| Abstract|| |
Background: Substance use disorders are believed to have become rampant in the State of Punjab, causing substantive loss to the person, the family, the society, and the state. The situation is likely to worsen further if a structured, government-level, state-wide de-addiction service is not put into place.
Aims: The aim was to describe a comprehensive structural model of de-addiction service in the State of Punjab (the "Pyramid model" or "Punjab model"), which is primarily concerned with demand reduction, particularly that part which is concerned with identification, treatment, and aftercare of substance users.
Materials and Methods: At the behest of the Punjab Government, this model was developed by the authors after a detailed study of the current scenario, critical and exhaustive look at the existing guidelines, policies, books, web resources, government documents, and the like in this area, a check of the ground reality in terms of existing infrastructural and manpower resources, and keeping pragmatism and practicability in mind. Several rounds of meetings with the government officials and other important stakeholders helped to refine the model further.
Results: Our model envisages structural innovation and renovations within the existing state healthcare infrastructure. We formulated a "Pyramid model," later renamed as "Punjab model," where there is a broad community base for early identification and outpatient level treatment at the primary care level, both outpatient and inpatient care at the secondary care level, and comprehensive management for more difficult cases at the tertiary care level. A separate de-addiction system for the prisons was also developed. Each of these structural elements was described and refined in details, with the aim of uniform, standardized, and easily accessible care across the state.
Conclusions: If the "Punjab model" succeeds, it can provide useful models for other states or even at the national level.
Keywords: De-addiction service, model, Punjab, state, substance use disorders
|How to cite this article:|
Basu D, Avasthi A. Strategy for the management of substance use disorders in the State of Punjab: Developing a structural model of state-level de-addiction services in the health sector (the "Punjab model"). Indian J Psychiatry 2015;57:9-20
|How to cite this URL:|
Basu D, Avasthi A. Strategy for the management of substance use disorders in the State of Punjab: Developing a structural model of state-level de-addiction services in the health sector (the "Punjab model"). Indian J Psychiatry [serial online] 2015 [cited 2019 Oct 14];57:9-20. Available from: http://www.indianjpsychiatry.org/text.asp?2015/57/1/9/148509
| Introduction and Rationale|| |
Substance use disorders (SUDs) are believed to have become rampant in the State of Punjab. Indeed, they are said to have assumed epidemic proportions and are definitely seen as a major public health concern. Tremendous burden can be expected on the individual, family, and larger society because of the problem of substance abuse, in terms of physical and mental health impairment, impairment of quality-of-life, economic hardship, lost productivity, accidents, and crimes, etc.
The following is a news report, worth citation in full: (Indian Express, May 22, 2009). 
"According to a Punjab Government survey, 66% of the school-going students in the state consume gutkha or other forms of tobacco; every third male and every tenth female student has taken drugs on one pretext or the other and 7 out of 10 college-going students' abuse one or the other drug. These disturbing details were submitted by Harjit Singh, Secretary, Department of Social Security and Women and Child Development, Chandigarh, in May 2009, in reply to a petition filed by some drug rehabilitation centers before the Punjab and Haryana High Court. The affidavit further read "In the recent times, the amount of narcotic substances seized in the state has also been among the highest in the country." The Secretary, on behalf of the Punjab Government, submitted "the vibrancy of Punjab is virtually a myth… many sell their blood to procure their daily dose of deadly drugs, even beg on the streets for money to continue their addiction. The entire Punjab is in the grip of the drug hurricane which weakens the morale, physique, and character of the youth. We are in the danger of losing the young generation. The vibrant Punjab that had ushered in the green revolution is today living in a dazed stupor as 67% of its rural household has at least one drug addict." He added that the use of alcohol and drugs is now a "part of the Punjabi culture." "No celebration is complete until liquor is served in plenty. However, in the last two decades, the pattern of drug use in the state has undergone a change in favor of new narcotic and synthetic drugs. Now the addicts consume multiple as well as single drugs," read the reply. Punjab alone accounts for roughly over one-fifth of the total recoveries of heroin in the country. The state submitted that studies have been conducted which shed light on the problem in different population groups. The drug traffickers use the cities of Gurdaspur, Amritsar, Tarn Taran, Firozpur, Kapurthala, Hoshiarpur, Ludhiana, Patiala as well as Chandigarh to smuggle the narcotic substances through Punjab. According to the survey report cited by the Secretary, opiates, their derivatives, and synthetic opiate drugs are used by 70% of the addicts, followed by a combination of opiate and other sedatives, including morphine. Extent of drug addiction in Punjab is 70%. Household survey indicates that there is at least one drug addict in the 65% of families in Majha and Doaba and 64% families of Malwa. Tarn Taran is the most affected rural district, and Amritsar is the most affected urban district in Punjab. Per head consumption of alcohol is the maximum in Punjab and Tarn Taran district tops the list. In border areas, the extent of substance abuse is 70-75% in the age group of 15-25 years and up to 40% in the age group of 35-60 years. Over 16% population is addicted to hard drugs" (end of citation from the news report).
Excessive use of psychoactive substances in Punjab has been highlighted in several studies dating back to the 1970s. Earlier studies by Deb and Jindal,  Mohan et al.,  Singh,  Lal and Singh,  Varma et al.,  Gupta et al.,  and later studies by Singh et al.,  Neerja and Goyal,  Sandhu,  Ambekar, and Tripathi  and the recent published study by Mahi et al.  all highlighted this basic fact. The only national-level multi-component drug abuse survey conducted in India also included Punjab, but the data were collected in 1999-2000. 
