Prescription drugs and their ingredients, or “precursors”, are being increasingly diverted for recreational use in India – the largest manufacturer of generic drugs in the world as per the 2021 World Drug Report of the UN Office on Drugs and Crime.
In 2018, India amended its law to regulate the painkiller tramadol after being named a leading supplier in clandestine markets. The entire world’s annual seizures of the drug fell from 125 to 32 tonnes in a single year. But tramadol is only one of India’s growing drug problems.
India ranked among the 10 countries reporting the biggest opioid seizures in the world in 2019, the report said – India’s opium haul in 2019 was the fourth biggest in the world, and of morphine and heroin the seventh-largest.
But the diversion of pharmaceutical drugs and ingredients is a relatively new trend. Can this diversion be controlled without impacting their medical use? We investigate.
Existing opioid problem
Opioid use is rising in India, and users are increasingly turning from opium to its more potent, processed forms such as heroin, said a 2019 report by the Ministry of Social Justice and Empowerment. This is happening even as opioids remain inaccessible to patients with legitimate medical needs and as dependent individuals fail to receive treatment for substance use, the report further said.
There are two classes of opioids. One, naturally occurring opiates such as opium and its derivatives (doda/phukki/poppy husk and so on) and heroin, also referred to as brown sugar or smack. All these are mainly derived from the white gluey resin that oozes from the pod of a poppy plant.
The second class of opioids includes synthetic or semi-synthetic ones, such as tramadol or fentanyl. These “prescription opioids” are mostly prescribed for pain relief, and are illegally diverted for recreational purposes.
A recent report by the Drug Enforcement Agency of the United States implicated India in illegal fentanyl trade – including its clandestine manufacture and the shipping of its ingredients and “unregistered pill presses, stamps, and dies” via mail services to other countries.
Among all drugs, opioids are by far the leading cause of disability, show global data. Each year, since the 1990s, opioids have accounted for more than two-thirds of all disability-adjusted life years lost due to drug use disorders in India as well as the rest of the world, as per the data collected by the Institute for Health Metrics and Evaluation centre at Washington University. Disability-adjusted life years refers to the sum total of an individual’s healthy years lost to a cause – say, the lives cut short by opioid overdose or the decades spent out of the workforce due to substance use.
India lies sandwiched between two of the world’s “three key production areas” for opium, leading to an illicit drugs crisis. But cross-border trafficking holds only part of the explanation for the illicit drugs trade that runs through India, as we explain later.
Afghanistan, on India’s northwest, accounts for 85% of the global opium production. The political instability following repeated foreign interventions cemented its rise as a “narco-state”. More than 40% of Afghanistan’s agricultural land was dedicated to opium poppy cultivation in 2019, per UN Office on Drugs and Crime. This grew by a further 37% during 2020, according to the Afghanistan Opium Survey 2020 report.
There has also been a seven-fold increase in methamphetamine seizures in Afghanistan in 2019, suggesting the country is fast becoming “an increasingly diversified market of synthetic drugs”. Airstrikes on Taliban-controlled areas blew up dozens of methamphetamine laboratories in a single day in 2019, UN Office on Drugs and Crime reported. The withdrawal of US troops from the country may have important implications for the flow of drugs into India.
India’s pharmaceutical industry is “the largest provider of generic drugs globally”, as per the department of pharmaceuticals, Ministry of Chemicals and Fertilizers. But there have been reports of clandestine manufacturing and siphoning of synthetic drugs, as well as illicit trade in chemical precursors.
Consider tramadol, the painkiller. For medical purposes, it is usually prescribed as a slow-release drug that works over an extended period of time and the dosage does not exceed 400 mg per day. But when crushed and inhaled or injected at once, it can produce powerful feelings of euphoria. Non-medical use of the drug leads to physical dependence and has been linked to seizures, psychosis and overdose deaths.
In 2018, when India amended the Narcotic Drugs and Psychotropic Substances Act in 2018 to classify tramadol as a controlled psychotropic, the global annual seizure of the drug fell to 32 tonnes from 125 tonnes in 2017.
India’s regulation may have pushed tramadol to the position of the second-most seized pharmaceutical opioid in the world; from 2014 to 2018, it had accounted for nearly 66% of all pharmaceutical opioid seizures, year after year. The 2021 World Drug Report further states that India was the most frequently mentioned country of origin, departure and transit of tramadol during 2015-19.
However, India’s attempts to regulate the drug may not be entirely successful, said experts. “At the retail level, the availability of and access to tramadol does not appear to have changed much,” said Atul Ambekar, a professor at the National Drug Dependence Treatment Centre and the department of psychiatry at the All India Institute of Medical Sciences, New Delhi.
This could be because the classification of tramadol as a psychotropic drug under the Narcotic Drugs and Psychotropic Substances Act “would largely impact [only] the bigger level transactions of tramadol (say, the requirement of more stringent record-keeping at the level of manufacturers and suppliers)”, he said. This implies that people with tramadol dependence may still be able to access the drug.
