|Ahead of print
|A cross-sectional study of sociodemographic profile, availability, pattern of use, and service utilization by opioid users in a tertiary care hospital
Shri Gopal Goyal1, Atul Ambekar2, Pikakashi Arora3, Prem Prakash4, Ravindra Rao5, Alok Agrawal6, Ashwani Kumar Mishra5
1 Professor, Department of Psychiatry (DIMHANS), Sardar Patel Medical College, PBM Hospital, Bikaner, Rajasthan, India
2 Professor, Department of Psychiatry, National Drug Dependence Treatment Centre, All India Institute of Medical Sciences, New Delhi, India
3 Senior Resident, Department of Psychiatry, Pacific Medical College and Hospital, Udaipur, Rajasthan, India
4 Assistant Professor, Department of Psychiatry, Jawaharlal Nehru Medical College, Ajmer, Rajasthan, India
5 Additional Professor, Department of Psychiatry, National Drug Dependence Treatment Centre, All India Institute of Medical Sciences, New Delhi, India
6 Associate Professor, Department of Psychiatry, National Drug Dependence Treatment Centre, All India Institute of Medical Sciences, New Delhi, India
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|Date of Submission||22-Jun-2022|
|Date of Acceptance||11-Nov-2022|
|Date of Web Publication||28-Feb-2023|
Background: The menace of substance abuse is not only socially unacceptable but also emerging as a major public health challenge in many States of India, including Rajasthan.
Aims: The aim of this study is to study the sociodemographic profile, pattern of use, availability of opioids, and process of seeking treatment services for opioid dependence.
Subjects and Methods: After ethical clearance, a cross-sectional observational study was carried out among those who fulfilled the screening criteria at a tertiary care hospital. A self-designed pro forma was used, which included a sociodemographic profile, drug use profile and pattern, behaviors and practices, service access, and the World Health Organization Alcohol, Smoking, and Substance Involvement Screening Test (ASSIST). Results were analyzed using SPSS version 22.
Results: The mean age of the participants was 41.25 (±12.4) years. The majority (98.3%) were males, married (91.7%), illiterate (33.3%), farmers (61.7%), 45.7% lived in Bikaner District, and 83.3% lived in rural areas. Crude opium was the most common drug used in the lifetime of 98% of users. The most common comorbid substance used was tobacco, used by 75% of them. In 85% of cases, opioid drugs were purchased with their own legal earnings. The major reasons for starting opioid drugs were peer pressure (38.3%), to relieve pain/stress (25%), and to increase physical stamina for work (33.3%). The majority (73.3%) of them had utilized services for deaddiction purposes earlier.
Conclusion: The rural population in Western Rajasthan was highly affected by opium dependence. Participants were mainly low-potency opioid users without significant impairment in socio-occupational functioning, and their use was mainly to relieve stress and pain and to increase work capacity.
Keywords: Opioid, pattern, Rajasthan, service
|How to cite this URL:|
Goyal SG, Ambekar A, Arora P, Prakash P, Rao R, Agrawal A, Mishra AK. A cross-sectional study of sociodemographic profile, availability, pattern of use, and service utilization by opioid users in a tertiary care hospital. Arch Ment Health [Epub ahead of print] [cited 2023 Mar 24]. Available from: https://www.amhonline.org/preprintarticle.asp?id=370762
| Introduction|| |
The World Drug Report, 2018 estimates that there were approximately 275 million people (5.6% of the global population) aged 15–64 years globally who had used an illicit drug at least once in 2016. The number of users of opioids in 2016 was 34 million. The use of opioids has been known to be historically prevalent in several states of the country, particularly the central and Northwestern States, which are part of the traditional opium-growing regions. Rajasthan is one such state where the cultivation and use of opioids have a long history and have widespread cultural and social acceptance. The state is known for its traditional use of raw opium in the form of amal or doda, due to its climate and difficult living conditions. Studies have reported that in rural areas of the desert of Western Rajasthan, crude opium is consumed with a social sanction by a notable proportion (8.0%) of adult males, and the prevalence rate of opium use is significantly higher in men than women in these desert areas.,, Opium was widely used for medicinal purposes in states such as Gujarat and Rajasthan, particularly among certain communities, and there is a strong link between opium use and cultural and caste membership.
