Substance Abuse among young people in India- approaches at curbing the menace

Introduction:

India also has a huge at-risk young population with 40% being below the age of 18 years. According to
UN Convention Reports on Narcotic Drugs and Psychotropic Substances in 1961, 1971 and 1988, it is
estimated that, in India, by the time most boys reach the ninth grade, about 50% of them have tried at
least one of the gateway drugs. A larger proportion of teens in West Bengal and Andhra Pradesh have
been using gateway drugs (about 60% in both the states) than Uttar Pradesh or Haryana (around 35%).
Smokeless tobacco in the form of gutka is commonly used by children and adolescents in certain states.
Every year, about 55,000 children take up to smoking generally hailing from low socio-economic strata
with poor social support, broken homes and victims of deprivation and discrimination. This risky
behavior is often initiated during childhood and adolescence, as more than 70% of adult smokers report
that they started smoking on a daily basis prior to age 18. Substance abuse creates a huge hindrance
for survival, protection, growth and development of healthy children, which is fundamental for
improving quality of life. Protecting children from substance abuse has to be considered the most
essential and urgent need for creating a ‘World fit for Children’ and for a meaningful
achievement of the ‘Millennium Development Goals’.

This paper looks at the extent, patterns and trends of substance abuse problem among children in
India, primarily through review of studies and also substantiates it with the field based
observations by linking personal experience of working with marginalized children with the
Bikash Bharati Welfare Society- a national level NGO running the Ministry supported Drug De-
Addiction Centre and Integrated Child Protection Scheme. The paper will also discuss the
existing challenges in addressing the substance abuse problem among children in India. It also
emphasizes the need to focus beyond the bio-medical and behavioral modification approach
based intervention while addressing the substance abuse problem, especially among the
marginalized children. It also suggests comprehensive approaches for substance abuse
intervention which is holistic, multidisciplinary and child centered, that would address the full
spectrum of determinants in the complex Indian context.

Extent, Trends and Patterns of Substance Abuse among Children in India.

A recent report titled "Extent, Patterns and Trends of Drug Abuse in India - National Survey" by
the United Nations Office on Drug and Crime (UNODC), put the figures at two million opiate-
users, 8.7 million cannabis-users and 62.5 million alcohol users of whom between 17 and 20 per
cent were dependent users(Sethi A, 2006). WHO estimates that globally 25 to 90 % of children
and adolescents indulge in substance abuse (WHO, 1997).

According to the 2001 Census, India is estimated to have more than 449 million children below
the age of 18 out of which 35 million children are in need of care and protection. A large
proportion of these children suffer in the quagmire of apathy and alienation, suffering from the
worst forms of deprivation and abject poverty and are victims of various forms of exploitation
and abuse. Substance abuse is one of the most serious problems among these children.

Substance abuse problem affects all categories of children who live in tribal, rural and urban
India. However there are some slight variations like in the enormity of the issues, like the higher
prevalence rate among the street based and slum based children compared to school going
children. The studies also show that the prevalence of substance abuse is higher among boys

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compared to girls and also the prevalence of use of substances among urban children are high
compared to the rural children. Most of the children getting into substance abuse were in the
adolescent age group, which is a crucial period for exploring new things in life. The age of onset
for using substances is quite early among the marginalized children compared to school going
children. Benegal et al, (1998) showed in their study that, street based children start off with
tobacco use when they are 10-11 yrs when they are little older they graduate to use inhalants. By
the time they are 13 yrs old the use of inhalants tapers off and they start experimenting with
alcohol and illicit drugs like cannabis, brown sugar etc.

A survey in Kolkata conducted by the Ashadeep Integrated Center for Addicts to study the
situation of substance abuse among children in the city and suburbs in 2002. The Study revealed
that 64% of patients coming in for treatment at their de-addiction centre were introduced to drugs
at a young age of around 15 years. Also according to the report 12.3% of the people involved in
drug and substances in Kolkata and suburbs, are below 20 years. The survey showed that of all
alcohol, cannabis and brown sugar users 21%, 4%, and 0.1% were below the age of eighteen
years.

Over the last fifteen years there has been several numbers of micro studies. Media has also been
focusing on this issue. A brief summary of selected studies to show the prevalence of substance
abuse across different strata of children all over India is presented in Table: 1.

