Role of Social Anomie in Peaking of Addictions: The Unusual Case of Punjab

Anirudh Kala*

       Punjab has just 2.0 % of land and 2% of population of the whole country. But it occupies a larger-than-life space in national consciousness. There are many historical and cultural reasons which contribute to Punjab’s footprint being larger than its foot.
                      Because of this salience whatever happens in Punjab gets noticed and commented upon early, and sometimes over-enthusiastically.
As happened to heroin addiction when it peaked in Punjab.
In 2014, a young political leader from Delhi, during election campaign in Punjab said in a speech that 70% of Punjabi youth are suffering from addiction.
That created quite a bally-hoo and a movie like ‘Udta Punjab’ got made.

As it turned out later, a study done in GN university, Amritsar, had said that in their sample of persons with addiction, 70% were youth, which was not surprising.

There is no hiding the fact that Punjab has a serious opioid use crisis.
However, according to the National Survey done in 2019, as far as the dependence and harmful use of Opioids is concerned, Punjab is only the sixth in the country, with 2.8% people having dependent/harmful use, with Mizoram leading at 6.9%.1
                     In Panjab, a benign tolerance for drugs and alcohol has always co-existed  in spite of a strict attitude of all three religions of pre-partition Punjab, including Sikhism towards intoxicants of all types.

During Maharaja Ranjit Singh’s rule (1780-1839), excise from alcohol, opium, and cannabis, was a major source of revenue. The British who came next tightened the collection and excise increased several folds.
In 1928, a study was published in the Indian Journal of Medical Research by R.N. Chopra who was an Indian Medical Services Officer, posted in Punjab and was considered the ‘doyen if Indian Pharmacology’.
“Percentage of habitual consumers of opium in India is less than 1% of the total population except in the central districts of Punjab, populated chiefly by the Sikhs, where the consumption of opium recorded is perhaps the highest except for Assam and Calcutta”.  Which included all the Eastern and the NE states at that time.

It is almost eerie, that a century later, the 2019 survey showed the same pattern with about 0.7 % of Indians using opioids in a dependent and harmful manner with Northwest and the North East showing much higher figures than rest of the country, confirming that proximity to the ‘golden crescent’ and to the ‘golden triangle’ continues to matter.
       While that pattern endures, what has changed is the type of opioids being used from natural opioids in the past to far more dangerous heroin..now being the commonest opioid used, all over India including Punjab. The villain of the piece of course is injectable heroin with its high mortality in form of over-dosage deaths and morbidity and mortality because of hepatitis C and HIV infections acquired through sharing of needles.2
If we add up the figures of injectable users from states in the North East and the Northwest we find that this one eighth of  country’s population has half of country’s injectable users.
And Delhi,  not Punjab, has the highest concentration of injectable users in the Northwest, with Punjab, J&K and Haryana not far behind and Himachal Pradesh catching up.
But nobody made a movie on Delhi!!

As far as the overall use of opioids in Punjab is concerned, it is more than four times the national average, (at 9.69% vs 2.06%) but only marginally higher than Haryana (8.68) and Delhi (7.79) among the NW states. The usage in  NE states is 2-3 times higher than even Punjab
(Mizoram-25.67, Nagaland-25.22, Arunachal Pradesh-22.18, Sikkim-18.74, Manipur-14.22).
     In Punjab use of opium and poppy husk, though never encouraged culturally, has been tolerated for the longest time because moderate use did not seem to impair functionality and did not lead to any social disruption or crime. The typical profile of the user was of a middle-aged farmer who continued to be fully functional and could not be told apart by someone not aware of his addiction. Also, during the back-breaking harvest season, twice in a year, it was a common practice to give poppy husk to the farm workers so that they worked tirelessly.

However, before NDPS, there were hardly any reports of over-dosage deaths or of Hepatitis/HIV or any law-and-order problem attributed to opium use. That is why the old timers in Punjab say, ‘Opium never killed anybody. NDPS did and continues to”
                 We all know that like most countries of the of the world, India signed the UN conventions held at the behest of the West.  And the NDPS Act was the inevitable follow up in 1985.
That alcohol and tobacco were more harmful than the banned opium, marihuana and cocaine and that commerce rather than humanitarian concern was the driving force behind these conventions, are separate but important debates.

