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Screening for addiction at primary healthcare centers is essential

Ninety seven per cent of people with addiction in India aren't getting help, according to the NIMHANS' mental health survey. Why does this happen? What needs to change?

The recent mental health survey conducted by NIMHANS threw up some startling statistics about addiction in India. The survey found that:

  • At least one in five people have a substance use disorder (22.4%)*
    (use of alcohol, tobacco or drugs)
  • At least one in five people are dependent on tobacco and cigarettes (20%)
  • Nearly one in twenty people has an alcohol use disorder (4.6 %)
  • And out of every 100 people who have an alcohol use disorder, only three seek help. Which means that 97 per cent of them aren’t getting any help at all.

Why are so few people seeking help?

The first hurdle: Most people don’t identify alcohol use disorder as a problem that requires medical intervention. Most people see addiction as a moral problem (“drinking is a bad habit”), or as a bad choice (“You just need to choose sobriety.”)
What actually happens: is caused by a combination of genes, personality traits and social influence. It has very little to do with willpower.

The second hurdle: Most people don’t connect their health issues to their smoking/ drinking/ drug habit. They report to a general practitioner - often, the physician at the primary healthcare center in their region - with complaints such as not being able to sleep, weakness of the limbs, loss of appetite, headache, etc. Some others may report to an expert for high or low BP or gastric troubles.
What actually happens: Often, general physicians and nurses don’t ask the person about their lifestyle habits. The physician may focus on the symptoms and miss out on the cause: i.e., alcohol or cigarette use. There is no screening at this stage to indicate if a person may have an addiction. Screening tests like the CAGE or the MAST can help identify addiction. 
If you think you are addicted to alcohol, cigarettes or tobacco, you may need to cut down on your habit. If you are unable to do so by yourself, you may need to seek help.

The third hurdle: When a patient goes to a physician to seek help for their addiction, they don’t receive scientific intervention. Physicians are often not equipped to diagnose or offer the right intervention. They may advise the patient to stop using alcohol or tobacco, but don’t help them in doing so.
What effective treatment means: Effective treatment includes identification of the disorder, support to quit using (this involves helping the client understand why they need to quit) and support to deal with the challenges of quitting (how to cut down on usage, how to deal with cravings, how to deal with withdrawal symptoms and how to deal with peer pressure or other social factors). Treatment of the withdrawal symptoms is also crucial. This would require the General Practitioner to have an awareness about addiction, how to identify it, and how to treat it.

The fourth hurdle: There are a few accredited institutions in India which offer specialized treatment for addiction. Also, there are several rehabilitation centers - some of them above-board, some others which aren’t, and some even with human rights violations.
What we need: While rehabilitation and long-term care are services offered by tertiary care centers, this cannot be the only method of intervention. Screening for alcohol and other addictions need to be done at the primary healthcare centers in order to be effective.

How do we bridge the gap?

Here’s how experts from NIMHANS suggest the problem be tackled:

1. Create public awareness that addiction is a chronic brain disease, and not a moral problem. Have people be aware of how much alcohol, tobacco or drug use is okay, and when it is a problem.

2. Improve access to care by ensuring that general practitioners, nurses and staff of primary healthcare centers are equipped to screen patients for addiction, and offer effective treatment. Train them to:

  • Routinely ask people about their use of tobacco/alcohol, irrespective of what they are seeking treatment for.
  • Link that information to their health issues and understand if addiction is the cause of their health and behavioral problems.
  • Treat them if possible, or refer them to specialized treatment centers if necessary.

For this, addiction needs to be a part of the training curriculum in undergraduate and postgraduate courses for doctors and nurses.

3. Set up an accreditation system to identify treatment and rehabilitation centers that are above-board and offer scientific treatment, including mental health support. This will help clients identify where help is available, and go a long way in reassuring people that it’s okay and safe to seek help. They may seek help before they reach a crisis.

But why is this important?

People who use alcohol or tobacco fall into three large categories:

Category 1: Those who use a substance occasionally or rarely.

Category 2: Those who use a substance regularly but without medical and psychological complications.

Category 3: Those who present with acute symptoms.

People from Category 3 (acute symptoms) are likely to seek help for symptoms other than that of substance abuse: gastrointestinal distress, involvement in violence or accidents, and liver damage. Treatment at this stage is not accessible, and involves a huge investment in terms of time and money.

People from Category 2 are the bulk of substance users. Because these people don’t have any medical or psychological complications, they may not seek help. But this is also the group that stands to benefit the most from timely intervention; in most cases, counseling can suffice to help the person quit.

A person who begins using a substance may take anywhere between 10 and 15 years to develop an addiction. An intervention before the acute stage could result in better treatment outcomes, be less expensive, and cause less harm to the person’s physical and mental health.