Addressing Substance Use: National Suicide Prevention Strategy of India from an Addiction Psychiatry Perspective

Sir,

The Ministry of Health and Family Welfare (MoH&FW), Government of India, released National Suicide Prevention Strategy (NSPS) very recently, a step long awaited and welcomed by all stakeholders. ¹ The strategy aims to (a) Reinforce leadership, partnerships, and institutional capacity in the country, (b) Enhance the capacity of health services to provide suicide prevention services, (c) Develop community resilience and societal support for suicide prevention and reduce the stigma associated with suicidal behaviors, and (d) Strengthen surveillance and evidence generation. In addition, the strategy emphasizes the need for a multi-sectoral approach and delineates multiple interventions to be carried out by different stakeholders. ²

One of the primary strategies, and rightly so, of NSPS is to deal with substance use in our country. Substance use is one of the common risk factors for completed suicide in India. National Crime Records Bureau (NCRB) data attributes around 6% of suicide to substance abuse. Along with this, many other common reasons, such as family problems, marriage-related issues, and bankruptcy/indebtedness, are also directly or indirectly related to substance use. As per the recent national drug use survey 2019, alcohol use is reported by almost 15% of our general population. The use of drugs like opioids and cannabis is also highly prevalent. The data from the National Mental Health Survey (NMHS) 2016 and National Family Health Survey reiterate the same. Thus, there is a major problem of substance use in India. All substances, including alcohol, tobacco, illicit drugs, and misuse of prescription drugs, are associated with suicide risk. The strategy also documents that it is not just dependence on substances—all aspects of substance use, harmful use, abuse, and intoxication have been associated with suicide.

Suicide prevention strategies need to incorporate both individual- and population-level strategies. The NSPS document has laid out the plan for policy-level addressing of underlying psychosocial issues such as addictive disorders. The strategy emphasizes the need for formulating national policy for alcohol use, community-level drug use prevention programs, and prohibition of alcohol advertisement. Though the policy mentions only the Ministry of Social Justice and Empowerment (MoSJ&E) as a key stakeholder, MoH&FW has a crucial role in policy development. The strategy also focuses on building capacity for psychosocial support for persons with mental disorders and substance use disorders (SUD) and calls for integrating mental health services in general healthcare. Among the various mental illnesses, the treatment gap is among the highest for alcohol use disorders (86% as per NMHS 2016). ³ Thus, there is also a need to integrate addiction treatment services under the Drug De-Addiction Program of India, MoH&FW, and the National Action Plan for Drug Demand Reduction of MoSJ&E with general and mental healthcare. Recently, National Institute of Mental Health and Neurosciences (NIMHANS), Bengaluru, has developed operational guidelines to integrate mental and SUDs into Ayushman Bharat—Pradhan Mantri Jan Arogya Yojana (AB-PMJAY) and provide treatment at Primary Health Centers and Health and Wellness Centers. ⁴ Also, the recently launched tele-psychiatry guidelines need to be modified considering the various concerns raised by Indian psychiatrists in relation to addiction treatment. ⁵ Unnecessarily stringent guidelines further hamper access to treatment in this group of patients.

Though the strategy document mentions various steps to support patients with SUDs, support for those with acute use/intoxication seems to be inadequately addressed. Thus, there is a need to explicitly include strategies to manage risks associated with acute substance use, heavy episodic drinking (for alcohol use), intoxication, and addiction. Those under intoxication should not be excluded from appropriate acute general and psychiatric health services, especially when in crisis. A public health model like Screening, Brief Intervention, and Referral to Treatment might be adopted in India. There is a dearth of research in this area, especially from India, to base strategies for dealing with intoxication-related suicides. The issue becomes complicated because around one-third of randomized clinical trials on suicide and self-harm prevention exclude participants with a history of alcohol or drug use problems/dependence. ⁶ Further, as they are not dependent, such patients might not require specialist addiction or mental health services. Hence, there is a need to develop clear policies and pathways for this group. Finally, the percent reduction in the number of persons with SUDs who die by suicide might not be the only indicator for such a purpose. A percent reduction in the number of persons with substance use/intoxication who die of suicide could also be included.

The NSPS should also include strategies that address the risks particular to different groups of substances, as the risk of suicide varies across different classes of substance use. ⁷ Thus, along with developing a national alcohol policy, the need to refine the Narcotic Drugs and Psychotropic Substances Policy could have been emphasized. ⁸ The policy highlights certain aspects, such as the SUD treatment needs, regulation of drug treatment centers by the government, harm reduction for blood-borne infections, and capacity building. However, the policy inadequately mentions (or instead, does not mention at all) aspects such as (a) substance use treatment and prevention targeted at key high-risk populations, (b) integration into general health services, (c) services for dual diagnosis, (d) harm reduction programs such as overdose prevention, and (e) evaluation and monitoring of the policy. The policy does not mention opioid agonist treatment as a demand reduction/treatment option (but for harm reduction among Persons Who Inject Drugs only and when they cannot be “convinced to undergo deaddiction treatment”).

Though the MoSJ&E is the nodal ministry for drug demand reduction in India, the same does not find a mention as a key stakeholder in objective 3, where the document mentions actions required to promote resilience in individuals, families, and communities. Also, the Ministry of Finance and the Ministry of Home Affairs, and many other central and state agencies that take care of the supply reduction aspects of illicit drug use do not find a mention in the strategy document. This becomes an important issue considering that Indian drug laws and policies are skewed toward supply reduction. ⁹

The NSPS is a big step forward for suicide prevention in India. Recommendations to tackle substance use and emphasis on the need for an alcohol policy are definite strengths of the strategy. However, cross-sectoral collaboration and implementation will be the key to its success.