After her husband died of an undiagnosed illness in the winter of 2011, Jigender Kaur, 45, from Dhanoa-Modey village in Attari district in Punjab, became completely dependent on her eight children and five grandchildren. She also became dependent on heroin.
Illicit drug use has spilled out of university campuses and private parties — Anmol Sarna, 21, was riding high on LSD the night he died of injuries in an upmarket south Delhi neighbourhood last week — to villages and mufassil towns across India.
Most drug users start with sniffing ink whiteners, cobbler’s glue and shoe polish, move to Iodex sandwiches, cannabis and opium before moving to injecting prescription opioid pharmaceuticals, such as buprenorphine, pentazocine and propoxyphene, which are illegally sold by chemists at five to 10 times the marked price, depending on the available supply and desperation of the customer.
Next comes heroin/smack, which most of the users start chasing but switch to injecting roughly in about a year, reports the UN Office of Drugs and Crime’s South Asia office. Injecting heroin or smack intravenously gives a rapid “rush” (within 7 to 8 seconds, compared to 5-8 minutes when taken as intramuscular injection, and 10 to 15 minutes when sniffed or smoked).
“If the supply is good, heroin costs `2,000/gram but if supply is low, it can go up to `6,000/gram,” says Taranbir Singh, 31, a heroin addict who lives in Amritsar works as a driver for a living. “The supply has been up over the past two weeks, there have been no police raids,” he says.
Kaur bypassed the traditional stages of addiction and started with injecting heroin. Her initial peddler was her teenage nephew. “After my husband’s death, I couldn’t sleep for weeks. My nephew offered to give me a shot, saying it’ll help me sleep. Initially, it did, so I started having it every night,” says Kaur, who lives with her husband’s family in their ancestral home near India-Pakistan border. And within weeks, she was addicted.
Smacking of trouble
The Class 4 dropout, with a tired face and blue nailpaint, was clueless about what she was getting into. “Everyone takes it, my nephews and their friends. I knew it was a nasha (intoxicant), what I didn’t know was that it was so addictive,” says Kaur, who’d not had anything stronger than tea in her life before she started injecting heroin.
She initially asked her seven married daughters and one son for money, but that dried up when they found out about her addiction. “I begged the neighbourhood boys to share their stash, sold possessions, and finally, my jewellery,” she said. “Someone told my daughter, who came and took me with her to Amritsar, where she said she’d get me cured,” says Kaur.
Kaur agreed and is now among the 774 injecting users registered for free treatment at the Opioid Substitution Therapy (OST) Centre at Government Medical College, Amritsar. Here, clients are given regulated medicines — methadone and buprenorphine — once daily to reduce craving and withdrawal and help them get off injecting street drugs.
Sharing injecting equipment puts IDUs at high risk of getting infected with HIV. Since most IDUs are young and sexually active, HIV infection rapidly spreads from drug injecting networks to the community.
“There are an estimated 177,000 IDUs in India, with roughly a third of them living in the North-eastern states of Manipur, Nagaland, Mizoram, etc. Over the past decade, pockets have emerged in Punjab, Delhi, Kerala and West Bengal and, more recently, in Uttar Pradesh, Bihar, Chhattisgarh, Madhya Pradesh and Odisha,” says Lov Verma, secretary, Department of AIDS Control that runs the National AIDS Control Programme (NACP), which runs 130 such centres across India. Since drug use is illegal and stigma is high, it’s a challenge to persuade people to come forward for harm-reduction treatments.
Among injecting opioid users, OST substantially reduces injecting and, with it, risk of infections such as HIV that causes AIDS, hepatitis B&C, etc. In some cases, the dependence to the drug stops completely, but it takes two years or more.
“The medicines are legally controlled due to their abuse potential and are available only at strictly-controlled government-run substitution treatment centres,” says Rana Ranbir Singh, nodal officer, psychiatry and de-addiction centre, Civil Hospital, Tarn Taran, where 501 active clients have been registered in 22 months, making it among the busiest OST centres in India.
Adult HIV prevalence in the general population is a 0.27%, but prevalence among IDUs is almost 30 times higher. Compared to 2.67% HIV prevalence in female sex workers, prevalence among IDUs is 7.14%, second only to 8.82% among transgenders (hijras). Pushing up the national average with the highest HIV prevalence among IDUs are Punjab (21%) and Delhi (18%).
The NACP made OST a part of its “harm-reduction strategy” for injecting-drug users in 2008, and currently has 13,000 drug users registered for treatment its 130 centres across 28 states and UTs. Globally, 70 countries use OST for de-addiction. “The NACP’s target is to offer treatment to at least one in five injecting users, for which 350 OST centres are needed in 175 high-priority districts with high injecting drug use and established HIV epidemics,” says Verma.
