Addiction Research Centres and the Nurturing of Creativity: National Drug Dependence Treatment Centre, India—a profile

Authors


Correspondence to: Rajat Ray, National Drug Dependence Treatment Centre, All India Institute of Medical Sciences, Ansari Nagar, New Delhi-110029, India, E-mail: rayrajat2004@yahoo.co.in

Abstract

The National Drug Dependence Treatment Centre (NDDTC) is a part of the All India Institute of Medical Sciences, a premier autonomous medical university in India. This article provides an account of its origin and its contribution to the field of substance use disorder at the national and international levels. Since its establishment, the NDDTC has played a major role in the development of various replicable models of care, the training of post-graduate students of psychiatry, research, policy development and planning. An assessment of the magnitude of drug abuse in India began in the early 1990s and this was followed by a National Survey on Extent, Patterns and Trends of Drug Abuse in 2004. Several models of clinical care have been developed for population subgroups in diverse settings. The centre played an important role in producing data and resource material which helped to scale up opioid substitution treatment in India. A nationwide database on the profile of patients seeking treatment (Drug Abuse Monitoring System) at government drug treatment centres has also been created. The centre has provided valuable inputs for the Government of India's programme planning. Besides clinical studies, research has also focused on pre-clinical studies. Capacity-building is an important priority, with training curricula and resource material being developed for doctors and paramedical staff. Many of these training programmes are conducted in collaboration with other institutions in the country. The NDDTC has received funding from several national and international organizations for research and scientific meetings, and, most recently (2012), it has been designated as a World Health Organization Collaborating Centre on Substance Abuse.

Introduction and Evolution of the Centre

The Government of India enacted a law for controlling drug trafficking and drug use—the Narcotic Drugs and Psychotropic Substances Act (NDPS)—in 1985. Subsequently (1986), a National Committee on Drug Dependence was formed by the Ministry to Health and Family Welfare (MoHFW) that recommended the establishment of treatment centres to address the problem of drug abuse. Two faculty members of the department of psychiatry of the All India Institute of Medical Sciences (AIIMS) (including the lead author of this article) were part of this expert committee. Thus, within a few years, 124 treatment centres were established, including one at AIIMS, New Delhi. AIIMS is an autonomous body (medical university) that has been in existence since 1956 as a centre of excellence in patient care, medical education and research in India.

The centre [then called the De-addiction Centre (DAC)] originated in 1988 as an offshoot of the department of psychiatry under the supervision of the head of the department. Subsequently, the faculty of the DAC was involved in the development of the National Master Plan—India for Drug Abuse Control [1].

Since 1975, the department of psychiatry of AIIMS has made concerted efforts in the field of substance use disorders (SUD), with some landmark research publications on epidemiological studies in the general population [2-4], schools [5] and university students [6], and emergency room [7]; the effects of chronic cannabis use [8, 9] and the emergence of heroin use in India [10]. Another contribution was a 30-episode radio programme that was broadcast simultaneously in multiple languages throughout India in 1988 (Radio Date—Drugs, Alcohol and Tobacco Education). This was a significant step in recognizing the enormity of SUD in India.

The staff of the centre comprise a multi-disciplinary team. Initially, there were 9 full-time faculty positions, which has now grown to 15. Currently, there are about 40 non-faculty positions. Postgraduate students (doing psychiatry doctorates at AIIMS) are posted at the centre for six months out of the total three years of their training. The centre also has seven positions for senior residents. This sustained exposure to addiction treatment provides the resident doctors with adequate skills and experience to be appointed not only as faculty in medical institutions, but also resource persons in national and international organizations.

To begin with, the centre had 30 beds, supported by outpatient and community services. The priority areas identified by the centre then were:

  • assessing the magnitude of drug abuse in the country;
  • providing models of clinical care to SUD patients through the hospital and community;
  • documentation and creation of a database on substance use;
  • manpower development;
  • developing resource material and training manuals;
  • establishment of a laboratory to detect drugs of abuse in body fluids and to assess resultant health damage;
  • developing health education material for tobacco, inhalant, alcohol and drug users, including issues related to HIV and AIDS.

The activities of the centre continued, and flourished, with support from the MoHFW, the World Health Organization (WHO) and the United Nations Office on Drugs and Crime (UNODC) over the years. Though the growth of the centre can be attributed to certain key members, the contribution and commitment of the team cannot be overlooked. Additional support and recognition by international agencies increased the vitality of the centre.