Over the past few decades, the legal and policy environment governing the availability and use of opioids in India has been becoming progressively restrictive. Experts believe that this has led to a shift in the pattern of opioid use away from traditional low-potency opiates toward more potent, processed opioids. Heroin (brown sugar) appeared on the Indian market in the early 1980s, and it effectively displaced opium and cannabis as the drugs of choice. A study reported a shift to synthetic opiates due to increasing control over poppy straw used in the opium drink preparation. The Narcotic drugs and psychotropic substance act, which criminalized opium use in 1985, had some effect on drug users' shift from cannabis and opium to inhaling heroin. This increase in heroin use was exacerbated by increased illicit heroin trafficking into India from Afghanistan through Pakistan during this time. Rajasthan had 82 legal opium depots in 2013, selling 18,000 quintals of poppy husk to the state's 24,841 registered poppy husk users. The Rajasthan high court issued an order in 2015 ordering the closure of all licensed doda/postshops. They instructed the government of Rajasthan to comply within a year. Hence, the state government intends to close down all such shops in 2016. With the forthcoming closure of licensed outlets for traditional forms of opium, there is a likelihood of change in the pattern of opioid use in Rajasthan in the near future. Hence, it was pertinent to study and document the current pattern of use of opioid drugs and their availability in the state. There were no recent studies on the pattern of use of opioids in Rajasthan, its prevalence, or its adverse consequences among users. This study was done to assess the sociodemographic profile, pattern of substance use, service utilization, and describe the existing landscape of availability of opioids in the state before the closure of licensed shops for opioids.
| Subjects and Methods|| |
After getting approval from the Ethical Committee of the Institution, a cross-sectional observational study was conducted among opioid users who were coming for treatment in a tertiary care hospital from March 1 to May 31, 2016. Those who were of any age, any gender, used one or more of the opioid group of drugs (opium – all forms, heroin/brown sugar, pharmaceutical opioids such as codeine, buprenorphine, pentazocine, and d-propoxyphene) at least once within the past 3 months, gave consent for participation and resident of Rajasthan were included in the study. Those who were unable to participate in the interview on the account of severe disability due to comorbid physical and mental health conditions and those who did not give consent were excluded from the study. The sample size was not calculated as we took all participants who fulfilled the inclusion criteria during the prescribed time. Sixty participants were included in the study. Twenty were excluded as they did not fulfill the inclusion criteria. Tools were applied and results were analyzed using SPSS version 22 (IBM SPSS Statistics for Windows, Version 22.0. Armonk, NY: IBM Corp).
- Screening tool to determine eligibility
- Informed consent form
- Semi-structured pro forma incorporating
- Sociodemographic profile
- The drug use profile and pattern
- Behaviors and practices
- Service access and uptake (including in-patient treatment from drug treatment centers in the preceding 12 months)
- The World Health Organization (WHO) Alcohol, Smoking and Substance Involvement Screening Test (ASSIST).
The ASSIST was developed for the WHO by an international group of substance abuse researchers to detect and manage substance use and related problems in primary and general medical care settings.
| Results|| |
[Table 1] shows the sociodemographic details of the participants. The mean age of the participants in our study was 41.25 ± 12.4 years and the maximum number was belonged to the age group of 38–47 years (30%). 98.3% of them were males. 91.7% were married. 33.3% of them were illiterate, 28.4% were educated till primary level, 15% to the high school level, and 10% to higher secondary level. 48.3% were currently engaged in a full-time job, 43.3% were doing a part-time job, and 5.0% were currently unemployed, whereas 3.3% were never employed. 61.7% of them were farmers and 11.7% were unskilled workers/laborers. 49.7% of the participants belonged to Bikaner district, 21.6% belonged to Shriganganagar, and 17.3% belonged to Hanumangarh. 83.3% were living in rural areas. Hindi was the mother tongue language in 32.2% of participants while 67.8% were having other languages as their mother tongue (Bagri, Marwari, and Punjabi). 58.3% were living in joint families and 41.7% were in nuclear families. The mean of family size of the participants was 6.25 with std. deviation of 2.8. About 40 % of them had family income above 5528 rupees.