However, despite the lack of updated state-wise representative epidemiological data, the substance use situation in Punjab definitely raises concern. Whatever direct data are available from the above studies, plus and more importantly the indirect data from drug seizures, drug-related crimes, treatment records of drug addicts, customs and excise data on sale of alcoholic beverages, medical emergency and other medical attendance data, cases under Narcotic Drugs and Psychotropic Substances (NDPS), data from addiction problem in special population especially the prisons etc., all would bear strong testimony to this fact. Such news is widely available from various sources in the lay press both nationally and internationally (e.g. Tehelka Magazine, April 14, 2012; The Tribune, December 31, 2012; The Washington Post, January 1, 2013; The Times of India, February 14, 2013, Al-Jazeera, April 29, 2014; The Hindustan Times, August 13, 2014, etc.). ,,,,,
Hardcore data on seizures of opium and heroin clearly show that Punjab was the state from where by far the highest seizures were made in the last few years, and the trend is increasing (Narcotics Control Bureau, Annual Report 2012).  Similarly, maximum cases were registered under the NDPS Act in 2012 in Punjab, with the nationally highest drug-related crime rate of 51.6 (per lakh population) in this regard, against the national average of 2.8 (National Crime Records Bureau, Annual Report 2013).  This figure is, in fact, much higher than that reported in 2010, that is, 19.7 against the then national average of 2.1 per lakh (National Crime Records Bureau, Annual Report 2011).  It shows that while the nationwide rate changed little from 2010 to 2012, Punjab clocked the highest NDPS crime rates both in terms of absolute as well as crime rate growth figures. Indeed, in 2012, Punjab alone accounted for 42.3% of all cases registered under NDPS Act in India! 
| Materials and Methods|| |
Given this grim scenario, it was felt imperative by the Hon'ble Chief Minister of Punjab that the Government of Punjab takes urgent and serious measures to curb the menace of substance (drug) abuse in the state. The authors were consulted to chalk out a strategy for the State of Punjab for management of SUDs at a state-wide level. A high-level meeting was held on 22.04.2012, chaired by the Chief Minister of Punjab, to discuss various strategies and actions needed to improve the de-addiction services in the State of Punjab, where the authors presented their model. This paper reports the development and strategic recommendations for such a state-wide model, christened as the "Pyramid model" (see later) or simply the "Punjab model" of de-addiction.
The model was developed by a detailed study of the current scenario, critical and exhaustive look at the existing guidelines, policies, books, web resources, government documents and the like in this area, a check of the ground reality in terms of existing infrastructural and manpower resources, and keeping pragmatism and practicability in mind. Several rounds of meetings with the government officials and other important stakeholders helped to refine the Model further. The strategy has been accepted by the Government of Punjab and is already being put in place. If successful, this structural strategy can provide useful models for other states or even at the national level. The aim of this article is to share the essentials of this structural model. The article is divided into the following sections:
- Overall structure and scope of the model
- Developing de-addiction services within the existing healthcare structure
- Strategies and recommendations for structural changes (the "Punjab model")
- Minimum standards of care and the need to go beyond: The model de-addiction centers
- The central hub of the Punjab model: District-level de-addiction centers and rehab centers
- The base of the pyramid: De-addiction services at community healthcare level
- De-addiction services in the prisons of Punjab
- Epilogue: What is needed to make this dream a reality?
| Overall Structure and Scope of the Model|| |
Control measures for SUDs comprise of three broad arms: Supply reduction, Demand reduction, and Harm reduction. These terms are defined as: (United Nations Office on Drugs and Crime Book "Demand Reduction: A Glossary of Terms", 2000): 
"Supply reduction" refers to a broad range of strategies and actions to stop or minimize the production, manufacture, and distribution of illicit drugs.
"Demand reduction" is a broad term used for a range of policies and programs which seek a reduction of desire and preparedness to obtain and use illegal drugs. Demand for drugs may be reduced through prevention and education programs to dissuade users or potential users from experimenting with illegal drugs and/or continuing to use them; treatment programs mainly aimed at facilitating abstinence, reduction in frequency or amount of use; drug substitution programs (e.g. methadone); court diversion programs offering education or treatment as alternatives to imprisonment; broad social policies to mitigate factors contributing to drug use such as unemployment, homelessness, and truancy.
"Harm reduction" - in the context of alcohol or other drugs, harm reduction refers to policies and programs that focus directly on reducing the harm resulting from the use of alcohol and other drugs, both to the individual and the larger community, without necessarily requiring abstinence. Examples include needle/syringe exchange programs, bleach distribution, education about safe injecting practices, condom distribution, etc., all focusing on reduction of risk of HIV and other infections in injecting drug users.
First, we defined the clear remit of the strategy to be developed. It was decided that keeping within our own area of expertise and experience, this strategy document would be primarily concerned with demand reduction, particularly that part which is concerned with identification, treatment, and aftercare of substance users. Supply reduction, though an extremely important strategy on its own was beyond the scope of this document. Salient features of Supply Reduction can be found in the NDPS Act 1985, and in the most recently announced National Policy on NDPS, approved by the Union Cabinet in January 2012 and released by the Union Finance Minister in February 2012.  Harm reduction too was not the direct focus of this document though it could be an important adjunct policy in selected cases. The makers of this particular document are psychiatrists with expertise and experience in de-addiction activities. As such, this document limited itself to the scope and the mandate of suggesting practical strategies and measures toward management of SUDs in Punjab.
| Developing De-Addiction Services within the Existing Healthcare Structure|| |
Management of SUD has to occur within the matrix of the existing healthcare system in the country. The state healthcare system is three-tiered: Primary, secondary, and tertiary. Primary care is directly based in the community; it takes place (in ascending order of population coverage) in sub-centers (SC), primary health centers (PHCs), and community health centers (CHCs). Secondary health care system is based at the district/sub-divisional level and is comprised of sub-divisional/sub-district hospitals (SDHs) and district hospitals (DHs). Higher treatment facilities comprise the tertiary level of healthcare.