Current Status

The centre is fully financed by the national government and receives no grant from the state/provincial government. It was designated the National Drug Dependence Centre (NDDTC) in 2003 by the MoHFW in recognition of its contribution to the field of addiction. It has also been chosen as a Regional Learning Centre by UNODC and WHO. Its recent recognition as a WHO Collaborating Centre (2012) on Substance Abuse is a significant achievement.

The NDDTC presently functions from its new premises, sprawling over a 10-acre site in a satellite town (Ghaziabad) about 42 km from New Delhi. Landscaped lawns and other horticultural efforts have helped to create a pleasant ambience. The centre now has 50 beds, specialty clinics (adolescent drug use, tobacco use cessation and dual diagnosis), a day care facility, community clinics in urban slum areas and a mobile clinic. Most patients are self-referred. The NDDTC does not have a defined catchment area; thus, patients come from both the adjoining areas and distant places. The availability of a quality treatment service spreads through word of mouth and from recovered patients. Annually, about 4000 new patients are registered and about 900 patients are hospitalized. The various facilities have recorded about 73 000 visits by ex-patients annually, many of whom travel long distances to seek help at the centre.

The NDDTC has well-equipped laboratories to detect various drugs in the body. Assessment of health damage, HIV screening, research on the genetic basis of SUD and pre-clinical research on addiction are the other areas of interest. The NDDTC has the requisite infrastructure for post-graduate study and research. Teaching programmes in the form of seminars or journal reviews are a regular feature at the centre.

Models of Treatment

Being a national centre, one of the mandates of the NDDTC has been to develop models of care in diverse settings. These include pharmacological options; psychosocial interventions, ranging from brief to intensive therapy; and models of rehabilitation. The treatment programme is flexible and responsive to patient needs. The in-patient programme varies from a short stay of three days to an extended stay of six months. Night hospitalization is provided to those who need intensive rehabilitation, but who also need to go out to work. Alternatively, a day care facility is available for outpatients with poor social support. Health education materials on drug abuse have also been developed for the public.

Long-term pharmacological options are available at the NDDTC for opioid-dependent patients, namely buprenorphine, buprenorphine-naloxone, oral sustained release morphine, methadone and naltrexone. Patients are assessed for their suitability to receive agonist/antagonist medications and are actively involved in the choice of medication, which is provided free of cost either as directly observed therapy or as take-home medication (buprenorphine–naloxone) following their stabilization. The dispensing hours have been prolonged (from 8 am to 8 pm) to aid accessibility and convenience. Recently, as a result of an increased emphasis on preventing HIV among intravenous drug users (IDUs), efforts have been made to integrate interventions to address drug-related HIV risk in routine clinical care.

The presence of a large number of dependent users of alcohol, heroin, and IDUs has led to the need to develop skills to treat these conditions in peripheral hospitals rather than in the departments of psychiatry in medical colleges. The WHO encouraged the centre to field test the Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) and Brief Intervention, while the UNODC and the National AIDS Control Organization (NACO) encouraged the scaling-up of Oral Substitution Treatment (OST). The choice of medication for this purpose expanded from lower-strength buprenorphine (0.2 mg) to buprenorphine 0.4 mg, 2 mg and 8 mg, a combination of buprenorphine and naloxone, oral sustained-release morphine and, now, methadone.

Other models of care developed include:

  • a district-based treatment model in three districts (in northern, eastern and central India) in collaboration with the local district health administrations;
  • addressing substance use concerns at the workplace (an oil refinery in Assam in the north-eastern part of India) in collaboration with a local medical college;
  • workplace intervention targeting business process outsourcing (popularly known as call centres) workers as a part of the E-health project, with WHO support, involving the development of a web-portal for on-line assessment and intervention for problem alcohol users;
  • development of psychosocial intervention for street children using inhalants;
  • a unique model using microcredit for the rehabilitation of recovering persons [11]
  • development of a manual in Hindi for screening, brief intervention and validation of the Hindi version of Alcohol Use Disorder Identification Test (AUDIT) [12] and ASSIST [13] followed by linking it with brief interventions.