However, laws such as these gloss over the fact that the periodic need to alter wake consciousness through a substance or a behavior is as natural an urge as to eat, sleep and have sex.
And come what may, human beings would use whatever is available.

Before 1985, the most used opioid, opium, was the least harmful. After 1985 the most used opioid, heroin is the most harmful. The reason for this reversal of order lies in what has been called the ‘Iron Law of Prohibition’ a term coined by Richard Cowan in 19863.
According to this when an intoxicant becomes illegal, smugglers enter the picture. And they prefer to smuggle in stronger intoxicants because these are less likely to be detected, packets being compact, and at the same time more profitable.
Whenever there has been prohibition of alcohol anywhere, beer becomes unavailable while one can still get vodka and whiskey. This results in a peculiar situation where even people who preferred beer shift to whisky. It happened in Covid lockdown in 2020.
And that is also how millions of opioid users in India who took opium and poppy husk in India before 1985 shifted to heroin and other synthetic opioids as the Act was unrolled over the years.

In a study published in IJP, it was reported that between 1994 and 1998, use of opium in Punjab decreased by 44%, while the use of synthetic opioids doubled4.
Thus, all the NDPS Act did other than putting thousands in jail, was to reverse the pattern of opioid use in India from poppy husk, opium, pharmaceutical opioids, and heroin in that order of prevalence to its exact reverse.
The other important change in Punjab was that… typical profile of a person with opioid addiction very rapidly changed from a middle-aged man to a young man in twenties. The reason for that change however lay elsewhere.

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                 In the nineteen sixties, the ‘Green Revolution’, a massive agricultural experiment with its epicenter in Punjab, had pulled India back from a near famine and had made the rural economy of Punjab, a model of economic development.
While the country became comfortable about food situation, Punjabi farmers prospered and Punjab, became the state with the highest per capita income in the country.
However, in late eighties, as experts had predicted, ‘green revolution’ started backtracking. It happened to be the same time the NDPS act was being unrolled.

Conversation
Paddy, being a water guzzling crop, lowered the water table and progressively more powerful pumps were required to pump out water, which required more loans and led to even more lowering of water table over the years. In desperation farmers resorted to overuse of fertilizers which degraded the soil further.
Meanwhile, with the breaking up of joint families, land holdings became progressively smaller to an extent where mechanized farming became less and less profitable.
This hit small farmers the most. Small farmers became marginal, and the marginal farmers became laborers in nearby grain markets.
            And Punjab which was number one state in India on the per capita income list in 1981 slid down rapidly and is today at number 19 among 28 states of the country.
           In the West, as in many other states of our country, the period of agricultural prosperity was used to create an industrial infrastructure for the community to fall back on since everybody knew the green revolution was temporary. However, that safety net did not materialize in Punjab.
      Industry in general including the national PSUs, had been wary of investing in Punjab because of its long border with Pakistan and the history of two vicious wars. The decade and a half long militancy during the eighties and early nineties made even the existing industry flee to other states.

So, what happened was this.
While the rest of   country had to deal with just the natural intoxicants disappearing and more harmful ones replacing them, for Punjab it was a double whammy as it was in the same time frame that the green revolution backtracked, and terrorism happened.
            The state was like a rich man having become pauper overnight. The worst affected were the young men left with nothing to do. Punjabi villagers faced a situation where the old pattern of life had become untenable, the new norms were not yet established, and the youngsters went about rudderless.

The French sociologist Emile Durkheim called such a normlessness, ‘anomie’ and described ‘anomic suicide’ as one of the three types of suicides 6.
In other parts of India, like Vidarbha in Maharashtra, farmers’ suicides increased and became an intense topic of discussion all over the country as a blazing sign of agrarian crisis.
However in Punjab, the epicenter of agricultural distress, where the farmers’ suicide rates were expected to be the highest, the situation played out very differently.

There has been no evidence that in Punjab, suicide rates among farmers has increased.  According to figures published by the NCRB, during 2021, overall suicide rate in the country was 12.0 while in Punjab it was 8.5.

The NCRB report also mentions: –
Majority of suicide victims engaged in farming sector were from Maharashtra (37.3%), Karnataka (19.9%), Andhra Pradesh (9.8%), Madhya Pradesh (6.2%) and Tamil Nadu (5.5%)” 7.
Punjab is nowhere in the picture.
And although Punjab government has a scheme for monetary relief for families of suicide victims of both farmers and agricultural laborers in four years (2015-18) only 2528 families had approached the state government.