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It is significant from these studies that the children are important victims of substance abuse
problem in India.Substance abuse problem affects all categories of children who live in tribal,
rural and urban India. However there are some slight variations like in the enormity of the issues,
like the higher prevalence rate among the street based and slum based children compared to
school going children. The studies also show that the prevalence of substance abuse is higher
among boys compared to girls and also the prevalence of use of substances among urban
children are high compared to the rural children. Most of the children getting into substance
abuse were in the adolescent age group, which is a crucial period for exploring new things in life.
The age of onset for using substances is quite early among the marginalized children compared
to school going children. Benegal et al, (1998) showed in their study that, street based children
start off with tobacco use when they are 10-11 yrs when they are little older they graduate to use

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inhalants. By the time they are 13 yrs old the use of inhalants tapers off and they start
experimenting with alcohol and illicit drugs like cannabis, brown sugar etc.

The studies show that the school going children are using mostly tobacco and alcohol, where as
the out of school children especially the street based, slum based and child laborers are at a risk
of experimenting with most dangerous substances both licit as well as illicit in nature. Ahmad et
al (2007) showed in his study the rising trend of substance use with age was significant. From
these studies we could see that most of the children are using tobacco products, alcohol and
inhalants. Alcohol, tobacco and inhalants are described as gateway drugs, which supposedly
causes its users to move on to harder drugs (Meyers and Petty, 2008) In case of street children
and migrants children it was observed they usually start with tobacco products then get into
inhalants, alcohol and move onto harder drugs like ganja, charas, heroin, opiods etc (Benegal V
etal 1998; Malhotra C 2007, CHETNA, 2007). All the gate way drugs are easily available to the
children. Moreover they are not ‘illegal’ and very less recognition that these substances can
cause severe addiction. There is a common misconception is that something is not a drug unless
it is illegal. Whatever type of substances children indulge in, it creates a huge hindrance for
survival, protection, growth and for their healthy development. On regular use of any of these
substances, the body develops tolerance for it. Tolerance refers to the condition where the user
needs more and more of the drugs to experience the same effect. Smaller quantities that were
sufficient earlier are no longer effective and the user is forced to increase the amount of drug
intake. This increased amount of consumption, eventually leads to psychological and physical
dependence.

Psychological dependence is a state characterized by emotional and mental preoccupation with

the effects of the substances and a persistent craving for it. As psychological dependence
develops the user gets mentally hooked onto the drug. When physical dependence develops, the
user’s body becomes totally dependent on the drug. With prolonged use, the body becomes so
used to functioning, under the influence of the drug that it is able to function normally only if the
drug is present (Ranganathan S, et al, 2008). When physical and psychological dependence
increases they are get into a phase of chronic addiction.

Addiction is the only disease where the victim does not fully realize the enormity of the problem.
The stigma associated with drug use, the guilt and shame resulting from inappropriate use and
the lack of awareness about the impact of drugs on their health and behavior— all these lead to a
denial of the problem of addiction. Addiction to substance abuse especially among the vulnerable
children can directly contribute to high risk lifestyle. As noted by Benegal et al (1998) and
Tiwari P (2007) in their study, these children get into illegal activities like gambling, drug
peddling, pick pocketing, stealing, fighting, rape and self directed aggression causing self harm
to slash themselves with sharp objects especially when they are intoxicated. Some of the children
reported to undergo severe depression and attempt suicide.

Another important finding Benegal’s study is that the children or forced into or paid for or
offered drugs in exchange for sex. There was nexus between street children and commercial sex
workers, many of whom abused drugs or alcohol. Children are made to act as pimps or go
between in exchange of money, drugs and shelter and sexual favours. Children who get into
substance abuse problem are easily prone to delinquent behavior and anti-social activities. They

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can also easily become victim of HIV/ AIDS and other sexually transmitted infections, when
they involve in unprotected sex under the influence of substance.

From the studies reviewed, we come to know that children mainly use six categories of
substances:

A) Stimulant: These drugs, excites or speed up the central nervous system. Both smoke and
smokeless forms of tobacco products belong to this category.

B) Volatile Solvents: These are most cheaply available drugs particularly for the street
based children.Correction Fluid, paint, thinners, petrol and glue are the commonest forms
abused. The correction fluid is highly used by the street based children ,it contains a
lethal chemical called toluene.