Capacity-Building

Capacity-building for non-specialist doctors working in the government health-care system was initiated by the centre in the early 1990s. The training courses for these doctors were decided in a meeting of national experts in 1988 and re-examined in 2003. The programmes vary in duration and include the provision of refresher training.

Until now, about 1000 doctors have undergone training at the NDDTC. Most recently, the centre has received funds from the Ministry of Finance to train general duty medical officers (GDMOs), each from 500 district hospitals of India, who aid in the identification and management of SUD. The trainings are being conducted in collaboration with five other institutions in India. Aside from in-country trainees, the centre has trained health professionals from neighbouring countries. Training activities through the national satellite system [provided by the Indian Space Research Organisation (ISRO)], available in some districts and medical colleges, have also been conducted. Furthermore, training and interaction with some African countries on SUD have been held using India's Pan-African satellite network. The centre is now working towards a peer review by WHO Collaborating Centres and other centres of the curriculum and resource material developed by it.

Collaborative Research

Over the years the NDDTC has been conducting studies funded by national agencies, such as the Indian Council of Medical Research (ICMR). Research proposals go through a review by the institute's ethics committee at AIIMS and by the Health Ministry's Screening Committee for projects that receive funds from international agencies. The NDDTC has also made in-house efforts to document articles related to substance use published over a period of 10 years from within the country by means of manual searching of non-indexed journals.

The epidemiological research on the magnitude of drug abuse began with several district-based surveys and was followed by a National Survey on Extent, Patterns and Trends of Drug Abuse with support from the Ministry of Social Justice and Empowerment and the UNODC [14]. Currently, a national survey on drug abuse is being carried out by the NDDTC in the Maldives with support from the UNODC.

The centre initiated OST with buprenorphine as a clinical service, subsequently documented the effectiveness and side effects [15-17] and provided data that helped in advocacy efforts to scale-up OST.

The development of a nationwide database on patterns of drug use and the profile of patients seeking treatment (Drug Abuse Monitoring System) at the government's drug treatment centres, which began as a pilot project through external funding (ICMR), has continued over the years and is now a regular activity of the NDDTC [18].

A searchable database on drug use and HIV/AIDS was developed with support from the UNODC, which included published, as well as grey, literature in the country. The NDDTC now has an ongoing collaborative project with the University of Pennsylvania (UPenn) sponsored by the US National Institutes of Health (NIH) on the efficacy of varenicline for smokeless tobacco use.

Besides clinical research, several pre-clinical behavioural studies have also been conducted using rodents to assess the role of neurotransmitters in understanding nicotine and opioid dependence [19, 20].

Policy and Planning

From the time of its inception, the centre has contributed regularly to the Drug De-addiction Programme of the MoHFW by providing technical inputs that are important for policy and planning. It has also been involved in the evaluation of the functioning of government drug treatment centres and has provided inputs to the Government of India's programmes on drug control. Several national consultative workshops on various themes have been held which have provided recommendations to the Ministry on the control of drug and alcohol abuse in India.

Data on OST with buprenorphine generated by the centre has helped to scale-up OST in the country, and there has been a visible increase in funding for OST with buprenorphine for IDUs with the assistance from NACO.

The faculty of the centre have been members of various international expert groups, such as the International Narcotics Control Board, the WHO working group on the revision of the International Classification of Diseases (ICD)-10 category of Substance Use Disorders, the development of the WHO guidelines on psychosocially assisted pharmacological treatment of opioid dependence, the WHO guidelines on pharmacological treatment of persisting pain in children with medical illnesses, the Committee on Problems of Drug Dependence (CPDD), the WHO expert group on Abuse Liability assessment, the United Nations Reference Group on HIV and IDU, and the WHO working group on coordinating the health system response. The faculty is encouraged to participate in national and international meetings, such as the WHO international meetings on drug use and tuberculosis, fetal alcohol syndrome, ASSIST phase-IV, the global strategy to reduce harmful use of alcohol, and the Kettil Bruun Society meetings. In addition, fellowships of the AIDS international training and research programme at the University of California Los Angeles (UCLA), USA, and National Institute of Drug Abuse (NIDA), USA invest fellowships have been granted to the centre's faculty. The pre-clinical faculty have also received training in assessment of drugs of abuse in body fluids through international fellowships.

Another significant contribution was in the development of an extensive report on South Asia Drug Demand Reduction [21] about the drug abuse situation in India and in neighbouring countries.