With the on-going National Rural Health Mission (NRHM) since 2005, there is concerted an effort by the India Government to strengthen and upgrade the primary and secondary health care systems (from SC to DH). The Indian Public Health Standard (IPHS) guidelines have been formulated under NRHM (and updated in 2010), which specify the criteria, services to be covered, and infrastructure at each level till the DHs. Psychiatric services, Tobacco cessation services, and de-addiction centers are also mentioned for some of these levels. A careful scrutiny of the IPHS Guidelines shows that "de-addiction center" is mentioned for the 1 st time in only at the DH level, that too only as "Desirable" (not essential) services, with no indoor facilities, only outdoor. No detailed guidelines/standards are mentioned. In contrast, tobacco-related activities have been mentioned from the lowest (SC) level itself, primarily because these are mandated by the National Tobacco Control Programme (NTCP), though a Tobacco Cessation Clinic is mentioned (as a "desirable" program) only at higher SDH level and later as essential program at the DH level. Alcohol and Drug abuse is mentioned for the 1 st time under Psychiatry Services at the higher SDH level, that too as an outpatient "Follow-up of alcohol and drug abuse patients" (in the 51-100 bedded hospitals), with no further details.
Clearly, there is a lot to be desired in this system, especially when facing the problem of drug abuse in Punjab. The relative lack of emphasis on the de-addiction services appear to be at least partly a fall-out of the fact that, unlike the National Mental Health Programme and NTCP, there is currently no "National Alcohol and Drug Abuse Control Programme." The recently announced National Policy on NDPS, as mentioned earlier, is focused much more on supply reduction than demand reduction or harm reduction. Of the 34 actions/activities listed in the National Policy, only six pertain to demand reduction and only one on harm reduction. Similarly, <4 pages have been devoted to the total 47-page Policy document toward Demand and Harm Reduction. 
Given this scenario and the dire situation in Punjab, it was felt imperative to improvise.
But before that, it is important to recapitulate the "three major players" in providing de-addiction services. The first major player is the nongovernmental organization (NGO) sector. There are around 400 Integrated Rehabilitation Centres for Addicts (IRCA) throughout the country, which are being run by NGOs, supported by the Ministry of Social Justice and Empowerment (MSJandE), Government of India. Another major group is the private sector; many doctors including a large number of psychiatrists are providing services to people for substance use-related problems. The third major group is the government de-addiction centers. The Ministry of Health and Family Welfare (MOHandFW), Government of India, has established about 122 drug de-addiction and treatment centers throughout the length and breadth of the country. Most of these MOHandFW-funded government centers are associated with either general hospitals at the district levels or with Departments of Psychiatry at certain Medical Colleges. In Punjab, only five such centers were there before implementation of the model proposed later: One each in Government Medical Colleges in Amritsar, Patiala and Faridkot, and one each in the DHs in Tarn Taran and Bathinda.
Last but not the least, there was a complete lack of drug abuse rehabilitation ("Rehab") centers funded and run by the State Government. The few that are in existence are run by NGOs funded by the MSJandE; they are perceived to be no match for the increasing demand, and the conditions there are far from satisfactory, as reported by many recent newspaper reports (e.g. India Today, May 9, 2014; The Hindustan Times, August 13, 2014). , Thus, it was felt imperative to set up State Government-funded drug rehab centers.
With this detailed background, the suggested strategies, and recommendations for identification, management and referral of substance users were developed.
[TAG:2]Strategies and Recommendations for Structural Changes (The "Punjab Model") (Envisaged in 2012)[/TAG:2]
- First and foremost, a comprehensive listing of all existing de-addiction service facilities in the State of Punjab was urgently required. This included all such facilities, listed by types (government, NGO, private sector), infrastructure (outpatient/outpatient plus inpatient), activities undertaken (counseling and other brief interventions, detoxification, relapse prevention, rehabilitation, etc.), and source of funding (MOHandFW, MSJandE, State Government, other sources, and paid by patients, i.e. private sector). This comprehensive list, along with the full details of their contact persons or responsible officers, served as the "existing resource list" with which the services were matched, and upgradation/expansion could occur.
- All these de-addiction centers were suggested to be surveyed as per published norms for "minimum standards of care" (see later). Those falling short of these minimum standards were required to comply with the standards within a stipulated period, say, 1 year, with support from the government in case of government-funded centers.
- Additional or upgraded government-run de-addiction centers were needed to be established in a phased manner. It was recommended that:
- It should be mandatory for all Government Medical Colleges to have fully functional de-addiction centers, with adequate trained manpower, infrastructure, and resources.
- At a later stage, again in a phased manner, DHs should also have these de-addiction centers so that eventually there should be de-addiction centers in each DHs.
- To begin with, five model de-addiction centers need to be established (or existing centers upgraded) in the Government Medical Colleges (one each in Amritsar, Patiala, and Faridkot) or affiliated with these Colleges (one in Bathinda, affiliated with Guru Gobind Singh Medical College Faridkot, and another in Jalandhar, affiliated with Government Medical College Amritsar). These would be 50-bedded centers with adequate staffing, trained manpower and provision for recurring expenditures. The psychiatrists working in these model de-addiction centers should be able to train other medical personnel in the other centers elsewhere.
