of subjects according to Ever use drug pattern (Table 8)

On assessing ever use drug pattern (life time use), alcoholic beverages emerged as the most
preferred psycho-active (78.2%), followed by tobacco products (71.0%). A significant point
was that 14% and 4% of alcohol and tobacco users respectively reported ‘Ever use’ but not
stated their use preceding the last 30 days of registration(Current use). Use of opium, heroin
and other opioids was reported by 49.3% of the registered patients while the corresponding
figure of current use of these psycho-actives was 40.7% (Table 7). Almost the same
difference was seen for cannabis and sedatives drug categories among male patients. The
ever use of cannabis products was 15.4% and sedatives/hypnotics was 17.1%; while current
use was 9.6% and 6.5% respectively. The use of volatile solvents (thinner, whitener etc.)
was reported by 196 persons ( 1.7%), whereas its current use was stated by 109 (0.9%)
persons.
Thus remission was seen among 5to 10% registered patients for different psycho-active
substances, reflecting treatment attempts or quitting on one account or others.

Among 117 women users, alcohol/tobacco or both was reported by more than 60%, while
current use was less by 10% for alcohol and 7% for tobacco. For opium, heroin and other
opioids 55 (47%) reported use during life time and 45(38%) were continuing at the time of
registration (current use). For cannabis difference between ever and current use was 5% and
sedatives/hypnotics, it was about 4%. Thus among women users, 4to 10% reported
cessation of drugs in their life time.

Distribution of subjects according to Injectable Drug Use (IDU) (Table 9)

Out of 11775 patients covered under Drug abuse Monitoring, about one-tenth (1090)
reported use of Injectables in their drug career. Out of these, 1073 (9.2%) were men and 17
subjects were women (6.5%). Further assessing their current use ( with in the last 30 days)
759 (6.5%) men and 14 (12.1%) reported use of pharmaceutical products like Proxyvon,
Spasmoproxyvon, tidigesic ( buperonorphine), fortwin and pure form of Heroin, no.4. A
positive indication was that about 30% of Ever user of injectables did not report use of
these substances during the last 30 days.

Distribution of Injectable users by route of administration ( Table 11)

Out of 759 men current users, who reported Injectable use, intravenous mode was the most
preferred ( 76.1%), followed by intramuscular (22.1%) and only 2 subjects subcutaneous
route of these drugs. The same trend was observed among 14 women ID Users, ie. 79%
reported intravenous and the rest through intramascular.

Sharing of needles among ID Users (Table 10)

The phenomenon of needle sharing was observed among half of current users among men.
Fifty percent reported that they shared needle with peers during shooting of preferred
pharmaceutical products. Among women users, the sharing was reported by 57% of ID
Users.

Paraphernalia sharing among ID Users (Table 12)

As far paraphernalia, one-third current ID Users among men admitted sharing of cotton,
boiling pot.
A large majority ( 65.5%) denied such sharing while injecting the dose. Among women
users sharing was reported by 50% current ID Users.

Part III: Drug related complications

Sexually Transmitted Infections (Table 13)

Among the subjects covered under monitoring, 389 (3.3%) reported Sexually Transmitted
Infections (STI) in their life time. The STI status was ascertained through a set of
symptoms, viz. genital ulcer growth, burning urination, urethral discharge, itching around
genital organs, vaginal and rectal pain/discharge. In case a person admitted occurrence of
one or more symptoms, it was taken as a positive indication of STI.

Among 117 women users, 13 cases (11.1%) suffered from STI, a comparatively higher
percentage than men drug users and suggesting vulnerability of women users towards
transmission of infections/diseases.

Occurrence of Jaundice (Table 14)

One-tenth men ( 9.5%) and 6% women drug users reported occurrence of jaundice, an
indication towards Hepatitis in their lifetime. Not given in the table, but these were reported
more among patients registered at treatment facilities, located in the North-east part of the
country.

Psychiatric illness among the patients covered (Table 15)

Among male users, 13.4% reported psychiatric morbidity along with substance abuse
disorder. The corresponding percentage was much higher among women drugs users ( 29).
The common psychiatric illness reported by the patients at these participating centers were
drug induced psychosis ( alcohol, cannabis), anxiety disorder, mild/major depression, anti-
social personality, insomnia, mood alteration and abnormal behavior.

