Society

A Hair Of The Dog?

A Tihar programme treats heroin addicts with a controversial substitute

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A Hair Of The Dog?
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Jail Or Lab?

  • Tihar is the first prison in South Asia to try oral substitution therapy to treat heroin addicts
  • Buprenorphine, an opiate and an oral substitute for heroin, is being used instead of the internationally popular deaddiction drug methadone, which is banned in India
  • Experts question the wisdom of substituting one drug with another and say addiction calls for long-term behaviour therapy

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Does treating addiction through the use of drug substitutes work? Or does it only result in another addiction, which proponents of the therapy may claim is benign? And is the state justified in imposing such therapy on prisoners? These are the questions being asked of a deaddiction programme that has been initiated at New Delhi’s Tihar Jail, the largest in South Asia. In a first-of-its-kind pilot project, the authorities are treating batches of 50 patients each with high doses of buprenorphine, an opium derivative that has had a brief and controversial life as a heroin substitute.

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Opinion is divided on the use of the drug, administered orally unlike injected heroin. A justice department study in the UK in 2007 showed that buprenorphine was being misused in prisons and became the third drug of choice for addicts after morphine/heroin and cannabis. New Zealand and Singapore have banned buprenorphine, finding evidence of its misuse and addictiveness. In fact, some studies describe buprenorphine as 15 times as addictive as heroin.

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In for trouble: Tihar jail in Delhi

Experts opposed to substitution therapy say addiction is a behavioural problem and needs to be treated via long-term counselling and behaviour change methods. The project at Tihar, therefore, is being viewed as an easy way out—controlling addicts through high doses of another drug, albeit a legal one, rather than putting them through the rigour of long-term methods. “Drug addiction is a behavioural problem, not a chemical disorder, so medicating it won’t help. To deaddict patients, one has to bring about behavioural change through heavy counselling,” says Dr Yusuf Merchant, head of Drug Abuse Information, Rehabilitation & Research Centre, Mumbai. “Once the addicts are off substitute medication, they’re likely to go back to drugs. A substitute is not the answer. Remember, heroin was created as a substitute for morphine addicts. And as far as buprenorphine goes, the side-effects of its long-term use haven’t been studied.”

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Shakuntla Choudhary, an NGO worker who counsels patients undergoing oral substitution therapy (OST), says, “It’s very hard to convince addicts that the medicine is meant to deaddict them. They see it as a substitute and need lots of counselling to change their mindset. Of the patients who received this treatment, 29 have left and we have ensured they continue their treatment outside.”

The high dosage being administered to addicts in jail is also a matter of controversy. Earlier, buprenorphine was available only in tablets of half a milligram. Now, it’s classified as a restrictive drug, and is available in 2 mg tablets, which are being given to inmates in doses ranging from 6 mg to 16 mg daily.

The Tihar authorities have their own defence of the treatment. They claim the therapy is augmented with extensive follow-up and counselling, even after prisoners are freed. This model of treatment, they say, has been borrowed from Iran, where methadone was used as the heroin substitute. Since methadone is banned in India, buprenorphine was the drug of choice; and unlike Iran, this programme has a follow-up regimen. They claim the initial success of the Tihar model has led to the programme being replicated in jails in Sri Lanka, Maldives and Nepal.

In recent times, the jail has recorded an increase in the number of inmates who are addicts—the authorities say some 8-10 per cent of new inmates happen to be addicts; of them, some 67 per cent use injectables and most using such drugs are HIV positive owing to unhygienic use of needles. “The idea of the project is to deaddict them. Since many of them are from the lower section of society, they often commit petty crimes for money to buy the drugs,” says C.R. Garg, deputy inspector general for prisons. He explained that after taking the addicted prisoner’s consent, he is admitted to the jail’s deaddiction centre, which can house 120 patients, and slotted into the OST programme. The jail has a separate wing for TB patients, but HIV positives aren’t segregated or identified, except for treatment of addictions, should they also be addicts.

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The project is being carried out in collaboration with the All India Institute of Medical Sciences (AIIMS) and the United Nations Office on Drugs & Crime (UNODC). The first phase of the project will be completed in March 2010. The jail authorities will themselves fund the deaddiction programme thereafter. For follow-ups, there are three centres in east Delhi run by AIIMS. These centres administer buprenorphine and counsel addicts, while NGOs try to ensure that the patients do not miss appointments.

Of the OST treatment, Rakesh, an inmate, says, “Initially, I felt very sick when I took the medicine so I discontinued it. Then doctors suggested I try it again as I was having cravings. The second time it was better. I don’t feel lethargic any more and feel the therapy has definitely helped me.”

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The debate surrounding the use of methadone, buprenorphine and other substitutes for deaddiction certainly isn’t unknown to those in charge of the programme at Tihar. But they choose to emphasise the positives of the programme and the pioneering efforts they are taking for the welfare of addicts in prison. “This is the first time buprenorphine is being used in an Indian prison,” says Dr N.K. Girdhar, resident medical officer at Tihar. “It’s a long-term treatment process and the initial results have been good. Our model will be replicated in other states and countries.”

For the authorities at the overcrowded prison—against a capacity of 6,500, it houses more than 11,500 inmates—managing addiction among inmates, like the presence of HIV positives, is a major complication. While the authorities’ efforts to go beyond mere penal and correctional methods need to be commended, they must also think about the wisdom of using methods still not in the clear scientifically.

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