C) Depressant: These substances depress or slow down the function of the central nervous
system. All type of alcohol products belong to this category. Usually the children tend to
use the cheapest forms liked brewed liquor, beer etc.

D) Cannabinoid: Cannabis drugs are made from Indian hemp plant- Cannabis sativa. This
plant has mind altering properties. The main products under this category are Bhang,
Charas and Ganja. These substances are illegal. Street based and slum based children are
used for peddling these drugs by mafias sometimes. Significant number of street children
found to be addicted to these drugs.

E) Narcotics: ‘Narco’ means ‘to deaden’ or benumb. The narcotic products have the
property of numbing and thus relieving pain. Narcotics of natural origin (eg.opium,
morphine, codeine), semi synthetic (eg.heroin) are referred to as opiates. The synthetic
narcotics known as opiods ( eg. Buprenorphine). A significant number of street children
get addicted to narcotic substances like heroin, opiods and codeine.

F) Prescription Drugs: It has become a common phenomenon, due to easy availability of

these pharmaceutical drugs; it is purchased and used by children. Cough syrups, pain
killers and sleeping pills are commonly abused by children.

Table -2 describes the types of substances abused by the children, the immediate intoxication
effects and the adverse health consequences it can create. As shown in the table that all the
substances creates a short term euphoric feeling, a sense of pleasure and relaxation. These short
term effects may hinder the user to perceive the long term consequences. However, with more
regular use tolerance and need for using substances regularly develops this creates several health
problems. The health consequences are quite severe; these substances act as a slow poison which
kills a person as the quantity and period of intake of substances increases.

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Source:
1. Ranganathan, S et al (2008 ) Drug Addiction :Identification and Initial Motivation-A Field Guide for
Service Providers and Trainers, T.T.Ranganathan Clinical research Foundation, Chennai
2. Kaur and Gulati (2007) Drug Abuse: Trends and Issues, paper presented in International Marketing
Conference on Marketing and Society, 8-10 April, 2007.
3. Drug of abuse Classification and Effects Available at http://www.addictionindia.org

Social and Cultural Factors Associated with Drug Abuse in Adolescents

There are many factors that play a part in initiation and maintenance of drug abuse in adolescents.
Initiation of drug use is complex3 with multiple factors contributing in the onset of this behaviour. The
social and cultural factors influencing the initiation of tobacco use vary from country to country, from
developed world to developing nations, region to region and culture to culture.

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1. Parental Influence
Parents have a tremendous influence on their children and the children of smoker parents are twice likely
to become smokers5 Parental disapproval of smoking makes an adolescent less likely to initiate smoking.6
Female adolescents are more likely to be smokers if both parents are smokers. There is a strong
correlation between mother smoking and the female youth becoming a smoker. It is a socially sanctioned
behaviour in certain cultural groups to use Bhang and Charas by adolescents and has parental approval
for that. Parental attitude towards alcohol plays an important role in initiating the adolescent to drink
alcohol.

2. Family Structure
Higher levels of parental education and socioeconomic variables have inverse relationship with tobacco
use and use of other psycho-active substances among adolescents. Prevalence of smoking is more
common in families which are with low socio-economic educational status of the society. Children using
inhalants generally hail from low socio-economic status, engaged in menial work with unstable family
income. Marital discord, divorce among parents, single parenting, areassociated with drug abuse among
adolescents.

3. Peer Influence
Adolescents form their own peer group. Friends have the greatest influence on the young smokers. The
initiation of tobacco smoker generally occurs in the company of a friend who is a smoker.10 Female
adolescents with a best friend who is a smoker are nine times more at risk to become smokers. Cannabis
abuse in school-going population has been associated with poor scholastic performance, school dropout
and reinforcement of conduct symptoms.

4. Role Model
Film and TV stars, pop stars and fashion models make smoking seem attractive and the adolescents
imitate them to smoke their style. They leave tremendous impact on adolescent mind.

5. Advertising and Promotion

Advertising is an effective weapon to influence the decision of young to initiate smoking. Advertising
bans have been found to be very effective in reducing cigarette smoking prevalence in youth. Indian
Government has banned advertisement of cigarettes and other tobacco products through an Act.

