Drugs of abuse are smoked, snorted, consumed orally or injected. Injecting drug users (IDUs) often share needles and syringes and infections spread through them. If a member of the group of addicts is HIV positive, the infection spreads to others through needles and syringes. IDUs, therefore, harm themselves in two ways - because of drug and because of the infection. Hard core IDUs are isolated and do not lead their normal lives.
Many other IDUs are not fully cut off from the normal life and lead sexually active lives. Such IDUs form the bridge population between the drug injecting and general population and pass the HIV to their non-drug using sex partners and through them to others. Thus, unlike the effect of drug itself, the drug-driven HIV spreads far beyond the drug using population and harms them.
1. There are two schools of thought on how to deal with IDUs - one which believes in the ‘abstinence only’ approach and the other which advocates ‘harm reduction’ approach. Those who advocate 'abstinence only' approach believe that if an IDU should be saved from infections, the only option is to de-addict him.
In contrast, advocates of ‘harm reduction’ approach argue that if the IDU cannot be de-addicted he should at least be saved from infections by helping him abuse drugs safely. There are strong advocates of both schools of thought and even nations are divided between the two approaches. There are several techniques of harm reduction such as:
i) Setting up shooting galleries where the addict is provided clean needles and syringes and good quality drug so that he can sit and inject without fear of effect of either infected needles and syringes or impure drug.
ii) Encouraging the addict to smoke instead of injecting, say, heroin.
iii) Needle syringe exchange programmes in which the addict is provided clean needles and syringes to inject but not the drugs;
iv) Oral substitution in which the IDU is supplied buprenorphine or methadone and persuaded to abuse them orally instead of injecting heroin or other drugs.
2. Our policy will be to allow only (iii) and (iv) above but not (i) and (ii). Injecting drug users will, as far as possible, be weaned from the drugs and not encouraged to sustain their habit by abusing drugs safely. However, addicts do not always come forward for de-addiction. Hence, if a strict 'abstinence only' approach is followed, a large number of addicts remain outside the services provided to addict population. Hard-core injecting drug users will be less willing to be de-addicted than to switch to, say oral substitution or use clean needles and syringes to shoot. On the other hand, if drugs for oral consumption or drug paraphernalia (such as syringes) are distributed freely on the streets, it will be seen as an official sanction and patronage to drug addiction and can promote drug addiction. If any NGO or person is allowed to promote ‘harm reduction’, there is a great risk of it being used as a cover to actually push drugs or promote them. Hence, harm reduction will be allowed only as a step towards de-addiction and not otherwise. Further, it should be practiced only by centres set up, supported by or recognized by the Central or the concerned State Government.
3. Injecting drug use is also a problem in many prisons. Some advocate harm reduction methods even in prison settings. However, considering that prison settings are completely regulated, it does not stand to reason to allow prison inmates who smuggle in and abuse drugs the benefit of getting clean needles and syringes or oral substitutes so that they can sustain their addiction and abuse drugs safely. Hence, IDUs among the inmates of prisons shall be compulsorily de-addicted and they shall not be given supplied clean needles and syringes and allowed to inject drugs. They shall also not be supplied oral buprenorphine or methadone for abuse as substitutes.
4. Opinion is divided among experts regarding the choice of drug to be used for oral substitution. While some prefer buprenorphine others prefer methadone. Thus, the appropriate policy will be to promote use of the drugs which can wean the addict away the fastest while discouraging drugs which will have to be given forever. A committee of experts will be constituted by the Department of Revenue in consultation with the Ministry of Health & Family Welfare and the Ministry of Social Justice & Empowerment to examine which drugs should be allowed for oral substitution based on this principle. If more than one drug is allowed for oral substitution, it is for the doctor or the centre to decide which drug to use in any given case.
5. In view of the above, the approach towards harm reduction will be as follows:
a) Drug addicts including injecting drug users (IDUs) will be identified and treated and their drug-using habit will not be supported or incentivised.
b) However, in cases where it is not possible to convince an IDU to undergo de-addiction, as a first step, clean needles and syringes or oral substitution may be provided to him.
c) Harm reduction techniques as indicated in (b) above may be practiced only by hospitals or centres set up or supported by or recognized by the Central Government or any State Government.
d) If anyone or any organisation other than those indicated in (c) above distributes needles and syringes or drugs for oral consumption to addicts, it shall be treated as abetting consumption of drugs and such person or organisation will be treated accordingly under the NDPS Act, 1985.
e) The centres indicated in (c) above promoting ‘harm reduction’ shall maintain records of each of the addicts and shall switch them to de-addiction as soon as possible preferably within one year but in no case later than two years.
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