Are Punjab farmers not debt-ridden?
Farmers of Punjab are in fact the most debt ridden in the country. According to a report submitted to the parliament, Punjabi farmers are on top of the list of Indian farmers with the largest institutional debt. (Tribune editorial, August 11, 2023).

Although suicides among farmers did not increase, the farming distress was very hard to bear, and something had to break.
And it did.

 Psychoanalyst Karl (ganga) Menninger considered drug addictions and alcoholism as ‘partial suicide or chronic suicide’ implying similar underlying psychological mechanisms in suicide and drug addictions, with self-destruction as the common theme.’8 Norman L. Farberow , a past president of the American Association of Suicidology, in his book The Many Faces of Suicide, asks these questions: –

‘Why do people continue to smoke when they know it is harmful? Why does a patient neglect prescribed medication, thereby endangering his life? Why does a sky diver wait until the last moment to pull the rip cord, coming as close as possible to almost certain death? Is this behavior suicidal?’9

 

If we look at human history closely to find the periods when addiction peaked dramatically, we can see that these were also the times of such normlessness during which the lines to follow had been erased and community support had crumbled: –

i) The native Americans of North America who were stripped of their land and culture by the white immigrants had lapsed into mass alcoholism.

ii) The English poor in early 18th-century Britain were driven out from their villages to far-off, scattered cities to work in factories. They responded by heavy drinking on a massive scale which was called ‘gin-craze’.

iii) In the 1970s and 80s, people in American inner cities were stripped of their factory jobs leading to a crack cocaine epidemic.
This major social event happened to collide with the Iron law of prohibition as the semi synthetic and much stronger crack cocaine became available around the same time.  The sufferers were mainly the African Americans.

From the perspective of addictions three major events happened in Punjab in the same time frame almost simultaneously.

The NDPS act was unrolled, green revolution backtracked, and militancy reached a peak.
May be Punjab could have tackled one or even two.
Three at the same time proved impossible and led to peaking of opioid addictions.
That is the hypothesis.

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What has been the response of the state government to the opioid use crisis?

            It has been mainly that of supply reduction with the usual ‘seizures and arrests’ methodology.
Initiatives towards providing a socially enriching environment and job opportunities on one side and stepping up scientifically driven treatment on the other, have been very few.

The issue of addictions has been heavily politicized. Each aspiring Chief Minister blames the incumbent for the mess and promises to eradicate drug addiction ‘from the roots in a month’ if elected. That addictions cannot be eradicated from the roots because the roots lie in the human brain, is not considered, not even by the electorate.

It goes without saying that the large consignments of heroin and other illicit drugs must be seized, and the smugglers jailed. Mere existence of smugglers creates a law-and-order chaos.
However, to expect addictions in Punjab to go down significantly only through supply reduction betrays a rank ignorance about the nature of addiction.

Among those arrested most are users, young men caught with small quantities. Jails are full of them.
NDPS Act is a cruel act, but there is also a compassionate side to it. Those users caught with small quantities can be discharged by court under sections 39 and 64-A, if they are willing to undergo treatment.

However, what happens is very different.
The Vidhi Legal Report published in 2018 had concluded:
‘Based on our data, no person has been sent to de-addiction centers by any court in Punjab under Sections 39 and Section 64A of the NDPS act, which allow addicts to be diverted out of the criminal justice system. These sections have been reduced to dead letters on paper.’
This is also why the title of the report is ‘Addict to Convict’.

Thus, a harsh law is being interpreted by the system as being even harsher by not implementing the only compassionate part in it.

Response of the state health ministry in Punjab, whose job is to create awareness and treat persons with addiction, has also been morally driven rather than scientific.
       The state does not allow more than half of its psychiatrists to treat addiction. There is a separate license required to run a ‘deaddiction center’ which takes years to get, and months to renew.  It is an offence to treat addiction outside the four walls of a ‘Deaddiction Centre’ and some psychiatrists who tried to do so were arrested under NDPS Act.