The treatment is free and offered to all injecting drug users who walk into the OST Centre, which is open 24x7. Before starting treatment, IDUs are assessed by a doctor and a counsellor to establish the need and dosage. The treatment involves a doctor or nurse putting powdered buprenorphine or methadone under the client’s tongue, where it is kept till the powder dissolves fully in about 5 minutes, after which they can leave.
The centre maintains detailed records of the doses and when needed, and counsellors speak to patients and their families to ensure there is a supportive environment. The treatment usually lasts for one to two years but may continue for longer. Clients are also guided about treatment for sexually-transmitted diseases, HIV testing and, if needed, anti-retroviral therapy to treat AIDS and other medical services needed during the treatment.
“OST stabilises the drug users, both physically and psychologically, and helps them think coherently and function normally. OST reduces crime rates, improving the quality of life and lowers socio-economic consequences of drug use,” says Alok Agarwal, programme officer, targeted interventions, National AIDS Control Organisation.
What’s most worrying, say doctors, is the sudden increase in heroin addiction over the past year. “Two decades ago, opium was popular, and next came cannabis and opioid injections. Over the past year, heroin and smack have started flooding the market, my patients tell me, and are available at street corners,” says Dr PD Garg, head, department of psychiatry, Government Medical College, Amritsar.
“Heroin addiction is tough to beat as detoxification alone doesn’t work. The craving persists for several months after detox, which explains why relapse is common even months after treatment,” he adds.
Property-dealer Tej Pal Singh, 40, got addicted simply because he grew up with illicit drugs traded like groceries around his Tarn Taran home. It started with opium when he was a teenager. “My father was an addict, and he sent me to get it for him when I was old enough to go out alone. I tried it and liked it, and by 18 I needed it every day,” he calls.
He moved to injecting buprenorphine when he was 21. “A friend owned a pharmacy, so getting it at cost price was never a problem,” he says. Next came heroin. His wife of 14 years, Amarjeet Kaur, 32, finally convinced him to go for OST because she doesn’t want her two sons to grow up with drugs around their home. “He’s been on OST for six months, but sometimes lapses back to heroin when he’s with friends. When he’s not having drugs because he’s calmer and less aggressive,” she says.
Each morning, Tej Pal is among the dozen-odd patients waiting outside the locked door of the OST centre at Tarn Taran to get their daily dose before going to work. “Those with jobs prefer to stop by on their way to work, but some others hang around use the clinic as a clubhouse where they can meet friends, watch television and swap experiences,” says Rana Ranbir Singh. Some, like Satnam Malhotra, 28, (see box) end up hanging around because they want to avoid their druggie friends.
Unlike in Tarn Taran, clients drop in all through the day at the OST Centre at the Urban Shelter Home in New Delhi’s Kotla Mubarakpur, which is across the road from the swish south Delhi neighbourhood of Defence Colony. Many of the 750 injecting users registered at the NGO SPYM-run centre are homeless and migrants, but some are residents of the surrounding urban village that has been engulfed and forgotten by the rapidly expanding city.
Rishi Pal, 64, is a caterer who doesn’t mind walking through a pile of rotting garbage and rain-filled potholes to reach the Urban Shelter for his dose each morning.
“I’ve tried everything, cannabis, opium, injecting painkillers, heroin, smack…,” he says with quiet pride. “I decided to quit three years ago when I realised I got no respect, not even from my children.” Less than two years on treatment, Pal is halfway down the path to full recovery: he started with 12 mg of buprenorphine and is now down to 6 mg. He plans to be free of dependence by the end of the year.
But injecting continues in the park just across the garbage dump by the Shelter Home gate. Hidden behind a broken wall is a “hotspot” where a Class 8 dropout Girish Badana, 19, and his friends meet to shoot up whatever they get their hands on. Badana moved to Delhi from Faridabad to live with his grandma three years ago and since then, picks pockets to buy cannabis and pharmaceutical drugs.
He lies easily and says he’s taking medicines to get de-addicted, and gets his ears boxed for lying by his disapproving grandma, Daulat Devi, 65. “But I will, soon,” he promises her with a winning smile, before jumping over the wall to say hello to a tripping friend.
“I don’t think I’m going to last out the year. I can feel death and weakness in every move I take. The eclipse of bad health is nearly complete. My lungs rale and wheeze through the night. I am breathless on waking. My first half an hour is spent coughing up the settled phlegm in my chest and smoking cigars to replace it. I feel tired all the time.