However, a sizeable part of the illegal drugs trade relates to not prescription drugs but their ingredients–chemicals that serve as raw material for synthesising or “cooking” drugs as it is commonly called, reports show.
India has a “well-developed chemical industry, which produces substantial quantities of acetic anhydride [a heroin precursor]... [The] availability of ephedrine and pseudo-ephedrine [two methamphetamine precursors] in India is of grave concern to Indian law enforcement authorities,” noted a South Asia Regional Profile by UN Office on Drugs and Crime in 2005. The report also flagged “several cases of diversions of significant quantities of precursor chemicals”.
But a significant amendment to regulate the online trade in such chemicals only came after about 10 tons of acetic anhydride were seized in 2018 in India, as per a 2020 report by the International Narcotics Control Board. This was the biggest seizure of the heroin precursor since 2002, the report said.
Transnational criminal organisations operating in Mexico rely on imports of chemical precursors primarily from India and China to produce illicit methamphetamine, claimed a recent National Drug Threat Assessment report by the Drug Enforcement Administration of the US released in March.
Another of its reports released last January implicated India in fentanyl trade: “While Mexico and China are the primary source… India is emerging as a source for finished fentanyl powder and fentanyl precursor chemicals.”
In 2018, an Indore-based operation run by Indian and Chinese nationals became the first illicit fentanyl lab to be dismantled in India. This takedown happened due to US Drug Enforcement Agency’s intelligence, the report claimed.
The operation may have shifted from China to India due to the stronger Chinese regulation of fentanyl precursors such as 4-anilino-N-phenethyl-4-piperidine or ANPP and N-phenethyl-4-piperidone or NPP. “This may serve as an important precedent,” the report warned, before noting a seizure of 100 kg of NPP by Mumbai authorities in December 2018.
In 2018, India introduced new laws to regulate ANPP and NPP. But precursors, in general, pose a regulatory challenge as they have many legitimate scientific and medical uses. Moreover, they are usually sold through online markets or business-to-business listings, with little oversight, the UN Office on Drugs and Crime report noted.
Opioids are, as we said, the leading cause of health burden from drug use disorders, in terms of disability-adjusted life years, globally. They also contribute to illicit drug use and dependence in India.
An estimated 2.1% of India’s population aged 10 years to 75 years were engaged in illicit use of opioids, per the 2019 report by the Ministry of Social Justice and Empowerment. This is more than twice the prevalence rate of drug use worldwide (0.7%) and more than four times the Asian average (0.5%). However, the Indian prevalence rate is far lower than both the Asian and global average for other drugs, such as cannabis, cocaine and amphetamine-type stimulants.
Opioid use and dependence may be growing worse: fewer than 1% of men used opium, according to the 2004 National Health Survey. By 2018, the number had risen to around 4%.
But “obvious methodological differences and the overall approach” do not allow the comparison of 2004 and 2018 reports, said Ambekar, who is also the first author of the Ministry of Social Justice and Empowerment report. “There is certainly an increase, but it may not be five times,” he noted.
The challenges India faces in tackling drug trafficking and abuse are manifold.
By 2030, developing countries, “in particular in Africa, and, to a lesser extent, in Asia” are projected to undergo significant increases in urban and younger population–both profiles linked to increased drug use, the UN Office on Drugs and Crime has warned.
Meanwhile, heroin and opioid seizures in the Indian Ocean region have increased, as per the UN, suggesting emerging overseas trafficking routes. Indeed, in 2019, India reported a 157% rise in overseas heroin shipments from its south-west.
Also, India and China are the top departure locations of drug shipments on the dark web in Asia, UN Office on Drugs and Crime notes, though Asia and Africa as a whole lag behind America and Europe in this respect.
While steps must be taken to stop supply by tamping down on cross-border trafficking, imposing harsher penalties under the Narcotic Drugs and Psychotropic Substances Act, or improving drug enforcement, experts say India must also address the problem on the demand side.
People affected by drug use, or even at the risk of it, should receive evidence-based treatment. However, less than 25% of the people trying to quit drugs currently receive any treatment, the Ministry of Social Justice and Empowerment report observed. The two flagship de-addiction programmes operated by the government “hardly have any reach or coverage” and “only a miniscule proportion of people affected by alcohol or drug dependence” receive treatment from either, added the report.
“[N]one of these supply-side strategies will be effective if the demand is not addressed,” said Ambekar. The Home ministry noted in 2016 how high street prices of opiates (such as doda and phukki), thanks to drug law enforcement, was “making addicts shift to pharmaceutical preparations like Tramadol and Buprenorphene”.
However, tight opioid regulations must not restrict access to legitimate medical needs. Research shows that only a minority of individuals prescribed opioids for pain conditions develop addiction, said Ambekar.
“We in fact have severe opioid under-availability [‘malnutrition’, if you will]. Less than 5% of opioid painkiller needs are currently being met in India by some estimates,” he added. Palliative care advocates, in fact, warn that regulators often lose sight of patients’ medical pain in their drive for eliminating illicit trade in pharma drugs.
This article first appeared on IndiaSpend, a data-driven and public-interest journalism non-profit.