     The Punjab government does not have a written down policy to treat persons with addiction and is driven from time to time by personal views of the current minister or the secretary who keep changing.
OST with sublingual Buprenorphine has to be done according to a stringent SOP specially designed for Punjab by PGI Chandigarh at the request of Punjab government.
The SOP has three warning at the outset, addressed to the government and to the treating psychiatrist: –

1. “…this treatment is a ‘double edged sword”
2. It should only be used for addiction to heroin and ‘pure opium’ and not for addiction to ‘poor quality opium’ or poppy husk.
(It does not clarify how a psychiatrist sitting in his clinic could assess the quality of opium a patient is addicted to, or if this advice is backed by any research.
Do we treat alcoholism caused by drinking beer differently from alcoholism caused by drinking whiskey. We do not’.
3. ‘The treatment should be terminated preferably within one year but in no case later than two years. If it is difficult to stop, patient should be admitted, detoxified with clonidine, and shifted to Naltrexone.

None of these warnings are evidence based.

The OST in the state is monitored from the state capital in real time through an online portal. The medicines can be dispensed, only for 14 days or up to 100 tablets, whichever is less, at one time. Strength of the tablet.
There is no provision to dispense medicines even for an already registered patient who is in hospital for a medical illness or has met an accident and is undergoing surgery even if there is a medical certificate brought by his family member.
Or for a bona-fide patient going abroad for more than 2 weeks.

The press in the state has taken a cue from the warnings in the SOP about Buprenorphine being a double-edged sword, its use only for pure opium and the treatment lasting only for 1-2 years.
Tribune published an editorial, ‘Hooked on Deaddiction Pills’ which went on to lament, ‘Many patients, during their journey of ridding themselves of habit-forming substances, often find themselves sinking deeper into the morass as they become addicted to the very medicine that was meant to cure them.”
The fact that the Tribune is considered a responsible newspaper made it highly damaging.
Show the cutting. I have talked to some of these reporters. They have a copy of the PGI, SOP

The Deaddiction Committee in every district is headed by the Deputy Commissioner.
The DC of a district sent an order last year that psychiatrists should reduce the dosage of the medicine as much as possible and send him weekly feedback.
During informal discussions with bureaucrats, they argue that it is their duty to enforce the SOP which was written by the most reputed institute of the region, and if infringed is a crime under the NDPS Act.
And they show you the warning which says this treatment is a double-edged sword.
Any further discussion is ended by the advice ‘why don’t’ you take it up with your colleagues who wrote it.
TISS email:-
The concern is that while Punjab has some very progressive policies as they relate to the opioid crisis there are perhaps some aspects of it that may not be entirely consistent with maximising patient welfare. These could include, for example, policies relating to the maximum duration for which the harm-reduction may be prescribed – current policy (driven by PGI, Chandigarh) for example requires treating psychiatrists to offer only 14 day regimens at a time and insist that the patient to return for a new prescription every two weeks. Psychiatrists that have violated these guidelines have even been meted out jail sentences and have been accused of profiteering.
Another idiosyncrasy    In 2018, after a spate of OD deaths, Deputy Commissioners of several districts banned the sale of syringes to anybody without prescription.
Indian Express described it as a ‘breathtakingly disastrous order’ putting persons with addiction at increased risk of HIV and Hepatitis-C (Indian Express, July 8, 2018). The order was withdrawn after some experts pointed out that many countries supply free syringes in addiction prone areas.

         The state government does not keep a record of OD deaths, because every such death is a reminder that addictions which the politicians had promised to eradicate are still very much out there.
Still Another idiosyncrasy.
We know that persons who inject heroin usually do so in twos or threes and in remote places to avoid being seen. Till some years back, such cases were rushed by their friends to the nearest hospital and many youngsters were saved.
However, in 2018, the government started arresting the persons with whom the deceased was using drugs and charging them with culpable homicide. Since then whenever a user appears to be too sick, his friends run away because of the fear of arrest, leaving their friend to die. Nobody has explained the rationale of this counter-intuitive move.
On the positive side, there are some green shoots. The health minister, who is a doctor, has hinted at a new drug policy .
He has also promised that he will work towards implementing sections of the NDPS act under which drug users caught with small quantities can be diverted out of the criminal justice system.
Two senior politicians have demanded legalization of opium and poppy husk.

And I have heard that even the five years old SOP is being modified to make it evidence based.

On that cautiously positive note, I conclude.

Thank you for your attention.