Scientific Developments and Major Outputs

The centre has been active and the major outputs have been:

  • the National Survey on Extent, Pattern and Trends of Drug Abuse;
  • South Asia Drug Demand Reduction report;
  • research and publication on Opioid Substitution Treatment in different settings;
  • national database on treatment seekers (Drug Abuse Monitoring System);
  • monitoring and evaluation of the drug dependence treatment centres funded by the MoHFW;
  • training of non-specialist medical doctors and paramedical personnel working in drug dependence treatment centres/district hospital settings, along with the development of resource material for the purpose.

Organizational Work Culture

AIIMS fosters a culture of intellectual freedom and positive growth among its faculty and medical students. The NDDTC encourages its faculty to develop their own areas of interests, which may include focusing on a specific treatment modality (pharmacological, psychosocial or a combination of both), a subgroup of population (adolescent, women, dual diagnosis, IDU, prison population, etc.) or a category of substance (tobacco, alcohol, inhalants, opiates, etc). Research by the pre-clinical scientists is often carried out in consultation with their clinical colleagues (e.g. abuse liability studies, treatment of withdrawal symptoms, etc.) and, similarly, clinical work is often put to test through experimental design by the pre-clinical scientists.

Faculty and staff enjoy academic freedom to choose research topics for these activities. Such activities foster cross-fertilization of ideas, provide inputs for future activities of the centre and encourage suggestions from younger trainees regarding the agenda of the centre. There is regular interaction among the faculty and students on academic matters through formal and informal mechanisms. These discussions help to refine research proposals, clinical and academic activities, and lend clarity regarding the future direction of work. The overall atmosphere fosters a sense of optimism, purpose and collaboration towards a shared vision. As an institution, AIIMS is currently involved in producing a vision document to which the centre has contributed.

The achievements of the centre are celebrated through programmes, such as annual day functions, public seminars on certain specified themes and public acknowledgement of the contribution made by the faculty in certain major national/international activities.

Obstacles, Problems and Challenges

Delivery of health-care in India is the responsibility of various state health departments and the central government (government of India) supports only a few large, national programmes. Treatment of SUD is not one of them. Barring a few states, most state health departments do not have financial resources earmarked to help control SUD; it has received a very low priority. The outcome following treatment has been exclusively abstinence-oriented. Only recently, through continuous advocacy, have health administrators, policy-makers and care-givers agreed to alternate treatment goals, including the harm-reduction approach. Thus, it is obvious that, in India, control of alcohol and drug abuse is a low priority area in the health ministry and receives meagre funding. Dialogue with state health departments is met with immense resistance and indifference.

Being away from a general hospital setting like AIIMS limits the ability of the centre to admit emergency cases and those with serious comorbid conditions. They are referred to the AIIMS for care. Additionally, the physical distance from AIIMS (42 km) causes the faculty to travel long distances between the centre and the AIIMS to participate in clinical duties at Ghaziabad and certain academic activities at the AIIMS.

Conclusions

The centre has a distinct public health orientation and the emphasis is on the development of various replicable models of care relevant to diverse Indian settings, including low-cost intervention strategies. In spite of the challenges and all the caveats, an encouraging development has been the sensitization of national law enforcement agencies (Narcotics Control Bureau, Department of Revenue, Office of the Narcotics Commissioner) towards allocation of resources for drug demand reduction. Efforts are being made to integrate treatment of SUD into the National Rural Health Mission (NRHM), an endeavour of the Indian government to provide care at the grass-roots level. This will make access to treatment of SUD a reality for a large section of the population, including those in remote areas.

Meanwhile, the NDDTC would continue to provide strategic advice to the government, work towards capacity-building for the health and non-governmental organization sector. It will also attempt to expand the reach of its programmes from the hospital to the community and workplace, providing services to groups with special needs. It would also focus on the evaluation of various intervention models developed.

Future priorities of the WHO Collaborating Centre will include substance abuse epidemiology, identification and management of SUD, improving the coverage and quality of treatment for opioid dependence, generating new research data and contributing to WHO global and regional information systems on alcohol and drugs.

The NDDTC also plans to venture into newer areas, such as the biological aspects of addictive disorders. The centre has initiated steps to introduce a specialized course in addiction psychiatry.

Declarations of interest

None.

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