- It was proposed that the identification of substance abusers will have to start from the grass root level, that is, primary healthcare (especially SC and PHC). The community-level workers such as Accredited Social Health Activists (ASHA), Multipurpose Workers (MPW) and others would need to be sensitized to identify substance users during their house visits and to encourage them and/or their families to seek de-addiction treatment. These workers and volunteers are often in the best position to do so by virtue of their vicinity and accessibility to the community. They can undergo brief orientation programs at the DH based de-addiction centers. These programs should be simple and focused, emphasizing the need to view addiction (substance dependence) as a medical disease that tends to be chronic and relapsing, but can be helped and treated. They should be taught the basics of motivational counseling, removal of stigma, and sustenance of hope. They should be able to motivate and refer the patients for quitting substance intake or seek treatment. The work done by these workers should be rewarded by suitable incentives to keep up the morale and motivation of the staff.
- It was further recommended that medical and nursing staff working at the SC, PHC, CHC, SDH, and those DHs without an existing de-addiction center should undergo training at the medical college-based de-addiction centers so that they can provide first-line outpatient detoxification for treating (by the doctors) and handling (by the nonmedical staff, primarily nurses) uncomplicated withdrawal, and can identify and refer complicated withdrawal cases to the next higher healthcare facility. These staff can also be trained in the basic elements of relapse prevention.
- It was proposed that those with complicated withdrawal or repeated relapses should be referred to the formal de-addiction centers for more comprehensive management.
- It was deemed important to establish and maintain cross-referral systems and parallel linkages with other agencies, facilities, or organizations (such as many NGOs, spiritual/religious organizations, social organizations, youth organizations, self-help groups like Alcoholics Anonymous and Narcotics Anonymous, etc.). De-addiction services have been hampered by fragmentation and lack of coordination. Different organizations work in their own ways and according to their own philosophical orientations, but if the ultimate goal is helping those with a substance use problem, then it is imperative to join forces rather than to split them. These parallel organizations can help in rehabilitation, social reintegration, and support followed by back referral to the healthcare system in case of relapse.
- Thus, we envisaged a "Pyramid model," later renamed as "Punjab model" [Figure 1] where there is a broad community base for early identification at the primary care level, detoxification and relapse prevention at the secondary care level, and comprehensive management for more difficult cases at the tertiary care level. It is important to note that a patient can enter the system directly at any of these levels. The three tiers of the system must have continuous "cross-talk" and communication up-and-down the "pyramid" ("vertical communication") as also parallel linkages with other agencies and organizations whenever available or feasible ("horizontal communication") at all the three levels.
|Figure 1: The structural, state-level, "Pyramid model" of de-addiction services in the health sector proposed for the State of Punjab (the "Punjab model"). The "pyramid" has a broad community base for early identification at the primary care level, detoxification and relapse prevention at the secondary care level, and comprehensive management for more difficult cases at the tertiary care level. It is important to note that a patient can enter the system directly at any of these levels. The three tiers of the system must have continuous "cross-talk" and communication up-and-down the pyramid ("vertical communication," represented by the vertical arrows) as also parallel linkages with other agencies and organizations whenever available or feasible ("horizontal communication," represented by the sideways arrows) at all the three levels.|
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- The proposed system is conceptualized as pyramid-shaped, with its "base" (Level 1) in the community at the primary healthcare level (SC, PHC, and CHC), an intermediate Level 2 operating at secondary healthcare level (SDH and DH) for those referred from Level 1, community camps, all NGOs and other organizations and also for direct (1 st -time) entrants, and finally, its "tip" (Level 3) based at a tertiary-care specialty hospital or "model de-addiction centers" providing comprehensive care for complex cases.
The purpose of the "base" is four-fold: (a) To raise awareness, (b) to facilitate the access to the services, (c) to initiate treatment, and (d) to refer patients to either of the two higher levels. This model envisaged integrating these three levels in an open, two-way direction (the vertical arrows). This is the vertical access pathway.
A patient may have access to the system at any level directly too, by self-referral, brought by family, or referred by any known NGOs or other social/spiritual organizations. This is the horizontal (or lateral) access pathway. Combined together, it may become easier for potential service users to make an entry at any of the levels (lateral access), and once entered, to make a movement to the higher level of care (vertical access), if needed.
| Minimum Standards of Care and the Need to go Beyond: The Model De-Addiction Centres|| |
There is an excellent document published by the National Drug Dependence Treatment Centre, All India Institute of Medical Sciences, 2009, titled "Minimum Standards of Care for Government Drug De-Addiction Centres" (editors: Tripathi and Ambekar).  It is freely available online for ready consultation at the relevant website. This is concerned primarily with the de-addiction centers established by the MoHandFW. Another important document, published by Federation of Indian NGOs for Drug Abuse Prevention, again freely available online, gives the minimum standards of care for the de-addiction supported by the MSJandE, namely, Awareness and Counseling Centres and Treatment and Rehabilitation Centres (currently combined into IRCA).  Both of these are very useful consultation documents for the Indian setups.
However, for our purpose, the single most important document was the Gazette Notification by the Government of Punjab, Department of Health and Family Welfare, notified in January 2011, titled "Punjab SUD Treatment and Counseling and Rehabilitation Centres Rules, 2011."  This official notification integrates various sources as above and makes an integrated set of specifications for any de-addiction center established under Section 71(2) of the NDPS Act 1985. It also lays down admission and licensing procedures and the relevant authorities and their functions.
