In India, addiction specialists warn that the existing heroin epidemic has created a fertile ground for the next wave of the “pharma opioid epidemic” — a public health crisis caused by unregulated sale, purchase and use of opioid painkillers.

 The 2019 National Drug Survey, spearheaded by the NDDTC, showed that after alcohol and cannabis, opioids are the most commonly abused substances in India. These include opium and its derivatives (like poppy husk, known as doda), heroin (including its impure variant known as smack or brown sugar), and pharmaceutical opioids.

This survey found that the rate of opioid use in the general population in India, at 2.06 percent is nearly three times that of the global average of 0.7 percent.

Within the broader category of opioids, showed the report, the population’s addiction rate to heroin—considered the most harmful and addictive opioid — stood at 1.14 percent. However, pharmaceutical opioids closely followed, with 0.9 percent of the population addicted to these drugs.

“In the first National Drug Survey in 2004, opium and its extracts were the highest used opioids, with pharmaceutical opioids comprising a miniscule proportion. But the trend has reversed now,” Dr Ravindra Rao, professor of psychiatry at NDDTC and a researcher on opioids, told ThePrint. “There are now signs of a widespread pharmaceutical opioid addiction in many states such as Punjab and some north-eastern states.”

The next round of survey, Rao added, is expected to give a clearer picture of the opioid consumption pattern in India.

“Given the anecdotal evidence, the penetration of pharmaceutical opioids could be far wider than what most people think,” he said.

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Crops, commerce, & rising opium challenge

Opium cultivation and its use have been prevalent in India since medieval times. However, during British rule, opium cultivation evolved into an organised and commercial enterprise.

India now stands as one of the few countries in the world where the cultivation of opium poppy for medicinal and scientific purposes remains legal. It is also the world’s leading producer of opium for the global medical market, exporting most of its production as controlled and prescription drugs.

Domestically, licensed opium cultivation is allowed in Madhya Pradesh, Rajasthan, and Uttar Pradesh, all under strict  governmental oversight.

In addition, poppy farmers operating in notified tracts within these states are obligated to submit their entire yield to the Central Bureau of Narcotics. These supplies are then directed to the Government Opium and Alkaloid Factories (GOAFs), located in Neemuch, Madhya Pradesh, and Ghazipur, Uttar Pradesh.

These government factories process the opium, preparing it for export and for use in alkaloid plants, which, in turn, supply major pharmaceutical manufacturers worldwide.

India also holds the distinction of being the only country authorised by the United Nations Single Convention on Narcotic Drugs of 1961 to legally produce opium gum. This extract contains several crucial, naturally occurring alkaloids such as morphine and codeine.

However, despite all of this, the country has taken a stern legal stance on opium consumption.

In 1985, it enacted the stringent Narcotic Drugs and Psychotropic Substances Act, which prohibits the production, possession, sale, and consumption of narcotic drugs and psychotropic substances.

This was followed by the Prevention of Illicit Trafficking in Narcotic Drugs and Psychotropic Substances Act of 1988, which provides additional measures aimed at preventing illicit trafficking in narcotic drugs and psychotropic substances.

While the problem of prescription opioids emerged as a major public health challenge in many countries over the last several decades, India was believed to have remained largely unaffected.

But this seems to be changing. Doctors and manufacturers attribute this primarily to the unencumbered sale of opioid medication by  chemists and pharmacists. This is despite the fact that medicines, classified in the Schedule H, H1, and X, cannot be sold without a doctor’s prescription.

“H1 scheduled opioids such as buprenorphine and pentazocine, used for pain management and also substitution therapy for those with heroin addiction, are sold freely by chemists across the country,” claimed a member of the Indian Drug Manufacturers Association, a network of generic drugmakers in India.

According to Dr Rao, there is also a concerning rise in the use of Tramadol, an opioid that is less powerful than fentanyl, but can be more potent if taken orally than injected due to its chemical makeup.