6. Socio-economic Factors
Higher drug-abuse rates are observed in lower income groups. Adolescents from low socioeconomic
background are more likely to become smokers than the middle-class counterparts. In India, beedi
smoking is more common in adolescents for the reasons of easy availability, low in price and convenient
to use. Adolescents from low income families tend to use cheap and spurious country-made liquor
prepared illegally. Use of inhalants is also common in the adolescents from poor families.

7. Availability
Availability and accessibility are important factors in initiation and maintenance of drug abuse among
adolescents. An adolescent who has an easy access to drugs or alcohol because his parents or elder sibling
is using, is more likely to use these drugs. Similarly peer group members making the product available are
likely to recruit new adolescents in the drug use behavior.

8. Knowledge, Attitude and Beliefs

Knowledge about the detrimental health effects has preventive effect on drug use. Some believe that
moderate alcohol consumption does not have adverse effects, tobacco cessation could lead to weight gain
and cannabis is a social and religious blessing of gods. These beliefs permit the adolescents to use drugs
without hesitation or guilt. Positive attitude towards the drugs is likely to initiate drug use among the
adolescents.

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Challenges in Addressing Substance Abuse Problem among Children in India

Substance abuse is a growing menace affecting children from all segments of the society. The
problem causes an additional burden in the lives of the children living in vulnerable conditions.
There are several challenges involved in addressing this problem especially in the case of
marginalized and vulnerable children in India. The substance abuse problem in their case, cannot
be viewed in isolation as it is intertwined with other health and social problems, such as those
related to discrimination, stigmatization, unprotected and unwanted sexual behavior and
violence.(GOI, WHO , UNDP , NACO , 1996).
Being neglected by the family, as their parents lack resources to provide protection and care,
many share the burden of the family at a very young age. The children are forced to work for
very long hours and suffer from excessive fatigue, and remain susceptible to infectious disease
due to poor nutritional status. Stunted growth is common among these children.(Gowri RA and
Manjusha CH, 2003). They engage in work that are too demanding to their size and strength,
causing irreversible damage to their physical and physiological development, resulting in
permanent disabilities, with serious consequences for their adult lives. They are subjected to all
kinds of occupational hazards and diseases. They are extremely vulnerable because of their
growing bodies, their lower threshold for toxics and their lesser ability to respond effectively to
hazards. Added to these, when they consume harmful substances it affects their immunity and
causes serious health hazard. These children are constantly denied of prospects to live healthy
and creative lives.
Then there are social-legal challenges that they face. Children and adolescents who live on their
own in the streets are also detained illegally, beaten and tortured by the employers, police and the
society to extract maximum labour out of them. Rag picking, shoe shining, working as coolies,
working in shops and restaurants, road side vending, cleaning and washing utensils in kalayana
mandapam are some of the works they take up for their survival. These children work for long
hours in these occupations which are termed ‘honest’ work. When there are no means for an
honest living, they sometimes engage in petty theft, drug trafficking, prostitution and other
‘dishonest’ or criminal activities. Yet there have been very few attempts to examine the causes of
such activities and to rehabilitate them.
These vulnerable children are also easy targets for police atrocities. The authorities forcibly
remove these children from the streets, often to incarcerate them, and sometimes chased away
through violent measures. Gross abuses are often quietly sanctioned against them. There are
reports of street children being beaten, tortured and even murdered by police (HRW, 1996).
Children and adolescents who have been physically maltreated are more likely to use substances
(Joseph TF, et al 2005; Tiwari P, 2007) These marginalized children not only under physical mal
treatment; they also undergo severe emotional abuse and sexual exploitation (Banerjee SR, 2001;
Pagare D, et al 2005). They face several challenges in their day to day life regarding food, safety,
employment, shelter and medical care and go through pain, violence and stress everyday.

They start taking drugs to overcome their loneliness and to escape their harsh realities in
life.(Karmakar T, et al,1998) The predominant reasons cited by the children for intake of drugs
in one the study is to overcome homesickness, to cope up with hard weather conditions, to over
the pain of exploitation, and sexual abuse and the compulsion to spend money (Asian Age,
2006). Using drugs also numbs their hunger pangs when food is not available to satisfy their
hunger (Paniker R, 1998). So the substance abuse problem in marginalized children in India

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cannot be solely treated as a medical problem, while dealing with the problem it requires an in-
depth understanding to deal with its social and economic determinants.