The above-cited Punjab Rules 2011 (Clause 14) give the Minimum Standards of Care to be followed by any de-addiction center. However, in order to establish and sustain high-quality de-addiction services throughout the state, one needs more than the minimum standards. Certain places or centers should be established or upgraded to higher standards and enhanced functionality because these "model de-addiction centers" represent the Level 3 (the "tip") of the Pyramid model described earlier.
The functions and activities these model de-addiction centers would be as follows:
- To provide safe, effective, and comprehensive de-addiction services for patients referred from the primary and secondary levels of care (vertical access) and also from other independent sources of referral such as self, family, NGOs, social/spiritual organizations, police and judiciary system, etc., (lateral access)
- To act as local teaching and training centers to provide continuous cycles of training for medical officers and nonmedical personnel working at the primary and secondary levels of healthcare elsewhere in the region
- To act as data and documentation centers for collecting data on drug abuse in patients registered with them as well as data from lower-level (primary and secondary) healthcare facilities so as to provide a Drug Abuse Monitoring System (DAMS) to be used for surveillance on extent and patterns of substance abuse in the region
- To act as local liaison centers between the community on one hand and the state administrative machinery on the other, so as to facilitate two-way communications between the two (needs, burden, real-life situation from the community, and the policies, resources, and support from the State Government).
To achieve these important functions, the model de-addiction centers must rise above the minimum standards of care and must be administratively and financially supported by the government on a continuous basis (i.e. not just a 1 time "Setting-up" of a de-addiction center). The psychiatrists working in these model de-addiction centers should be able to train other medical personnel in the other centers elsewhere. Thus, these centers were proposed to be developed as model de-addiction cum resource and training centers for the rest of the state. These centers would work as tertiary care centers for the patients with SUDs.
As the purpose of these centers is conceived to act as resource centers and centers for manpower development for rest of the state in addition to provision of quality care, it was recommended that wherever possible such centers should be attached with Psychiatry Departments of the nearest Medical College.
List of services which should be available at model de-addiction centers:
- Registration and documentation
- Outpatient Treatment
- Inpatient Treatment
- Emergency services
- Dispensing of medications (pharmacotherapy)
- Psychosocial interventions
- Laboratory services
- Record maintenance
- Training of other medical staff from primary and secondary care levels (General Duty Medical Officers [GDMOs]).
Detailed infrastructural planning, staff requirement with eligibility, resources needed (including laboratory and medicines), practical requirements like furniture and equipment, and financial considerations were worked out for each of these centers. These centers are at various levels of progress.
| The Central Hub of the Punjab Model: District-Level De-Addiction Centres|| |
These "de-addiction centers at district/sub-divisional level" represent the Level 2 (the intermediate level) of the "Pyramid model" (Level 1: SC, PHC and CHCs; Level 2: DH and SDHs; Level 3: Designated "model" de-addiction centers). These represent the central "rung" or "hub" of the three-layered model, and they are in a uniquely important position to liaise between the level above and level below, other than performing their own service-related duties.
A total of 31 such centers was envisaged, one each in the 22 district-level hospitals and 9 for the sub-divisional hospitals. A few of these were already in place, but they needed upgradation and compliance with the minimum standards of care. Others were needed to be constructed. These too would also have an inpatient section, but the strength of beds would be less (at least 10-bedded).
The functions and activities these Level 2 centers would be as follows:
- To provide safe, effective, and comprehensive de-addiction services for patients referred from the primary levels of care (vertical access) and also from other independent sources of referral such as self, family, NGOs, social/spiritual organizations, police and judiciary system, etc., (lateral access)
- To act as local training/orientation centers to provide continuous cycles of training and/or orientation (identification and referral) for nonmedical personnel working at the primary level of healthcare in the district
- To act as data and documentation centers for collecting data on drug abuse in patients registered with them as well as data from lower-level (primary) healthcare facilities so as to provide a DAMS to be used for surveillance on extent and patterns of substance abuse in the region
- To act as local liaison centers between the community on one hand and the state administrative machinery on the other, so as to facilitate two-way communications between the two (needs, burden, real-life situation from the community, and the policies, resources, and support from the State Government).
List of services which should be available at Government De-Addiction centers in district/sub-divisional hospitals:
- Outpatient Treatment
- Inpatient Treatment
- Emergency services
- Dispensing of medications (pharmacotherapy)
- Psychosocial interventions
- Laboratory services
- Record maintenance
- Training/Orientation of other staff from primary care level such as GDMOs (Medical) or ASHA (nonmedical).
Thus, the functions of the middle-level de-addiction centers would be similar to those of the model de-addiction centers, but at a lesser magnitude of scale.
Detailed infrastructural planning, staff requirement with eligibility, resources needed (including laboratory and medicines), practical requirements like furniture and equipment, and financial considerations were worked out for each of these centers as for the model de-addiction centers but in keeping with their envisaged level of operation. These centers too are at various levels of progress.
An important later offshoot of the Level 2 services was the establishment of rehab centers at the district/sub-divisional level. These rehab centers are conceptualized as residential facilities of 50-100 capacity each, functionally attached with, but geographically separated from, the de-addiction centers. These will house patients after successfully completed detoxification but with complex and unmet psychosocial needs, keep them for at least 3 months, teach them skills necessary for a drug-free independent optimal functioning, and promote whole-person recovery. The details of such centers in terms of architecture, manpower, and resources have been worked out, and training of medical officers to be posted in these has been completed.
| The Base of the Pyramid: De-Addiction Services at Community Healthcare Level|| |
There are total 131 CHCs in Punjab. These are served by GDMOs. These centers represent the Level 1 (the broad, community-based, first level) of the "Pyramid model" (Level 1: SC, PHC and CHCs; Level 2: DH and SDHs; Level 3: Designated "model de-addiction centers").
