What We Get Wrong About Drug Abuse
Words by Ronny Sen
September 06, 2020
Illustration by Aarman Roy
Update (September 8, 2020): Rhea Chakraborty has been arrested by the Narcotics Control Bureau, Mumbai, under various charges outlined by the Narcotics Drugs and Psychotropic Substances (NDPS) Act. She is the eighth person to be arrested in relation to the investigation into the death of actor Sushant Singh Rajput. Chakraborty will be first taken for medical testing before being produced in front of a magistrate via video-conferencing for remand later today. Her arrest comes after three consecutive days of interrogation by the NCB, over her relations with the late Rajput and his alleged drug use. During the interrogation, Chakraborty admitted to procuring drugs for Sushant Singh Rajput and consuming them at times. Satish Maneshinde, Chakraborty’s lawyer called her arrest a ‘travesty of justice.’ ‘Three central agencies hounding a single woman just because she was in love with a drug addict who was suffering from mental health issues for several years and committed suicide due to consumption of illegally administered medicines, drugs,” Maneshinde said in a statement.
Drugs and addiction are fundamentally intertwined, and yet the word ‘addiction’ does not appear in the Narcotic Drugs and Psychotropic Substances Act (1985) of India. The NDPS Act is our primary piece of parliamentary legislature around drug use, and pertains to the possession, sale, purchase, production and use of narcotic or psychotropic substances. The Narcotics Control Bureau (NCB) was established under the act in 1986, and was designed to both enforce the NDPS and also uphold India’s commitments to global anti-drug conventions and treaties. The NDPS Act does make provisions for the care, attention and legal rights of addicts, but there are no systems in place by which to enable this; more fundamentally, since the Act does not define what addiction is, how can it successfully treat addicts? Furthermore, it is not able to successfully differentiate between a recreational drug user and an addict.
The NDPS, India’s first narcotics legislation, was brought into effect in 1985 by Rajiv Gandhi’s government due to the United States’ worldwide war on drugs. But in recent years, most Western countries, including many states in the US, have adopted alternative policies on drug consumption, including a rush to legalise marijuana or to decriminalise its possession and use. In India we cannot blindly follow this rhetoric, which is the same mistake we made in 1985 by hastily making an Act criminalising drug use, without fully being cognisant of on ground realities. We have to start in more basic and fundamental ways: first, by recognising addiction as illness, and not confusing this with a misguided moral or ethical position.
Today, the NDPS Act is being used as a rhetorical device by which to suit the agenda of a corrupt and invasive prosecution and bloodthirsty media. On August 26, 2020, the NCB registered a First Information Report against actor Rhea Chakraborty and others under the NDPS, in an investigative probe linked to the death of actor Sushant Singh Rajput. At the time of writing, Chakraborty is being questioned at the NCB office in Mumbai, and eight people, including Chakraborty’s twenty-four-year-old brother, and Rajput’s former house manager, have been arrested. The NCB’s case against those arrested, and Rhea Chakraborty, hinges on allegations that they enabled and abetted Rajput’s drug use.
This high-profile drug scandal reflects how Indian society sees drug use and addiction as a moral crisis, not as the public-health issue that it really is. If addiction is defined and acknowledged as illness – the ostracization, stigma and the shame attached to it will naturally dissipate. The first point of reckoning is with the law: because the law currently perpetuates bigoted misunderstandings, and creates entirely unsafe environments for addicts or users to either be treated or put on trial.
There is a deep lack of sophistication and nuance in the understanding of addiction in India – either on the level of society, or the law – and our laws are a reflection of our collective ignorance and bias. Governments across the world have written out specific laws to define addiction in detailed and elaborate ways. This helps to successfully identify and treat addiction, and give rights to those that suffer; it also creates awareness among the public. In the US, there are a number of laws that address drug addiction, for instance, the treatment of opioid dependence with opioid medication is governed by federal regulations, under the Substance Abuse and Mental Health Services Administration, which acknowledges that ‘addiction is a medical disorder that may require differing treatment protocols for different patients.’ The Supreme Court of Canada recognises the following definition of addiction: ‘a primary, chronic disease, characterized by impaired control over the use of a psychoactive substance and/or behaviour.’ Which is all to illustrate that in some parts of the world, addiction is understood and treated as the medical condition that it is.
Rajput’s alleged drug use is being linked to his eventual suicide, and has thus become the primary concern of this investigative inquiry. In many ways, this is a gross violation and conflation of what is at stake when it comes to drug use, and pivots on a total misunderstanding of addiction. In such a context, it becomes imperative that terms like ‘addict’, ‘addiction’ and ‘substance abuse’, and other such related words, are formally recognised and explicitly defined. Their definition must be kept airtight, so judiciary bodies cannot let their moral biases or ignorance sway their judgements and positions.
India needs to do this with urgency: recognise addiction as an issue of public health, and correct and complexify the language of the law that surrounds it. The legislative actions of the NDPS Act need to be restructured accordingly, and form this basic foundation.