Physical complications reported among subjects covered under DAMS (Table 15)

One-sixth of male patients covered under monitoring admitted one or more physical
complications on account of sustain the habit of alcohol/drugs. Among women users, the
figure rise to double (33.3%).

The common physical complications seen were: alcohol liver disease (ALD), hepatitis,
gastritis, GI bleeding, anemia, weakness, pulmonary kock’s, septic wound and different
types of injuries.

HIV Screening and Status (Tables 19&20)

Among male patients, 685(6%) had undergone screening for Human Immunodeficiency
Virus (HIV) and out of those screened,7.3% had a positive status, a figure 20 higher in
comparison to general population prevalence figure of 0.36%. These figures again suggest
vulnerability of alcohol/drug users towards transmission of HIV and AIDS.
Previous Treatment (Table 17)
From Table 17, it became clear that subjects covered under DAMS from 51 participating
centers, about one-sixth (17.5%) had history of previous treatment. However, it may not
necessarily from the same treatment facility. On the other hand, around 80% of subjects
covered under DAMS during this period came for the first time for treatment of substance
abuse disorder. Such a figure among women users was 87.2%.

Hospitalization (Table 18)

It appears that those who reported previous treatment, majority of them were hospitalized
(in-patient treatment). Out of 2035 men, 1442 (70.86%) were hospitalized at one or more
occasions. Among 14 women users who had history of earlier treatment, 12 admitted at a
treatment facility (facilities) at previous occasion.

5. Conclusions

As a part of WHO Biennium activity, this drug abuse monitoring feasibility study proves
successful in many ways:

5.1 Participation

First of all, about half of the Drug Dependence Treatment Centers with the funding of or
one time grant from the Ministry of Health and Family Welfare gave their consent to
participate in the monitoring study on voluntary basis. Out of 122 Drug De-addiction
Centres, 60 gave their consent of participation and 51 Centers were able to send data as per
schedule set for the study. Nine Centers were not able to sent data either on account of
substance abuse patients not getting registered or, non-availability of staff and other
administrative problems.

These participating treatment facilities are geographical spread over through out the
country. With the exception of 6 De-Addiction Centre run by Central Institutions/
Hospitals; others are governed by State governments. The settings of these treatment
facilities differ i.e. medical colleges/institutes, designated De-addiction Centers and mostly
through District/Civil Hospitals. This provides a fair representation of existing treatment
services through government sector at national level.

During the study period of one year, a total sample of 11775 persons was registered. These
were the persons with substance abuse problem, who got registered for the first time as a
new patient at a participating treatment facility. The patients registered varied from a mere
30 to maximum 3000 within 12 months. There were 5 treatment Centers, who reported
more than 500 patients in this period. Another 26 Centers reported new patient load
from100 to below 500 and remaining 20 treatment facilities reported less than 100 patients.
Thus, there is a need for strengthen services of these Centers where new patient load is less
than 100 in a year.
5.2 Profile of new registered patients:

Drug Abuse monitoring data reflects the broad profile of substance abusers. As seen form
the results, an overwhelming patients were men (99%).The positive aspect is that 117
female patients got registered and came for treatment for the first time.
Another noteworthy feature was that about one-fourth registered patients were below 25
years among both men and women, reflecting a trend of early age of initiation, progression
towards problematic use and seeking treatment within a period of 5-7 years. Earlier the
experience suggest that such period was more than 10-15 years. This can be an indication
of availability of de-addiction treatment services and also success of health campaigns
against drugs and an early recognition of problem.