The functions and activities these Level 1 centers would be as follows:
- Information, Education, and Communication (IEC) activities: To prevent substance use and promote a healthy lifestyle
- Identification: To be able to identify people in the community who are in need of counseling or treatment because of substance abuse and related problems
- Documentation: To generate and maintain a list of such identified persons for onward transmission to higher levels, eventually contributing to building up a state-level database. This will also help later in monitoring the situation
- Initial outpatient based treatment (at the CHC level): For those substance users who can be treated at home with anti-withdrawal and supportive medications. This can be feasible in many cases, and will avoid overburdening of the higher levels (district levels and above) which can then cater better to those with repeated relapses, complications, etc
- Referral: Finally, referral to higher levels of care for those a mentioned above (those with repeated relapses, complications, major physical or psychiatric comorbidity, etc.).
Unlike the levels above, there would be no inpatient de-addiction facility at Level 1. The focus here would be outdoor and field work. The PHCs would engage only in IEC activity, detection, and referral to higher-level.
Specific recommendations for this level
- Identification of substance abusers will have to start from the grass root level, that is, primary healthcare (SC and PHC). The community-level workers such as ASHA, MPW and others will need to be sensitized to identify substance users during their house visits and to encourage them and/or their families to seek de-addiction treatment. These workers and volunteers are often in the best position to do so by virtue of their vicinity and accessibility to the community. They can undergo brief (3 days) orientation programs at the DH based de-addiction centers. These programs should be simple and focused, emphasizing the need to view addiction (substance dependence) as a medical disease that tends to be chronic and relapsing, but can be helped and treated. They should be taught the basics of motivational counseling, removal of stigma, and sustenance of hope. They should be able to motivate and refer the patients for quitting substance intake or seek treatment. The work done by these workers should be rewarded by suitable incentives to keep up the morale and motivation of the staff
- Training: Medical and nursing staff working at the SC, PHC, and CHCs should undergo training at the medical college-based model de-addiction centers so that they can provide first-line outpatient detoxification for treating (by the doctors) and handling (by the nonmedical staff, primarily nurses) uncomplicated withdrawal, and can identify and refer complicated withdrawal cases to the next higher healthcare facility. These staffs can also be trained in the basic elements of relapse prevention
- Referral: Those with complicated withdrawal or repeated relapses should be referred to the formal de-addiction centers for more comprehensive management. The referral cases should be documented at each level so that tracking and monitoring is possible
- It is extremely important to establish and maintain cross-referral systems and parallel linkages with other agencies, facilities or organizations (such as many NGOs, spiritual/religious organizations, social organizations, youth organizations, self-help groups like Alcoholics Anonymous and Narcotics Anonymous, etc.). De-addiction services have been hampered by fragmentation and lack of coordination. Different organizations work in their own ways and according to their own philosophical orientations, but if the ultimate goal is helping those with a substance use problem, then it is imperative to join forces rather than to split them. Even at the primary care level, these parallel organizations can help in rehabilitation, social reintegration, and support followed by back referral to the healthcare system in case of relapse
- Medicines: Basic medicines may be made available at the CHC level for providing community-based outpatient detoxification. These are: Chlordiazepoxide tablets (10 mg and 25 mg); clonidine tablets (0.1 mg); ibuprofen tablets (200/400 mg); multivitamin preparations (both tablets/capsules and injections); nitrazepam tablets (10 mg); anti-diarrheal (e.g. loperamide capsules) and anti-spasmodic (dicyclomine tablets 10 mg), and antacids. These should be able to tide over most of the uncomplicated cases of withdrawal
- IEC material: Posters, banners, leaflets, pamphlets, electronic material, and short documentary/video films may be prepared for wide dissemination and display. Print, electrical, film, and electronic media should be utilized for spreading the central three messages in different ways: (a) Alcohol, tobacco, and other drugs can cause addiction and many other harms, hence avoid them; (b) Addiction, once settled in, is a disease on its own and not just willful social or moral deviance, hence recognize it as such without stigma; and (c) Like all diseases, addiction can be treated, and treatment/help is available, so seek professional help which is now available.
[Table 1] lists the unique characteristics of the "Punjab model" of de-addiction services, with its assets as well as caveats.
|Table 1: Unique characteristics of the "Punjab model" of de-addiction services|
Click here to view
| De-Addiction in the Prisons of Punjab|| |
Though outside the "pyramid" (which pertains to de-addiction in the general population), the Punjab model also incorporates a very important component: De-addiction services in the prisons.
The rampant problem of substance abuse in the prisons in Punjab has been highlighted.  Thousands of addicts incarcerated in the jails suffer from acute withdrawal and are suspected to obtain illicit drugs inside the jail premises by several means.
It was felt imperative to start de-addiction services within the jails along with strict implementation of measures to curb supply of drugs inside the prisons. While the "supply reduction" strategies (e.g. strict and regular physical and material checks, provision of CCTV and mobile phone jammers, etc.) are beyond the scope of our recommendations, it is emphasized that there can be no excuse for continued supply of drugs inside a closely monitored system like jails and it is where supply reduction measures are mandatory and feasible. Further, demand reduction can never work successfully in a closed system like the prisons if supply cannot be curtailed.