"Not physically tired, but a tiredness that hangs in my face and has a physical weight. I’ve started getting piercing headaches and have a weird second heartbeat in the extreme left side of my chest. Every so often, twice a day, my entire chest will cramp from the middle as if some force is trying to pull my breast plate apart. My feet are brown from over 10,000 injections per foot and bad circulation. My ankles and shins swell up after each fix.
"If I pick a scab I scar. Stairs almost kill me. I can manage no more than a flight without getting out of breath. And it’s been like that for a while, but now I’m starting to feel really ill with it: old ill, like I’m an old man. If I have to predict how I’ll go I’ll say my heart will give out. I do believe I’ll die alone in this room in France and will not be found for at least a week. I never wanted to die and I never wanted to hurt myself. I only ever wanted to tame the pain and be happy. I am happy. That’s the contradiction.
"I was never really sad anyway. I guess when you’re young and feel so strong and offended by death that you think you can do just about anything and get away with it. Nothing effects youth but time. Then one day, suddenly, the stitching’s all undone. My only hope now is that I really am a hypochondriac.”
(From “Memoires of a Heroinhead”, a blog by artist/writer Shane Levene, 39, who lives in France and describes his profession as “shitting on publishers’ desks”. He started using drugs by the age of 14 and was a heroin and crack addict by 24.)
I can eat now and I get into fewer fights: Gurdeep Singh, 35
Pooja Singh, 12, laughs out loud as her grandma describes she found her father one morning asleep hugging a lamp-post. She, like everyone in her family and neighbourhood, knows her father Gurdeep Singh injects illicit drugs.
She knows it makes her mother cry. She also knows when he’s not taking them because there are fewer fights at home. Abusing drugs for 11 years has taken its toll. Singh is frail and looks a lot older than he is. He started with opium at 24, and had graduated to injecting by his 27 birthday. “I’m a Sikh, I never smoked,” he says with some pride.
He decided to quit after a very bad trip from injecting smack. “After the rush, my arms and feet started tingling, and then my whole body felt as if it was being sucked in, violently, painfully. Then I blacked out,”he recalls. That was in December last year. Singh, who lives with his parents in Amritsar, is on OST since January 11, 2013. “I can eat now, I get into fewer fights,” says Singh. “He doesn’t beat his wife now,” nods his mother Satnam Kaur, 58 .
Because of the stigma, women are tougher to reach: Satnam Malhotra, 28
Malhotra wears her hair short and dresses up like a man, more out of necessity than choice. “It’s safer and makes it easier to buy drugs,” she says.
Now that she’s been regular at the drop-in OST centre at Tarn Taran for three months, she’s trying to grow out her hair and has even bought make-up. “I wish I knew you were coming today, I’d have worn better clothes,” she says wistfully.
Malhotra is the youngest of five married sisters and a brother, who moved out of home to live with her eldest sister after their father, a mechanic, died of TB five years ago. When her mother died within six months, she was suddenly alone in their home above commercial shops her family rented out.
That’s when trouble started. “I worked as a cashier’s assistant at the Tarn Taran City Council, earned Rs 4,500 a month and rode a bike. I bought clothes four times a month and looked a lot better. I had lots of friends, mostly affluent girls in college,” she recalls.
So when one of them suggested they all hang out at her home, she agreed. “They came over, injected buprenorphine and watched porn. I knew about alcohol, not drugs. I asked them what it was, they said it was medicine that made them happy,” said Malhotra.
When she tried avoiding them, her friends started stopping by at her workplace. They even bought her a cellphone to make it easier to be in touch. Within weeks, Malhotra was injecting alprax, and next came shooting 5-7 gm of propoxyphene daily. She started missing work and soon lost her job. “I started heroin a year ago and became a wreck. I couldn’t break away,” she says.
Malhotra first came to the OST Centre at Civil Hospital Tarn Taran scrounging for heroin. “ I couldn’t get drugs anywhere and had severe withdrawal. My head was pounding, my legs didn’t work, I was dripping sweat. Then I recalled someone saying a lot of junkies hang around the hospital, so I came here hoping one of them could give me some,” she says.
Instead of drugs, she found hope. “A junkie I met promised to give me some, but only after I meet Rana sir,” she says.
Malhotra has been drug free for three months.
“Now I send the girls away. My cellphone got stolen so they bought me a new one. I haven’t activated it because I don’t want to be in touch with them,” says Malhotra.
Rana Ranbir Singh, nodal officer of the OST centre, hopes she will. “I’m hoping she persuades her friends to come here. Because of the stigma, women are tougher to reach,” he says.