Deaddiction Services in India: Current Status

Deaddiction Services in India: Current Status

Substance use disorders (SUDs) are prevalent mental health issues in India. ¹ The Ministry of Social Justice and Empowerment and the Ministry of Health and Family Welfare are responsible for addressing drug and alcohol-related challenges in the country. They implement strategies aimed at reducing demand and providing rehabilitation and treatment for SUD patients. ² The current substance abuse treatment system in India encompasses various approaches, including brief outpatient treatments, medical detoxification, institutional rehabilitation, replacement therapies, community-based interventions, and opioid substitution clinics. The Integrated Rehabilitation Centers for Addicts, ³ are widely accessible.

Moreover, numerous district hospitals and medical institutions provide de-addiction therapy. Additionally, there are more private de-addiction and rehabilitation centers than public ones. However, a 2019 survey highlights a significant treatment gap, with only 2.6% and 12% of all alcohol- and drug-dependent individuals, respectively, having access to treatment. ⁴ In India, a substantial portion of the affected population lacks access to professional help, while concerns persist about the effectiveness of the available de-addiction and rehabilitation facilities.

In 2018, the Delhi State Legal Services Authority submitted a comprehensive report on de-addiction centers in the NCT of Delhi to the Delhi High Court in response to a legal case. The report highlighted that 35% of residents were admitted involuntarily. It also pointed out violations of human rights, lack of basic facilities, poor record-keeping, shortage of qualified staff, and other related issues. ⁵

Similar situations exist in various other parts of the country. Surprisingly, a few private addiction treatment centers operate without adhering to national laws and regulations. ⁶ Social media frequently shares alarming stories from these treatment centers. The management of addiction poses several legal, ethical, and professional concerns.

Challenges that Require Immediate Attention

Illegal Deaddiction Centers

A few centers function from rented/leased spaces without receiving permission from the regulatory bodies, ⁷ and operate despite needing to be registered with the relevant government authorities. They may not hold a license from the Department of Social Welfare. Because they are not inspected and registered with appropriate authorities, they may lack competent personnel, sanitary living conditions, and basic first aid supplies. Patients may get scheduled medications, which should only be administered to a patient under a doctor’s supervision. However, instances like this are mostly highlighted when reported by the media. ⁸

Lacking Essential Amenities

The Mental Healthcare Act of 2017 (Section 20), ⁹ mandates that patients undergoing treatment in mental health facilities should have access to recreational amenities, privacy, and a safe and hygienic environment. Patients are supposed to have access to nutritious food and their daily dietary needs. ¹⁰ However, a few deaddiction centers do not comply with these regulations. Some residents have reported receiving only boiled rice for meals and hot water to drink and having to sleep on the floor on mattresses due to the lack of beds. ¹¹ Issues such as inadequate housing, limited bed space, lack of potable water, insufficient restroom and toilet facilities, and overcrowding have been documented. ¹²

Deficiency of Qualified Experts

All individuals involved in the management of SUDs are part of the multidisciplinary field of addiction therapy. Addiction professionals can be broadly categorized into three groups: medical and para-medical professionals (including psychiatrists, doctors, and nurses); non-medical personnel (such as addiction counselors, psychologists, social workers, and family therapists); and support providers (such as peer counselors, recovery coaches/mentors, and other support personnel). Each of these experts has specific responsibilities in the management of SUDs.

Despite this, many institutions lack qualified staff, and the responsibilities are often delegated to individuals referred to as “counselors” who may lack essential knowledge about SUD and counseling. Because the requirements for becoming a counselor are ambiguous, their role is arguably the most misconstrued in addiction treatment settings. Furthermore, serious incidents, such as assault, have been linked to counseling or non-medical staff. ¹²

A counselor is described as someone who is trained to offer guidance on personal or psychological issues. The minimum qualification for a counselor is a graduate degree in Clinical Psychology, Psychology, or Social Work, along with at least six months of experience in de-addiction services. ¹⁰ However, some facilities employ individuals who have recovered from SUD to work as “counselors.” These individuals, known as “peer counselors,” draw their legitimacy from experiential knowledge and expertise rather than traditional education credentials. ¹³ While peer counselors undoubtedly play an important role, they must find a way to substitute for qualified and trained counselors. In some cases, staff members provide medication to inmates who become unwell. ¹⁴ To ensure effective clinical governance, it is recommended that addiction treatment centers have a sufficient number of adequately qualified staff who receive ongoing evidence-based training, certification, support, and supervision. ¹⁵

The high prevalence of comorbid mental illnesses among individuals with SUDs underscores the importance of offering Postdoctoral Fellowships in Addiction Medicine and Doctor of Medicine (DM) programs in Addiction Psychiatry. ¹⁶ However, there is a notable scarcity of degree programs in addiction counseling in Indian universities. While NIMHANS and the National Institute of Social Defense offer some short-term addiction certificate courses and training, government agencies and educational institutions need to make concerted efforts to cultivate a pool of professional and qualified addiction experts.