A large majority of the samples were married but 138 cases reported separation from
spouse on account of their drug seeking behavior. Family disorganization was more
conspicuous among women drug users as one-tenth of the sample had marital problems.
The substance abuse phenomenon is no longer confine to illiterates or semi-literates but in
this samples,35% patients had education up to 10th &12th class level and one-tenth had
graduation and above. The same trend was reflected among women patients, where one-
tenth had education level up to graduation, mostly from north-east region.
About 30% men treatment seekers were not working but the rest were engaged in some
productive work. As many as 22% subjects indicated full time employment. Among
women users only 7% were full time employed.
Contrary to the common perception, majority of the patients were staying within the
institution of family. Ninety five percent men patients were staying in nuclear/joint
families. Among women users majority were living within the family set up but 10% were
living alone or outside.
Thus substance abuse treatment seekers remain within the gambit of family and social
fabric and rarely project an image of “junkie” or “skid-row” of the West.

5.3 Drug Use Pattern

Drug use pattern was assessed from the treatment seekers on the basis of use of one or more
substances during 30 days of registration (current use) and during their life time (Ever use).
Among men treatment seekers, most commonly used substances were alcohol and tobacco.
Opium and its derivatives (heroin, other opioids) emerged as second preferred drug
category as 40% men reported its use (14% each for opium and heroin and 12% other
opoids mainly Proxyvon, Spasmoproxyvon, fortwin and norphine etc.). Cannabinoids
(bhang, ganja) was reported by one-tenth and sedatives/ hypnotics remained part of ploy
drug abuse scene. The monitoring data also reflect introduction of Volatile solvents
(toluene etc. mainly in the form of whitener) as reported by 109 of the subjects.
Among women users, tobacco and alcohol was reported by more than half of the subjects.
About 40% of women registered patients reported use of opium, heroin, and other opioids.
Sedatives/ Hypnotics were choice of 8.5%. Cannabis use was negligible.
On assessing ever use drug pattern (life time use), a remission was seen among 5to 10%
among men and women registered patients for different psycho-active substances,
reflecting successful attempt of quitting on their own or through external help
5.4 Risk Behavior

One of the risk behavior emerged among the study subjects was Injectable Use as one-tenth
(1090) reported such a practice in life time and about 7% were continuing preceding 30
days of registration. The preferred pharmaceutical products were Proxyvon,
Spasmoproxyvon, tidigesic ( buperonorphine), fortwin and pure form of Heroin( no.4)
The three-fourth current ID Users reported intravenous route and the rest through
intramuscular. The phenomenon of needle sharing was observed among half of current
users among men while one-third admitted sharing of cotton, boiling apparatus etc.

Among male patients, 685(6%) had undergone screening for Human Immunodeficiency
Virus (HIV) and out of those screened,7.3% had a positive status, a figure 20 higher in
comparison to general population prevalence figure of 0.36%. These figures again suggest
vulnerability of alcohol/drug users towards transmission of HIV and AIDS.

5.5 Physical and Mental Health problems

The study was able to get some data on physical and psychiatric complication arising out of
substance abuse disorder. Three percent male subjects reported Sexually Transmitted
Infections (STI) in their life time. The corresponding figure of 11 percent among women
drug users suggested vulnerability towards transmission of infections/diseases.
One-tenth men ( 9.5%) and 6% women drug users reported occurrence of jaundice, an
indication towards Hepatitis in their lifetime
Among male users, 13.4% reported psychiatric morbidity along with substance abuse
disorder while among women users it was 29 percent.
One-sixth of male patients covered under monitoring admitted one or more physical
complications on account of sustaining the habit of alcohol/drugs. Among women users, the
figure rise to double (33.3%).

These figures are a fair indication of cost of illness and co-morbidity arising out of a self
inflicting disease of drug dependence and a challenge to health and welfare agencies.

5.6 Difficulties encountered:

Difficulties were encountered at various levels. After the introductory letter sent to 122 De-
addiction Centers, response of participation was not adequate and it was followed by more
reminders. It took about two months for initiation and collection of data. At few Centers,
the In Charge of the program and administrative authority differs and it took a long time to
get consent of participation. Since the participation in the program was on voluntary basis,
only half of the listed Centers were able to give the consent. A few participating Centers
were unable to collect data on various accounts. The main reasons were alcohol/drug
abusers not getting registered and inadequate manpower. The fear of underground elements
was another hindrance in data collection.
During scrutiny of filled in Performa, certain items were not properly filled and codes were
missing. This took longer time in scrutiny and at few occasions filled in performa was sent
back to individual Centre for necessary corrections. Duplicate cases were also identified
and these were not considered for data entry. A few Centers were not able to follow to sent
data on quarterly basis and data got accumulated at the end.