[Table 2] shows the pattern of use of opioids and comorbid nonopioid drugs in the participants. Among the nonopioid drugs, tobacco was the most commonly used drug by 75% during their lifetime, by 71.7% in the last year and by 66.6% in the past 3 months. Alcohol was used by 26.7% during their lifetime, by 18.3% during the last year and by 16.6% during the last 3 months. Sedatives were used by 16.6% during their lifetime, by 13.3% during the last year and by 10% in the last 3 months. Cannabis was used by 5% during their lifetime, 5% during the last year, and 3.33% in the last 3 months. Opium was the most commonly used opioid by 98% of users in their lifetime, 97% in the last year, and 95% in the last 3 months. Heroine was used by 5% in their lifetime, whereas none of them used heroine in the last year. Capsule dextropropoxyphene was used by 3.3% of them. Other oral pharmaceutical opioids were used by 6.6% of them. None of them had ever used injectable opioids in their life.
[Table 3] shows the severity of opioid use in the last 3 months. It shows that 95% of participants used opioids daily and the same (95%) had a strong desire or urge to use opioids daily. Forty-five percent reported that they never faced problems regarding health, social, legal, or financial, 36.7% reported that they faced such problems almost daily and 18.4% reported they faced these problems monthly. 28.3% reported that they failed to do what was normally expected to do due to the opioid use daily. Sixty-five percent of them reported that a relative or friend had ever expressed concern about their use of opioids in the past 3 months. Fifty percent reported that they had ever tried and failed to control, cut down or stop using opioids in the past 3 months.
[Table 4] shows the pattern, initiation of opioid use, and drug use network. In the last 3 months, the most common opioid substance used was opium (afeem/doda/bhukki/amal) by 96.7% of participants. Other most commonly used oral opioids were, namely, tramadol, corex, lamotil, etc., Substances such as heroin, dextropropoxyphene, injection heroine, injection buprenorphine is not commonly used. Eighty percent reported that they consumed the drug 2–3 times/day, 13.3% consumed it four times/day, and 6.7% consumed it once a day. The source of funding for opioid drug expenditure was their own legal earnings in 85%. In 58.3% of cases, the opioid drug was obtained from a licensed opium shop, 41.7% from a peddler, 3.3% from a pharmacy, and 3.3% from other opioid users. 42.4% of cases get opioid drugs from usual source within <30 min, 28.8% in 30–60 min. Five percent of the users have been caught by the police while trying to purchase/consume or carry opioid drugs. 38.3% said their friends, who were opioid addicts themselves, forced/encouraged them to try opioid drugs; 20% said they started it out of curiosity after seeing others using opioids; 16.7% said they were looking for something to produce a pleasurable effect; 3.3% said other opioid drugs they were using were no longer available/had become very expensive; and 25% said they wanted to relieve pain/strength.
[Table 5] shows the recent trends in the availability and use of opioid drugs. 71.7% disagreed that traditional opioid preparations such as afeem and doda have become cheaper and easier to procure, while 27% agreed with it, whereas 1.7% could not comment. While enquiring whether heroin has become cheaper and more easily available, 3.3% agreed with it, 18.3% disagreed, and the majority (63.8%) could not comment. Similarly, a majority (70%) could not comment on the availability of pharmaceutical opioids such as morphine, fortwin, and proxyvon. 70% of them agreed that all the opioid drugs have become costlier and difficult to procure. Forty-eight percent agreed that the proportion of those using traditional opioid preparations such as afeem/doda/bhukki/amal has been increased, while 46.7% disagreed. A majority (55%) could not comment on the recent trend of the use of pharmaceutical opioids such as morphine, fortwin, and proxyvon as well as heroin (smack/brown sugar/chitta). Fifty-six percent agreed that the number of opioid drug users has increased, whereas 26.7 disagreed with this. 86.7% reported that they use opioids alone, while 13.3% consume them in a group.