With these provisos, de-addiction centers or services should ideally be set up in every jail. However, as a phased activity, initially, it was felt necessary to start the services in the 8 Central Jails (some of them called "Model Jails" in Punjab). These should operate under the broad principles outlined earlier, except that (i) de-addiction can be made mandatory under these circumstances and (ii) following detoxification, relapse prevention and rehabilitation measures should also start while the prisoner is still inside the jail.
Some specific suggestions and recommendations that were made:
- A necessary first (and laborious) step is to have an idea of the size of the problem. Though not easy, it is feasible, given the "captive" nature of the population by definition. An on-going register for this should be generated and updated by the prison authorities.
- The model established by the Tihar Jail De-addiction Centre can be followed. This Centre has been running for a number of years, and it obtained ISO 9001:2000 QMS Certification in January 2009. Thus, the second (concurrently running) step should be coordination meetings between the authorities of the Tihar Prison Complex De-Addiction Centre and the prison authorities of Punjab. During these meetings, the logistics and requirements for setting up such centers (one each in every jail) can be worked out.
- Initial detoxification for opioid dependence should be attempted with nonopioid medications (clonidine, analgesics, sedatives, antidiarrheals, and other symptomatic treatments as needed, vitamin supplements). However, if this fails, and in case of severe or complicated withdrawal, opioids (sublingual buprenorphine-naloxone combination or oral/injectable tramadol in the absence of the first) may be given for withdrawal for a short period, usually up to 2 weeks. Medical supervision is essential.
- There is a controversy regarding the use of opioid substitution treatment (OST) with buprenorphine or methadone on a long-term basis for prison inmates. While OST can be definitely useful for some opioid-dependent persons (especially injecting drug users or repeated relapsers) in conjunction with psychosocial management for the purpose of harm reduction, it is difficult to justify on a long-term basis within the prison setup, because (a) withdrawal management would take care of the acute short-term distress, (b) psychosocial relapse prevention would continue inside the prison itself to minimize chances of later relapse, and (c) despite all precautions, long-term provision of opioids inside the jails would lead to risk of diversion.
- The recently approved National Policy on NDPS is quite clear on this issue:
"71 - Injecting drug use (IDU) is also a problem in many prisons. Some advocate harm reduction methods even in prison settings. However, considering that prison settings are completely regulated, it does not stand to reason to allow prison inmates who smuggle in and abuse drugs the benefit of getting clean needles and syringes or oral substitutes so that they can sustain their addiction and abuse drugs safely. Hence, IDUs among the inmates of prisons shall be compulsorily de-addicted, and they shall not be given supplied clean needles and syringes and allowed to inject drugs. They shall also not be supplied oral buprenorphine or methadone for abuse as substitutes."  Although controversial and under consideration for possible amendment (a specific committee has been set up which is looking into the issues presently, though no decision has yet been taken formally), this is the current mandate of the National Policy on NDPS.
- There is a special section in the aforementioned National Policy on "Smuggling of drugs into prisons" and it is worthwhile to be cited verbatim:
"56 - Prisons are one of the most tightly secured premises. However, traffickers manage to smuggle drugs into them, and usually, addiction levels among prison populations are much higher than among the general public. India is no exception. Drug addiction breeds crime and criminals comeback to prisons and expand the market for drugs within the prisons. If this vicious cycle has to be broken, sale of drugs within prison settings has to be tackled effectively. In order to deal with this problem:
- Prison staff will be sensitized and trained in detecting and apprehending drugs
- Wherever necessary, prisons will be equipped with sniffer dogs to check the visitors and packages for drugs
- All addicts within the prison shall be registered and compulsorily sent for drug de-addiction
- Every new entrant into the prison will be tested for addiction and will be de-addicted if he is found to be addicted.
58 - While conducting a medical examination on an arrestee before production in a court by the arresting agency, the doctor examining the arrestee should also record the history or symptoms, if any of drug abuse. Wherever an arrested person shows signs of addiction, the police should take him to a doctor or a hospital to determine if he is an addict, and if so, take measures to treat him. Efforts may be made to ensure that at least one doctor in each prison establishment is trained by National Drug Dependence Treatment Training Centre to identify, treat, and manage prison inmates with drug addiction and dependence problems.
59 - Prisons should, however, as a part of the medical check-up, test every inmate for possible use of drugs and treat every inmate who is found to be addicted to drugs so that the nexus between drugs and crime can be broken effectively." 
Again, without entering the moral-ethical debate and the possibility of amendment in the future on the recommendations of the Committee as mentioned above, this is the current official stand as promulgated in the National Policy.
With this background, the proposal in the Punjab model for de-addiction services in the Central Jails of Punjab was as follows:
- Every new inmate coming to Central Jail would be compulsorily clinically examined and screened for the possibility of SUD.
- A separate area or barrack will be identified in each Jail for the purpose of indoor treatment of inmates. The inmates found positive on urine screening, or clinical examination would be kept in this identified area and would be started on detoxification medication. These inmates shall be kept in this area till completion of detoxification. This area itself should be highly secured and placed under constant surveillance manually and/or electronically.
- The inmates already residing in Jail would be given option of getting themselves detoxified. Upon the basis of severity of withdrawal symptoms, the inmates can be taken up for either indoor treatment or day care treatment.