India is the biggest supplier of Tramadol, prescribed as a pain medication. Its stimulant effects can lead individuals to believe they are high-functioning even when taking dangerously high doses.

Problem of plenty — and scarcity

Opioids are a common choice for managing acute pain. According to Dr Republica Sridhar, a pain management specialist and founder of RMD group of hospitals in Chennai, they not only reduce the perception of pain but also enhance tolerance to it.

However, there is a paradox. Doctors say that those who need opioids to manage pain in conditions such as cancer sometimes face difficulties in accessing the drugs due to strict regulations, while those who want to abuse these medications can easily get them.

“People who use these medications just for recreational purposes are able to get them through the diverted route. Clearly, there are leaks in the supply chains somewhere,” said Dr Atul Ambekar, a professor of psychiatry at the NDDTC and secretary general of the Addiction Psychiatry Society of India.

On the flipside, patients in dire need of palliative care continue to suffer pain.

“Terminally ill cancer patients endure immense suffering during their final stages of life due to the inability to access opioids for pain relief,” said Dr Rajshekhar C Jaka, consultant in surgical oncology and robotic surgery at Manipal Hospital in Bengaluru.

“Inadequate pain relief can be attributed to the poor availability of opioids, the lack of expertise of healthcare professionals in prescribing them, and concerns about opioid side effects and addiction,” he added.

The existing national palliative care policy also requires substantial updates to help resolve these issues, Dr Jaka said.

In 2014, an amendment to the Narcotic Drugs and Psychotropic Substances Act created a category of six essential narcotic drugs, including codeine, fentanyl, hydrocodone, methadone, morphine, and oxycodone. This move aimed to improve access to these drugs and eliminate state barriers.

With the creation of this new class of narcotics, the government acknowledged, for the first time, not just the medical usage of opioids, but also its responsibility to make these opioids available to the general public.

Yet, pointed out Dr Jaka, less than 10 percent of cancer patients in India have access to adequate pain relief.

Nevertheless, despite the ongoing problem of access to crucial pain drugs, the relaxation of prescription opioid laws has led to a proliferation of opium-derived painkillers in pharmacies, hospitals, and pain management centres across the country.

Balancing act

Dr. Ambekar highlighted that among the broad spectrum of opioids, heroin stands out as the most harmful and with the highest prevalence of use in India.

According to him, far more people who use heroin suffer from addiction as compared to those who use pharmaceutical opioids.

“Almost half of heroin users have opioid use disorder as compared to one-third of pharma opioid users,” he said.

Ambekar said that given the relatively lax enforcement of pharmaceutical dispensing rules in India, it was intriguing to see that heroin is used more than pharmaceutical opioids.

At the same time, he said, there is cause to be concerned about the diversion and misuse of pharmaceutical opioids.

“I would not like to paint a doomsday kind of scenario but yes, India’s situation of opioid epidemic is concerning. So far, it appears to be manageable with a judicious combination of supply control, demand reduction, and harm reduction strategies,” he said.

Harm reduction refers to measures that minimise the negative consequences associated with drug use. It may include strategies such as providing medication to reverse overdoses, counselling, and even providing clean syringes to prevent blood-borne diseases.

Unless such strategies are employed consistently from now on, the situation may worsen in the coming years, Dr Amebkar warned.

He also cautioned that relying too much on supply control measures may be counterproductive, especially given a shortage of treatment facilities. If heroin is not available, he pointed out, addicts may shift to more harmful ways of drug use, such as injecting.

This method is more ‘economical’, as a smaller amount of the drug gives a stronger high when injected. It would also increase the risk of large-scale overdose deaths and the spread of infections such as HIV and hepatitis, Ambekar said.

“The existing heroin epidemic has made the stage ripe for the next wave of pharma opioid epidemic, especially if there is shortage of heroin and no availability of treatment,” Ambekar said. “So while the nation needs to act on a ‘war-footing’, the ‘war on drug’-like approach must be avoided.”

(Edited by Asavari Singh)

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