[Table 6] shows the service utilization for opioid drug use. 73.3% had tried to give up the use of opioid drugs, and 63.3% had received any help/treatment to give up use. Among these, 35% went to a government health facility, 30% to a government deaddiction center, 21.7% to a private medical doctor, 5% to a private deaddiction center, and 3.3% took spiritual/religious help. 13.3% of them have also been admitted for opioid use problems.
| Discussion|| |
The majority of opium users were illiterate married males of age group 28–47 years. Most belonged to rural areas living in joint families and were employed full or part time, were farmers by occupation having a family income in the range of rupees 5500–14,000.
Among opium users, the most common comorbid substance use was tobacco (75%) followed by alcohol (26.7%). A study conducted among polysubstance intravenous drug abusers in urban resettlement area in New Delhi, the most common comorbid substance abuse was tobacco (91%), followed by cannabis (50%) and alcohol (28%).
Most of the opioid users reported a pattern of use and craving to use opium daily. However, almost half (45%) of patients reportedly never experienced any type of physical, social, legal, or financial problems and did not face any problems in occupational functioning. It indicated that approximately half of the opium users were socially and occupationally productive and were performing their duties responsibly even while consuming opium daily. Ganguly et al. in their study found that 90% of traditional opioid users were well accepted in society. Opium use in Western Rajasthan is socially sanctioned and culturally accepted and considered to be nonintoxicating substance causing no behavioral and social problems.
The most common type of opioid used was opium and most consumed it more than once a day. This is in contrast with the study conducted by Jhanjee and Sethi in New Delhi in which the most common opioid abused was heroin (97%). Intravenous abuse of opioids is a rarity in rural areas and heroine abuse is still an urban phenomenon.
Over the past few years, the legislature and judiciary have made production and selling opium illegal, leading to the scarce availability of raw opium that had been traditionally consumed in rural areas. Experts believe that this has led to a shift in the pattern of opioid use away from traditional low-potency opioids toward more potent synthetic opiates.
Most opioid users reported that they did not get involved in illegal jobs to procure opium and their usual source of income was enough to procure it. The majority procured opioid drugs from licensed opium shops, and very few reported that they were caught by the police for possession of opium. The common reasons for starting abuse of opioid drugs were peer pressure, relieve pain and stress, increase physical stamina for work, and for pleasurable effects. In the current study, most of the patients were farmers, they started using opioids to relieve fatigue and increase work efficiency. The available literature shows evidence that in earlier times, opium was provided to soldiers to feel energized, to have euphoric high, and to increase their capacity to overcome injuries caught in wars.
We noted a significant change in the attitude of opioid users regarding the availability of opioid drugs. The majority disagreed that opioid preparations became cheaper and easier to procure. Mostly, opioid users took low-potency opium. The majority of opioid users were not familiar with the use of synthetic and semisynthetic opioid drugs.
The majority of opioid users tried to quit opioid drugs in the past and a significant number of opioid users took help/treatment. The majority of the opioid users sought treatment from government hospitals/deaddiction centers, however, very few reported admission to the hospital. The increased treatment-seeking tendency after the closure of licensed opium shops may be due to the rise in cost and difficult availability of opium. The results of the study conducted by Parmar et al. were in line with the pathways to care in opioid users.
| Conclusion|| |
The rural population in Western Rajasthan is highly affected by opium dependence. Despite adequate control measures, high amounts of opium were still available in the rural areas of western Rajasthan. Participants were mostly consuming low-potency opioids (afeem and doda post) without significant impairment in socio-occupational functioning, and they use it chiefly to relieve stress and pain and to increase work capacity. There had been no transition to high-potency synthetic opioid preparations. Most of them had tried to give up the use of opioids earlier.
- The study was a cross-sectional study done before the closure of licensed opium shops, and the sample size of 60 appears inadequate for a comprehensive insight into the problem. There is a need for a longitudinal study of long duration with a large sample size to observe changes in the pattern of opioid use after the closure of licensed government shops for opium
- The study was done in a tertiary care hospital among treatment-seeking opioid-dependent individuals. Hence, the findings of the study could not be generalizable to the population.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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Department of Psychiatry, Jawaharlal Nehru Medical College, Ajmer, Rajasthan
Source of Support: None, Conflict of Interest: None
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]
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