Unless we clearly define these terms, we cannot help people recover or seek appropriate treatment. Addiction is a complex biopsychosocial condition. Being an addict is permanent. A person is born an addict and will die an addict regardless of whether they are still using. At any given time: an addict is either using or recovering. As per the language of the NDPS, an addict is defined as ‘a person who has dependence on any narcotic drug or psychotropic substance’. This is a gross oversimplification because a person who is chemically dependent on a certain substance at a given point, may not necessarily be an addict. Whereas an addict who might be in sobriety for decades, could easily relapse back into substance abuse at any given moment. The complexity of the behavioral pattern, which is characteristic of addiction, and addictive personality, is entirely lost in such a simplistic set of definitions and ultimately self-defeating. Binge users may be addicted to substances temporarily, and quit on their own, whereas addicts have an inherent pathological relationship with substances, and an obsessive compulsive behaviour pattern which constitutionally prevents them from exercising self-will to stop using a given substance. This is the fundamental difference between the two. The NDPS is primarily designed to criminalise and punish people dealing drugs or narcotic substances. What is implied by the way that the NDPS Act is written and structured is an egregious misunderstanding: that addiction can be treated by limiting the circulation of addictive substances.
As the law does not define what addiction means, and how it relates to the actual, lived life of addicts, the law itself has become a major obstacle to recovery. The physical symptoms suffered by addicts – like withdrawals, for instance – are not even mentioned in the NDPS. This makes it almost impossible for lawyers and judges to effectively argue cases or produce judgements. One has to presume, and hope, that the sitting judge on a case knows about something as fundamental as withdrawals. This is incredibly dangerous. Withdrawal is when an addict who is not given their substance in a timely fashion might not be able to talk, walk, eat, sleep or be able to properly function. In extreme cases, they may even die because of the intensity of their withdrawals. Are judges cognisant of the seriousness of this? We don’t know, and the fact that the word ‘withdrawal’ doesn’t even appear in the law makes the courtroom an incredibly dangerous place for an addict to occupy.
There is a provision in the NDPS Act where it states that the government may supply drugs to drug users in special circumstances, which seems to allude that those that drafted the law had some understanding of withdrawals. The NDPS gives the government power to supply drugs to addicts where it is a ‘medical necessity’, but the Act fails to explain that this medical necessity arises, in fact, from withdrawals. By keeping the language ambiguous, withdrawals are not legally recognised by the state as the aforementioned ‘medical necessity’.
The entire pillar of intent and motive – through which a court structures itself around a crime – is simply vanished from the criminal justice system in such a context. Withdrawals are just one example of the nuances of an addict’s lived experience. In the NDPS, there are fundamental misconceptions over the definitions of ‘user’, ‘addict’, ‘peddler’ and ‘dealer’. Small-time peddlers are at the most risk of being criminalised by the Act, but they primarily sell to sustain their own addictions. These distinctions are not clearly marked and hence are deeply misunderstood in the courtroom. The fair trial or eventual conviction of addicts also entirely depends on the structures of caste, class and economy. Upper caste and class people maintain an unfair advantage over the system, mobilised by privilege and access, and the proximity to social capital.
According to the NDPS, the possession of marked drug or narcotic substance is a criminal offence, and the offender may be imprisoned for up to ten years. In 2018, the Government of Punjab recommended to the central government that a mandatory death penalty be initiated for those convicted of drug peddling or smuggling, even for first time offenders. Section 31A of the NDPS – ‘enhanced punishment for offences after previous conviction’ – does in fact make provisions for the death penalty, after an amendment was introduced in 2001. In 2011, the Mumbai High Court ruled against the mandatory death penalty in the Indian Harm Reduction Network vs The Union Of India case. The law was once again amended in 2014 to make the death penalty discretionary, and now has a new lease on life by the aforementioned recommendation by the Punjab Government.
The law also fails to make provisions toward the availability and accessibility of treatment options. At the moment, the most robust ecosystem of therapy is entirely volunteer-run by addicts, and for addicts. Self-help groups are largely free: there are no membership fees, and there are thousands of meetings by recovering addicts all over the country. The only requirement of membership is the desire to stop using. In Kolkata, for instance, there are more than four meetings every day, on every day of the week. This is an extraordinary ecosystem of support groups, run without any corporate or government support.
There are also several pharmaceutical treatments. In India, the statistics hardly show recovery rates with these, as treatment is so severely restricted, and the legislature is instead focused on stopping the circulation of substances. The most widely used non-pharmaceutical treatment for addiction so far is the Minnesota Model – also known as the ‘abstinence model’ – first initiated by a psychologist and a psychiatrist in the 1950s, it loosely ties itself around the Alcoholics Anonymous (AA) model, where individuals provide support to each other. This model proliferates in most rehabilitation centres in India. The treatment creates a humane therapeutic community where one addict helps another.