5.7 Viability of drug abuse monitoring system:

The modest success of implementing a cost-effective mechanism at half of the De-addiction

Centres in health sector suggests viability of such program at national level. The DAMS
component has facilitated a mechanism where data acquisition can be carried out on
continuous basis from De-Addiction Centers run by the Central and State governments.
Further efforts are required to pursue the remaining Centers to become part of DAMS
network so that a fair representation can be achieved. The data gathered on continuous
basis can help in resource allocation and strengthening of program at national level.

References

Caribbean Drug Information Network (CARIDIN 2001) www.carec.org

Drug Abuse Monitoring System (DAMS): A Profile of Treatment Seekers

(2002).Monograph, Ministry of Social Justice & Empowerment, Govt. Of India & United
Nations Officer on Drugs and Crime, Regional office for South Asia, New

Mohan, D., Ray R., Sharma H.K., Desai, NG. Tripathy,B.M.,Purohit,D.R. and Sitholey,
P.(1992) Collaborative Study on Narcotic Drugs and Psychotropic Substances , Report,
Indian Council of Medical Research New Delhi

Mohan, D., Ray R., Pal H. and Sharma H.K.(2000) Community-based pilot project at
Barabanki, Mandsuar and Imphal. Report, Ministry of Health & Family Welfare, New
Delhi.

Roland Simon, Michael Donmall, Richard Hartnoll, Ana Kokkevi, A.W. Ouwehand,
Michael Stauffacher, Julian Vicente (1999) The EMCDDA/Pompidou Group Treatment
Demand Indicator Protocol: A European Core Item Set for Treatment Monitoring and
Reporting. European Addiction Research; 5:197-207

Rootman I and Hughes P. 91980). Drug Abuse Reporting Systems. World Health
Organization, Geneva (WHO Offset publication, No.55)

Sharma, H.K.( 2005) Substance Abuse In India-A Socio-Cultural Perspective,In Drugs and
Substance Abuse problems, interdisciplinary studies of cause, consequences and
preventions (Ed) M.C.Paul, Mittal Publication, New Delhi, pp 193-208.

The South African Community Epidemiological Network on Drug Abuse(SACENDU

2001) www.sahealth.org
Table 1 Distribution of the Sample by Sex
n
Sex Male 11658 99.0%
Female 117 1.0%
Total 11775

Table 2 Distribution of the Sample by Sex and Age

Sex
Age Male Female Total
upto 15yrs 47 2 49
(.4%) (1.7%) (.4%)
16-25 2085 29 2114
(17.9%) (24.8%) (18.0%)
26-35 4139 35 4174
(35.5%) (29.9%) (35.4%)
36-45 3346 33 3379
(28.7%) (28.2%) (28.7%)
46-55 1544 7 1551
(13.2%) (6.0%) (13.2%)
more than 55 481 11 492
(4.1%) (9.4%) (4.2%)
Not Known 16 - 16
(.1%) (.1%)
Total 11658 117 11775
Table 3 Distribution of the Sample by Sex and Marital Status
Sex
Marital status Male Female Total
Never married 2674 18 2692
(22.9%) (15.4%) (22.9%)
Married 8460 57 8517
(72.6%) (48.7%) (72.3%)
Divorce/Separarted 240 11 251
(2.1%) (9.4%) (2.1%)
Widow/Widower 128 18 146
(1.1%) (15.4%) (1.2%)
Separated due to 138 13 151
Drug Abuse (1.2%) (11.1%) (1.3%)
Not known 18 - 18
(.1%) (.1%)
Total 11658 117 11775