Programmes and Interventions

India has been signatory to all International Conventions and has set up necessary legislative
structures and other structures to fight drug menace as well as protection of child rights. India
has also brought out some measures in enforcement, legal and judicial systems to protect
children from substance abuse. Despite the commitments to International Conventions, the
Constitution providing for most important rights, a national policy, several laws and schemes for
Child Protection, there has been inconsistent implemention at the ground level.

A National Master Plan for substance abuse was evolved in 1994 which focuses on the,
establishment of treatment and rehabilitation centres, training of primary care doctors and other
personnel in substance abuse. This plan also ensured collaboration with non-governmental
organisations to carry out education and awareness building programmes. There are currently
around 400 integrated rehabilitation centres for addicts (IRCA) for substance abuse prevention
under the Ministry of Social Justice & Empowerment in India. The government also finances
more than 50 NGOs, which are engaged in substance abuse prevention activities (Child Line
India, 2008). But most of these NGO’s are private run and they specifically cater to adults who
are addicted to substance abuse.

Comprehensive approaches at curbing the menace of drug addiction among young people

As known most of the adolescent start using substance to satisfy their curiosity or to have fun
with their peers without knowing its future consequences. In case of the street based and slum
based children the studies have shown that substance abuse plays a functional role in their daily
lives. The current intervention programmes to deal with substance abuse problems among
children lack comprehensiveness in its approach. Many prevention programme limits itself with
creating mass sensitization about the issue without adequate follow-up measures. Treating
children afflicted with substance abuse mostly based on the bio-medical and behavioral
modification approach. They also lack child centric approach. While addressing the substance
abuse problem, especially among the marginalized children, there need to be holistic,
multidisciplinary and child centered programmes that would address the full spectrum of
determinants in the complex Indian context.

When children get into substance abuse problem, they remain secretive about their behavior,
fearing their parents and elders. Until there are manifest impacts on their health or involvement
in unwanted violent behavior or accidents caused under the influence of substances, no one will
know their substance abuse habits. While in the case of children on streets, who are cut off from
the family system and school system their problem could be even more serious.

The first challenge is to identify the children who have become victims of substance abuse. For
this community based intervention programme needs to be implemented. This community
intervention programme should be participatory in nature, where all those who are closely
associated with children at personal as well as professional level are involved.

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The community based programme can be designed as per the needs of the specific child
population. For instance, in the case of street children or slum children, one has to reach out to
their community where they are prominent. Innovative strategies like street play methods can be
used to create awareness. In case of schools A regular substance abuse awareness programme
can be organized by school teachers or the school counselors in their own premises. The overall
aim of the community based programme should not be limited to create sensitization for parents,
school, community and peers on the issues of substance abuse problems and its consequences. It
should be followed by tracing the children who are into substance use/abuse and start early
intervention programmes, which increase the chances of early prevention of substance abuse.

Motivating the children to undergo treatment to quit the substance abuse may not be a simple
task, particularly in the case of street children. Regular contacts with them on the streets,
motivating them through peers, organizing motivation camps combined with counseling,
providing them with clear information and communication about consequences and benefits of
recovery, are of prime importance. Once the children with substance abuse problems are
identified, they require professional help to recover from it. They need to undergo short term or
long term treatments, depending on the severity of the substance abuse problem.

The treatment strategy to deal with substance abuse problems in children and adolescents should
be different from dealing with adults. The professionals should empathetically assess the needs
of the children and ensure that every stage of the programme is child centric. Conscious effort
should be taken to create conducive child friendly atmosphere. Particularly the physical
environment of the treatment centre should be non-threatening and not too ‘hospital like’ to
avoid the child feeling that s/he is a ‘patient’. Every person who deals with the child should be
understanding and non judgmental. This will help the child to trust, open up, accept the treatment
and discuss the problem freely.