The psychiatrists and the pharmaceutical industrial complex essentially use the same logic albeit implement it differently. The standard pharmaceutical treatment plan involves substituting one drug to combat the dependency on another. In Punjab, the government is giving addicts something they are calling “de-addiction pills”, which are basically Buprenorphine. Heroin was made to substitute Morphine. Synthetic morphine is Norphin, Buprenorphine is exactly that. It’s a twisted cycle: addicts are given a chemical compound which was the very reason heroin was made in the very first place. The state – despite its delusions – cannot solve drug addiction by handing us Buprenorphine, or issuing death sentences to addicts. This feels like a form of denial, reflecting the dispossession of addicts and the moral high ground taken by a large part of Indian society. Harm reduction and daycare programmes, like the Methadone programme, which were once very popular, have been recognised as largely substitutional methods with a high rate of relapse – and thus not sustainable, long-term solutions. These are now being reconsidered in most parts of the world. Addiction is an illness that cannot be outrightly cured by a pharmaceutical intervention, this is something that Dr. Robert G. Newman, who pioneered methadone maintenance, long fought to advocate.
In 2018, several randomised clinical trials in the UK, Canada, Norway, Belgium and the Netherlands, began administering small doses of heroin to heroin addicts, under supervised settings, to combat withdrawals. There also exist treatments that involve administering Naltrexone Hydrochloride tablets to addicts, which block the opioid receptors of the brain – after consumption, if the addict smokes Brown Sugar after they will not get high. It is also possible to operate on addicts’ bodies and place implants of Naltrexone Hydrochloride, which will periodically secrete and block the opioid receptors. But when administered incorrectly, people have died because of the side effects. These are painful deaths, where the patient suffers for days on end. For instance, if a doctor asks an addict whether they have had Brown Sugar that day, and because of societal pressure and stigma the addict says no, and the doctor proceeds to administer Naltrexone Hydrochloride – this has disastrous effects, and can result in unimaginable pain in the patient’s body and often fatal. It is worth noting here that doctor/addict relations are rarely safe spaces in which the addict feels that they can be honest about their consumption and habits: this is because even medical industry professionals operate from a place of ignorance and stigma. This is also a reason why the Minnesota Model is so effective: the model asserts that one addict helping another is a relationship that cannot be paralleled.
Doctors administer this treatment by citing that it reduces the overall urge to use Brown Sugar or alcohol. This is a flawed logic because addiction, or the desire for substances, is complex (and is as much psychological as it is biological), and cannot be simply diminished by blocking a person’s opioid receptors. There are many horrendous treatments still in practice, that operate on this mistaken logic: including the administration of Electroconvulsive Therapy (ECT), which has repeatedly shown itself to be hazardous and traumatising, and hardly effective. One argument is that the only space where pharmaceutical intervention is a required treatment is in the management of withdrawals. The excruciating pain an addict suffers when they are in withdrawal cannot be managed without medication. Different drugs have different withdrawal symptoms: Brown Sugar withdrawals are extremely physically painful, whereas alcohol withdrawals are not necessarily physically painful but have physical symptoms like shaky hands, insomnia, hallucinations (after the first few days have past) and sweating. In an ideal situation an addict is first helped with withdrawal management through medical attention, which is then followed up with a long term rehabilitation program for several months, one that is non-pharmaceutical, and is based on the Minnesota Model.
As of now, in India, there are no active steps being taken by the government to reframe the legal premise around addiction. We must each begin this exercise on a personal level, as well as in the institutions that we occupy. The first step of which is to engage in public discussion, involve all vulnerable parties, and create safe and welcoming platforms to aid the conversation. A less policed, more long term, nuanced approach will be the most successful, as entering this conversation requires the destabilising of fundamental misunderstandings. Issuing death sentences is a populist choice for politicians – it is not as though the Punjab government has been successful in issuing death penalties to addicts, but the sheer demand of the death penalty puts across a certain message to the public. This defeats the purpose of handling addiction with sensitivity or empathy, and is purely the result of political posturing.
There are obvious dangers involved in extolling the pre-1985 standards. It’s important to understand the global structural mechanisms that pushed us towards hard-line legislation like the NDPS, and how we cannot depend on the lawmakers, the justice system, the priests, the law enforcement agencies or the psychiatrists. We have to go beyond these structures – indeed, even abolish them – and spend time with people that are actually suffering, who are addicts and co-addicts (the family members of addicts), and those who are being disproportionately criminalised by existing laws.
Please dial SAMHSA's National Helpline phone number: 1-800-662-HELP (4357) or the National Toll Free Drug De-addiction helpline Number: 1800-11-0031 if you or anyone you know is struggling to cope with drug abuse.
RONNY SEN is a film director, writer and photographer based in Calcutta. His debut feature film ‘Cat Sticks’ world premiered in the competition section at Slamdance Film Festival, 2019 where it won a Jury Award. He has made two photo books, Khmer Din (2013) and End of Time (2016).