A few MHPs have their medical qualifications registered with a single State Medical Council. However, they often “lend out” their licenses to multiple deaddiction centers or those located in other states, which is legally unacceptable. This practice becomes problematic when legal cases are filed against the deaddiction center, as the attached MHP automatically becomes responsible. Therefore, all MHPs must strictly adhere to legal and ethical guidelines in this regard.

Abuse at both Physical and Emotional Levels

In deaddiction centers, incidents of mistreatment and human rights abuses are unfortunately not uncommon. There have been a few newspaper reports of staff members physically abusing patients,^8,14,17–19 sometimes resulting in fatalities. ¹² There are reported instances of deaths of inmates while attempting to flee from the facilities. ²⁰ Due to a lack of training in non-violent de-escalation techniques, staff members may resort to aggressive and forceful behaviors when faced with emergencies.

The practice of using forced labor under the guise of therapy is common at treatment centers, where clients are made to perform tasks such as cleaning, tending to livestock, and working in the kitchen.^{12,14,17,21,22} Treatment providers justify this practice by claiming it empowers clients to take on life’s responsibilities. However, in reality, by employing fewer staff, they are able to save on labor costs. Families are sometimes misled into believing that forceful client handling and forced labor are integral parts of addiction therapy.^12,23 According to the MHCA of 2017, ⁹ mental health facilities are required to discontinue the use of forced labor and compensate clients for the work they perform while in treatment.

Treatment Under Coercion

Patients are required to give their informed consent before commencing treatment, as mandated by the MHCA 2017. ⁹ As per Section 89, individuals are entitled to an independent examination on the day of admission or within seven days before undergoing a “supported admission.”

Some facilities admit patients involuntarily and lack licensed mental health professionals (MHPs), leading to increased instances of physical and psychological abuse experienced by patients. These actions violate Section 86 of the MHCA, 2017, as they deprive individuals of the right to withdraw the consent given at the time of admission or request release from the facility. Consequently, these individuals are frequently confined, subjected to verbal and physical assault, and restricted from engaging with the outside world. ¹²

Some residential deaddiction centers prohibit patients from communicating with their loved ones and restrict access to cell phones and the internet. ¹² As per regulations, all facilities seeking registration or a license must affirm that they will allow supervised communication between patients and their families. ¹⁰

The “abduction” of SUD patients from their residences to rehab centers is the most awful kind of coercion. This violates both national and international norms. Additionally, this also raises worries regarding staff and patient safety. Without a competent examination and advice from experienced MHPs, such forced admissions occur. ¹²

The global approach to addressing addiction is shifting from social isolation toward social recovery, aiming to restore the dignity and respect of those struggling with addiction. Incorporating evidence-based therapy modalities into practice is crucial for achieving this goal. Different nations are embracing this paradigm shift at varying paces. Unfortunately, India’s addiction treatment system still reflects an outdated punitive “Teach addicts a lesson” approach. ¹² Consequently, some treatment centers continue to subject individuals with SUDs to degrading treatment. Many of these institutions, particularly those in private ownership, have regrettably become synonymous with places of torment rather than healing sanctuaries. Although mandatory drug detention centers are not endorsed by Indian law, several treatment facilities bear a striking resemblance to such establishments. Failure to adhere to the regulations in the addiction field and the limited awareness among patients exacerbates the situation. Operating within an ethical framework becomes challenging when treatment facilities are unregistered and unlicensed, fail to meet minimum staffing standards, and violate human rights.

Section 20 of the MHCA 2017, ⁹ mandates the protection of individuals with mental illnesses, including SUDs, from cruel, inhuman, or degrading treatment. Deaddiction facilities, research institutions, and relevant government agencies should diligently work to implement the MHCA 2017, ⁹ and other guidelines that are in force at that point in time. Professional and support personnel need to receive mandatory ethical training and consistent, high-quality clinical supervision. Indian institutions should consider offering degrees that encompass deaddiction counseling. Similar to other countries, India should establish accreditation, certification, and licensing processes for specialists to regulate deaddiction treatment services.

Based on my recommendation, the Government of Telangana has started ten-bed deaddiction centers in all medical colleges across the State. At the Institute of Mental Health, Hyderabad, Telangana, the Drug Treatment Center, under the supervision of AIIMS, New Delhi, and regional center KEM Mumbai is functioning. The center provides both pharmacological and psychosocial treatments to patients with SUD. Also, evaluation, treatment, and certification of individuals booked under the Narcotic Drugs and Psychotropic Substances Act (NDPS Act 1985, amended in 2014). ²⁴ Training programs for the concerned personnel are underway. As the Superintendent, I promptly addressed complaints from the stakeholders, formed inspection committees, and endeavored to implement guidelines.

Conclusions

Implementing a robust regulatory framework can enhance patient care and support recovery by improving the quality and effectiveness of addiction treatment programs. To strengthen India’s addiction treatment system, it is imperative to adopt rights-based and compassion-driven approaches alongside evidence-based therapy.