Substance use is becoming a large problem in India, and at the same time, one that we don’t pay enough attention to. The recent Mental Health Survey by NIMHANS says that at least one in five people has a substance use disorder, and that out of 100 people with alcohol or substance use disorders, only three end up seeking help. White Swan Foundation’s Sriranjitha Jeurkar spoke to Dr Pratima Murthy, head of the Deaddiction Center, NIMHANS, about what these numbers mean, and what needs to be done to ensure that help is accessible to all.
The survey refers to substance use disorders. What does the term mean? How is it different from using or being addicted to a substance?
I think the biggest problem with substance use disorders - we call them substance use disorders because it’s not only addiction one is worried about - it is the range of the use of any kind of chemical substance, whether it’s a licit substance like tobacco or alcohol, or an illicit substance like brown sugar, cocaine, stimulants, or prescription drug abuse, it’s right across the board. In India we know these days that several people - whether it’s adults, younger people, the elderly, women, all are using various kinds of substances. So I think everyone should be concerned, because it’s very difficult to say when the use of these substances becomes problematic.
The mental health survey reports that at least 85 per cent of people with substance use disorders don’t get medical help. Why do you think this is happening?
One reason people don’t get help is because they don’t think of it as a problem till it becomes very severe. The second thing is that some of the social consequences of substance use are not adequately recognized. For example, violence in families, accidents, emergency room attendance (injuries and health crisis), other kinds of emotional problems for family members, workplace problems - these are not often recognized adequately, and this delays help-seeking. The third thing is people don’t know where to go because health facilities have not been adequately primed and professionals have not been adequately trained to recognize and provide treatment for substance use disorders. The fourth thing is the stigma associated with the use of substances. People still feel very hesitant to admit that they are using substances and are unable to give up. So I think a whole lot of these issues need to be addressed.
How can these issues be addressed to encourage people to seek help?
We need people to understand that substance use disorders are important public health problems. It’s also important to understand that the earlier the treatment is taken, the better the outcome. The third thing is in training health professionals to actually be able to deliver and support services for substance use disorders. Many health professionals also share the same kind of attitudes as the public that, you know, people should be responsible for their substance use all the time, they bring on the addiction themselves...we know that’s not true. There are several reasons why people start using substances. But the important thing is, that whatever the cause, people progress to using substances because of the biological nature of addiction. And once that develops, it’s very difficult for them to help themselves, and that’s why we need treatment services that are responsive to their problems.
What kind of treatment does someone with a substance use disorder need?
There is enough literature to suggest that addiction, for example, is a disorder of the brain. And that people who become addicted actually need care and support and not blame and humiliation. But remember, there’s a whole spectrum of problems that occur before addiction develops. And that’s where we have to bring about a good policy on alcohol and other drug use in our communities, we need stringent laws which regulate the use of these substances, and most importantly, we need public awareness about the use of these substances to prevent some harm occurring from them.
What professional help is available at the moment?
At this point in time, the only real help that people with addiction are getting is in specialised deaddiction centers. But, as I mentioned earlier, there's a long gap between when people start having these problems and when they reach these centers. So I think the first thing is that all health professionals - from the primary healthcare level to medical colleges, hospitals, etc - are able to recognize substance use disorders. The second thing we know is that substance use disorders are what we call preventable risk factors for noncommunicable diseases. In our country, non communicable diseases like heart disease, diabetes, cancer, respiratory disorders and mental health problems have become the new epidemic. And tobacco, alcohol, substance use are known to be preventable risk factors for these. So the first thing would be that at every healthcare consultation, doctors ask people about substance use, and indeed about other lifestyle problems like diet, exercise and so on. And then offer people interventions early. For example, modifying lifestyles, trying to find out why a person uses these substances and trying to replace them with healthier alternatives. The next thing is to be able to recognize harmful use and dependence. Counseling can be provided either by health professionals or indeed by any other trained counselors who might be able to help people change their behaviors.
How can a doctor help the person change their behavior?
People change when they know that their current behavior is undesirable, when they know that there are benefits of change. So discussing the benefits of change with a person, finding out why the person uses the substance. If it’s due to withdrawal, then treatment of the withdrawal is important. If it’s due to craving, helping the person deal with the craving is important. If it’s other emotional reasons, for example, loneliness, it’s important to help the person to gain social support. And of course, modern treatment also provides a lot of anti-craving medication, things that are available along with counseling to help people deal with their substance use disorders effectively.
At the end of the day, the important message is that one can actually prevent substance use disorders by understanding whether one is at risk to do so, by limiting substance use, by getting help to recognize when their substance use is getting out of hand, and by getting prompt treatment. It’s eminently treatable. I mean, it’s just like diabetes, high blood pressure and so on. If one takes the appropriate treatment, modifies one’s lifestyle, improves one’s day to day stresses, and learns how to deal with it, a lot of it can be prevented.