- Once completely detoxified in indoor treatment, the withdrawal-free inmates should be placed somewhere else for a period of 2-4 weeks where further recovery can take place. They should not be sent back to the very same barrack/dormitory/cell where they came from or where drug addicted inmates are housed; otherwise relapse is almost certain to occur. Those detoxified should not be again sent back to barracks where they can mix with suspected or known drug abusers. Recreational facilities (exercise, play, reading, occupational therapy, gardening, etc.) should be provided to the recovering addicts to the extent possible. Spiritual (meditation, Yoga, Art of Living, prayers, religious songs, etc.) and psychosocial (counseling, group discussion, debates, other drug-free group activities) aids to recovery should be provided as feasible.
- Given the very large numbers and new inmate influx (many of them with addiction), the turnover rate in the detoxification area needs to be high. The acute phase of detoxification may be achieved in 7-10 days. Further recovery may then take place elsewhere, in another designated area of the same barrack or another barrack (but see number 4 above).
- The Civil Surgeons of respective districts may be directed to make the services of Psychiatrist posted in the district available for at least once a week. Regular medical supervision will be provided by the Medical Officers posted in the jails.
- Medication for detoxification:-The list for essential drugs for detoxification has been recommended. As mentioned above, long-term opioid substitution therapy is not permissible in the prison under the National Policy on NDPS (Clause 71). However, while inside the de-addiction center and for those suffering from very severe opioid withdrawal not responding to usual medications, opioids (e.g. buprenorphine-naloxone combination, tramadol) may be considered for short-term (not exceeding 2-3 weeks) detoxification only.
- Availability of Psychiatrists (on a part-time basis) and other staff need to be ensured.
- Training of doctors: Because of acute shortage of psychiatrists, medical officers may be trained in providing de-addiction services. Such training was initially provided by Postgraduate Institute of Medical Education and Research, Chandigarh. Later such training will be conducted by the psychiatrists in the model de-addiction centers.
- Urine screening equipment: As immediate measure, urine testing kits were made available in each Central Jail and later equipment for testing may be procured
- Other additional measures suggested which could help Jail authorities in tackling the problem:
- Regular routine medical examination of inmates
- To control influx of addicting substances into the Jail
- Organizing religious discourses in Jail
- To regulate the supply, prescription and dispensing of habit forming drugs by health staff of Central Jails.
| Epilogue: What is Needed to make this Dream a Reality?|| |
- Political will and resolve
- Funding - in a phased but sustained manner
- Coordination at multi-sectoral, multi-departmental, and multi-disciplinary levels
- Staff selection and/or rationalization
- Medical leadership to psychiatrists
- Persistence in the face of challenges and frustrations.
- Training of trainers - so that a cascade of training programs can go on in a self-sustained manner
- Monitoring, detection of slack in the system, and taking quick reparative action.
It is beyond the scope (and length!) of this paper to chronicle the journey, with its achievements and lessons learnt so far, since the inception of the "Punjab Model of De-addiction Services" in April 2012, when the journey was flagged off by the Chief Minister of Punjab in the first multi-sectoral meeting chaired by him on April 22, 2012. In fact, the entire initiative has been spearheaded and driven by him in person, without which such a massive movement would not have been possible. The detailed "progress report" of this initiative with a critical evaluation will be presented later in a separate publication. In short, at the time of submission of this paper (mid-October 2014), all the five model de-addiction centers are in various stages of progress (two are fully functional in Amritsar and Faridkot, and the other three are in the process of completion in Patiala, Jalandhar, and Bathinda); 25 intermediate-level de-addiction centers are in place and others should start functioning over the next few months; training of 34 master trainers has been accomplished, who have, in turn, trained nearly 200 GDMOs posted in CHCs; many new posts have been created at various levels and staff posting and/or recruitment are going on in full swing; essential drugs for running the service have been made available; orientation course for social works/counselors has been completed; rehab centers are being put in place in each district of Punjab and the medical officers to be posted there have been trained; 17 Medical Officers from the Central jails were provided training in de-addiction and the prison de-addiction services in all eight Central Jails are in place. A detailed guideline for opioid agonist treatment for opioid dependence has been prepared for compliance throughout the state. A Central Registry for inpatient substance users has been started. Monitoring of the entire system has started recently. Finally, the Punjab State Board for De-addiction and Rehabilitation has been constituted to oversee the entire program.
All these massive initiatives have required major financial inputs by the State. A Cancer and De-addiction Fund has been created, out of which nearly 2 crore rupees have been utilized for De-addiction Program in prisons for purchase of medicines, lab equipment, ECG machines, urine and blood test kits. The five model de-addiction centers and the 22 rehab centers have cost or would cost, around 5 crore rupees each. Each of the district/sub-divisional level de-addiction centers has cost 40 lakhs. The overall annual running costs for each of these centers has been estimated at 30 lakhs for the de-addiction centers and up to 1 crore for the rehab centers. These figures may appear daunting, but they have to be weighed against the even more huge loss to the State because of the tolls taken by substance abuse in terms of lost life, productivity, resources, and manpower.
If successful, this "Punjab model" can be a pioneer for other states to follow with local modifications. Punjab has been a pioneer in many aspects marking the growth and development of India - now it is also the first to present and pursue a state-level de-addiction policy and program that may be adopted by other states to meet their own needs. Today's dream may become tomorrow's reality!
| Acknowledgments|| |
We are deeply indebted to the Government of Punjab for extending all support to implement the Punjab model on a top priority basis. We especially acknowledge the pivotal contribution made by Mrs. Vini Mahajan, IAS, Principal Secretary Department of Health and Family Welfare, Government of Punjab for providing the administrative leadership.
| References|| |
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Dr. Ajit Avasthi
Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh
Source of Support: None, Conflict of Interest: None