Table 4 Distribution of the Sample by Sex and Education

Sex
Education Male Female Total
Illiterate 1411 30 1441
(12.1%) (25.6%) (12.2%)
Literate 833 18 851
(7.1%) (15.4%) (7.2%)
Primary 1641 15 1656
(14.1%) (12.8%) (14.1%)
Middle 2394 20 2414
(20.5%) (17.1%) (20.5%)
Upto 10th/12th 4028 22 4050
(34.6%) (18.8%) (34.4%)
Graduation 1130 11 1141
(9.7%) (9.4%) (9.7%)
PG/Tech/Prof. 201 1 202
(1.7%) (.9%) (1.7%)
Not known 20 - 20
(.2%) (.2%)
Total 11658 117 11775
Table 5 Distribution of the Sample by Sex and Employment
Sex
Employment Male Female Total
Never Employed 759 22 781
(6.5%) (18.8%) (6.6%)
Presently Unemployed 2765 18 2783
(23.7%) (15.4%) (23.6%)
Full time employed 2618 8 2626
(22.5%) (6.8%) (22.3%)
Part time employed 1067 23 1090
(9.2%) (19.7%) (9.3%)
Self employed 3851 16 3867
(33.0%) (13.7%) (32.8%)
Student 236 2 238
(2.0%) (1.7%) (2.0%)
House wife/Girl 39 27 66
(.3%) (23.1%) (.6%)
Any other 288 1 289
(2.5%) (.9%) (2.5%)
Not known 35 - 35
(.3%) (.3%)
Total 11658 117 11775
Table 6 Distribution of the Sample by Sex and Living
Arrangement
Sex
Living arrangement Male Female Total
Joint family 4674 34 4708
(40.1%) (29.1%) (40.0%)
Nuclear family 6339 70 6409
(54.4%) (59.8%) (54.4%)
Alone 290 6 296
(2.5%) (5.1%) (2.5%)
With friends 120 3 123
(1.0%) (2.6%) (1.0%)
Any other 185 3 188
(1.6%) (2.6%) (1.6%)
Not known 50 1 51
(.4%) (.9%) (.4%)
Total 11658 117 11775
Table 7 Distribution of the Sample by Sex and Current drug use
Sex
Drug use Male Female Total
Alcohol 7535 60 7595
(64.7%) (51.3%) (64.5%)
Heroion 1667 20 1687
(14.3%) (17.1%) (14.3%)
Opium 1666 5 1671
(14.3%) (4.3%) (14.2%)
other opioids 1405 20 1425
(12.1%) (17.1%) (12.1%)
Cannabinoids 1118 2 1120
(9.6%) (1.7%) (9.5%)
Sedatives/hypnotics 759 10 769
(6.5%) (8.5%) (6.5%)
Cocaine 23 - 23
(.2%) (.2%)
Other stimulants 17 - 17
(.1%) (.1%)
Hallucinogens 15 - 15
(.1%) (.1%)
Volatile solvents 109 - 109
(.9%) (.9%)
Tobacco 7875 66 7941
(67.6%) (56.4%) (67.5%)
Any other 237 2 239
(2.0%) (1.7%) (2.0%)
Total 11658 117 11775
Table 8 Distribution of the Sample by Sex and Ever drug use

Sex
Drug use Male Female Total
Alcohol 9116 72 9188
(78.2%) (61.5%) (78.1%)
Heroion 1923 23 1946
(16.5%) (19.7%) (16.5%)
Opium 2031 6 2037
(17.4%) (5.1%) (17.3%)
other opioids 1789 26 1815
(15.4%) (22.2%) (15.4%)
Cannabinoids 1989 8 1997
(17.1%) (6.8%) (17.0%)
Sedatives/hypnotics 1133 15 1148
(9.7%) (12.8%) (9.8%)
Cocaine 51 1 52
(.4%) (.9%) (.4%)
Other stimulants 28 - 28
(.2%) (.2%)
Hallucinogens 23 - 23
(.2%) (.2%)
Volatile solvents 196 1 197
(1.7%) (.9%) (1.7%)
Tobacco 8270 74 8344
(71.0%) (63.2%) (70.9%)
Any other 272 3 275
(3.0%) (2.6%) (2.3%)
Total 11658 117 11775
Table 9 Distribution of the Sample by Sex and Injectable use