After the medical assessment, detoxification is the first step in the treatment of substance abuse.
Abruptly stopping substances can result in withdrawal symptoms and can be physically
dangerous to one’s health. Detoxification is the process of safely getting out of the drugs under
medical supervision. After detoxification, the person may become stable as the craving for intake
of drugs is reduced and the body slowly regains its normal condition. Once the person is stable,
psychological assessment has to be carried out to rule out any associated mental health problems.
Many times the treatment approach is limited to this level with the short counseling session
without dealing with the complexities of related problems in life of the substance abused child. It
is very important that the treatment approach should not limit itself to mere bio-medical nature of
intervention or using counseling strategies to modify or change the behavior of the children.
Even while counseling a child , the traditional counseling approach only through ‘talking’ and
listening’ will not help , because children are often withdrawn, scared as they undergo
confusions of guilt and fear. Rather than forcing an emotionally withdrawn child for a
conversion, one has to adopt innovative methods to help the child to express through art, story
telling, music, drama, writing etc. The treatment process should be participatory and reflective in
nature. The medical treatment should be combined with self exploration, self expression as well
as training them on life skills, vocational skills, academic skills, coping up strategies, sports,
recreation etc; and all these should become part of therapeutic process.

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To carry out this comprehensive treatment process one requires a multidisciplinary team. A team
that comprises of medical doctor, nursing professional, child psychologist, counselor, social
worker and vocational therapist would be ideal to contribute their professional skills to
implement a substance abuse prevention programme for children. The medical and mental health
professionals may limit their role to medical, psychological assessment and detoxification. The
role of social worker is very crucial after this stage to assess the impact of substance abuse at
various facets of life; especially, social, familial, educational, life skills, financial and behavioral
deterioration that has occurred as a result of substance abuse. The social worker also takes the
responsibility to identify the appropriate support system for the child as this would play a key
role in the pre and post rehabilitation process. The social worker along with the child and the
support systems should plan remedial measures for the process of recovery. The Ministry of
Social Justice and Empowerment’s Scheme for Prevention of Alcoholism and Drug Abuse, run
through NGOs in India, provides for multidisciplinary team for treatment and rehabilitation of
drug users. But the centres are mostly located in the cities, with hardly few in the rural areas.
Again these centres caters to adult drug using client and their indoor treatment facilities heavily
booked with adult patients, leaving little scope for in-house treatment scope for adolescents.

Support systems like peers, parents, well wishers, community workers, teachers or anyone who
has genuine interest and concern about the welfare of the child should be integrated as part of the
pre and post rehabilitation process. Particularly, the social workers and peers form an important
support system in case of children rescued from streets and those who lack total support of
family systems. These children may require a long term care in the institutional setting because
the complexities of their problems are higher as they constantly face the hostility of the society
and miss other protective mechanism when compared to those children living with stable support
systems. Teaching life skills, vocational skills, occupational skills should constitute an important
part of rehabilitation process especially for the marginalized children who are school drop outs
and who cannot get back to mainstream education. The role of vocational therapist is vital to
each the vocational skills to eventually help these children to lead a normal life back in the
society.

While reintegrating the ‘street child’ back to their family in the post rehabilitation process, the
social worker needs to counsel the family members to make them understand about the factors
that forced the children to come on to streets and how they developed they got into the problem
of substance abuse. They need to be told not to victimize or demoralize the child’s behavior.

For those who underwent treatment for substance abuse, recovery remains a life-long process.
The chance of falling back to substance abuse or getting relapsed is quite high. To prevent this,
consistent monitoring and guidance from the support systems and follow-up through continuous
contact by the counselor/ social worker at-least for a year is crucial and vital for better recovery
of the child.

Summing up

Understanding the issue of substance abuse problem holistically and plan appropriate actions to
intervene as early as possible is very crucial to create a ‘fit world’ for children and to restore
their rights for protection from substance abuse. Until children are protected from substance

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abuse and appropriate ‘child centric’ rehabilitation measures are implemented, it will not be easy
for many children in India to regain their capabilities to achieve their fullest human potential
which is very important to achieve the Millennium Development Goals.

It needs to be stressed that knowledge of the extent of problem and socio‐demographic risk
factors is essential to devise effective preventive strategies against substance use among
adolescent. Accordingly school and community based intervention programmes need to be
implemented. Besides, convergence of Government programmes for drug abuse prevention,
education of children and care and support for children at risk under the various Ministries, as
well as the Governments departments in the States, is needed at the right earnest for children and
adolescent – both studying and out-of-school to save the onslaught of the substance abuse.

References:

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2. Addiction India (2008) Drug of abuse Classification and Effects, accessed from
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