Sex
Male Female Total
Injecting Drug use(Ever) 1073 17 1090
(9.4%) (14.9%) (9.4%)
Injecting Drug use( current) 759 14 773
(6.5%) (12.1%) (6.6%)

Table 10 Distribution of the Injectable users by Sex and Sharing

Sharing of Sex
syringe/niddle Male Female Total
Yes 369 8 377
(49.2%) (57.1%) (49.3%)
No 390 6 396
(50.8%) (42.9%) (50.7%)
Total 759 14 773
-
Table 11 Distribution of the Injectable users by Sex and Route of
use

Sex
Route of Administration Male Female Total
I.V. 572 11 583
(76.1%) (78.6%) (76.1%)
I.M. 166 3 169
(22.1%) (21.4%) (22.1%)
S.C. 2 -- 2
(.3%) (.3%)
Not known 17 - 17
(1.6%) (1.6%)
Total 759 14 773
-

Table 12 Distribution of the Injectable users by Sex and

Paraphernalia

Sex
Paraphernalia Male Female Total
Yes 253 7 260
(34.5%) (50.0%) (34.8%)
No 506 7 513
(65.5%) (50.0%) (65.2%)
Total 759 14 773
Table 13 Distribution of the Sample by Sex and STI Symptoms

Sex
STI Symptoms Male Female Total
Yes 389 13 402
(3.3%) (11.1%) (3.4%)
No 10770 100 10870
(92.4%) (85.5%) (92.3%)
Not known 499 4 503
(4.3%) (3.4%) (4.3%)
Total 11658 117 11775
(100.0%) (100.0%) (100.0%)

Table 14 Distribution of the Sample by Sex and Jaundice

Sex
Jaundice Male Female Total
Yes 1102 7 1109
(9.5%) (6.0%) (9.4%)
No 10143 107 10250
(87.0%) (91.5%) (87.0%)
Not known 413 3 416
(3.5%) (2.6%) (3.5%)
Total 11658 117 11775
Table 15 Distribution of the Sample by Sex and Psychiatric
illness

Sex
Psychiatric illness Male Female Total
Yes 1560 34 1594
(13.4%) (29.1%) (13.5%)
No 9731 82 9813
(83.5%) (70.1%) (83.3%)
Not known 367 1 368
(3.1%) (.9%) (3.1%)
Total 11658 117 11775

Table 16 Distribution of the Sample by Sex and Medical illness

Sex
Medical illness Male Female Total
Yes 1769 39 1808
(15.2%) (33.3%) (15.4%)
No 9495 76 9571
(81.4%) (65.0%) (81.3%)
Not 394 2 396
known (3.4%) (1.7%) (3.4%)
Total 11658 117 11775
(100.0%) (100.0%) (100.0%)
Table 17 Distribution of the Sample by Sex and Previous
treatment
Sex
Previous treatment Male Female Total
Yes 2035 14 2049
(17.5%) (12.0%) (17.4%)
No 9227 102 9329
(79.1%) (87.2%) (79.2%)
Not known 396 1 397
(3.4%) (.9%) (3.4%)
Total 11658 117 11775

Table 18 Distribution of the Sample by Sex and Hospitalization

Sex
Hospitalisation Male Female Total
Yes 1442 12 1454
(12.4%) (10.3%) (12.3%)
No 9799 104 9903
(84.1%) (88.9%) (84.1%)
Not known 417 1 418
(3.6%) (.9%) (3.5%)
Total 11658 117 11775
(100.0%) (100.0%) (100.0%)
Table 19 Distribution of the Sample by Sex and HIV Screening

Sex
HIV screening Male Female Total
Yes 685 22 707
(5.9%) (18.8%) (6.0%)
No 10534 92 10626
(90.4%) (78.6%) (90.3%)
Total 11652 117 11769

Table 20 Distribution of the Sample by Sex and HIV Screening

results

Sex
HIV screeing results Male Female Total
Positive 50 1 51
(7.3%) (4.8%) (7.3%)
Negative 496 16 512
(72.7%) (76.2%) (72.8%)
Not Known 139 5 144
(19.9%) (19.0%) (19.9%)
Total 685 22 707