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Prakat Karki
Aug 248 min read

A Commentary on the Socio-cultural aspects of Substance Use in India

The use and abuse of psychoactive drugs is one of the biggest public health concerns globally, and it leads to death, disability and range of other negative consequences. There are currently more than 2 billion people worldwide who regularly use some form of psychoactive drugs or mind altering substances (UNODP, 2022). Despite the negative effects of substance use being well known, people still continue using it for various reasons. In determining the causes or factors that lead to substance use, it is important to consider the influences at various levels of individual, family, community, etc. According to Bronfenbrenner’s (1979) social ecological model, any health behaviour such as substance use has a myriad of contributing factors at individual, interpersonal, community, organizational and policy levels; and it is important to consider each of those in the aetiology of substance use and addictions (Sudhinaraset et al., 2016). A summary of the various influences has been given in a figure below.



There has been a lot of research over the years on the aetiology, progression and treatment of substance use and addictions. There is huge evidence to suggest a significant biological basis of addictive behaviours, and substance use tends to aggregate in families (Kendler et al., 2012). However, genetic and neural markers are only one of the contributing factors and there are also influences from family, community and society. While biological structures and processes are comparable for most people worldwide, there are considerable differences in the social situations and lives of people. It is important to consider the socio cultural factors that either increase the risk for or build resilience against substance use behaviours. There is a lot of regional, national and cultural variations in the types of substances used, their influences and prevalence, and the way societies perceive and treat substance users and addicts. A lot of scientific research is conducted to document these different dynamics of substance use. In that regard, India has been an interesting niche in substance use.


          India is one of the fastest growing economies and also the second most populous worldwide. The use of various psychoactive substances has been deeply interwoven in the lives of different ethnic groups in the Indian subcontinent and at present, the most commonly used substances in India are tobacco, alcohol, cannabis and opium derivatives (Murthy et al., 2010; Ambekar et al., 2019). More than 270 million people use tobacco and 160 million use alcohol regularly, and the two account for the highest mortality and morbidity related to substances in India (Gajalakshmi & Kanimozhi, 2010; WHO, 2018). Alcohol and tobacco is legally sold in most places in India, which accounts for its high use. In terms of illicit substances, cannabis (31 million per year) and opioid (23 million) are the most common. There has been a culture of substance use for recreational, medicinal or religious reasons for centuries, and there are huge variations in substance use among the many religious, ethnic, and regional groups in India. In the sections below, some of these socio cultural related to substance use specific to India have been discussed.

           The Indian subcontinent has supported human settlements for thousands of years, and there have been a number of significant influences of migration, conquest by invaders, social reform, etc. which have shaped the Indian society today. Among the major religious groups of Hindus, Muslims, Silkhs, Jains and Christians, there are a number of norms related to substances which regulate their use. Alcohol is prohibited in Islam and its use among Indian Muslims is very low. A number of Hindu higher castes of Brahmins and Vaishyas also prohibit alcohol use (Sharma, 1996). Due to religious connotations, a number of states in India have continued to ban the sale of alcohol despite it being legal in the rest of the country. Similarly, tobacco is proscribed among Sikhs and thus its use is low. On the contrary, cannabis is regarded as a valuable medicinal herb in Hindu traditions and is used auspiciously in a number of Hindu festivals (Karki & Rangaswamy, 2022). Despite its illegal status, cannabis has widespread cultural acceptance. While alcohol use is low among Muslims, tobacco and opium use among them is more prevalent. Opium also has some historical and cultural significance to Hindu groups of Rajputs from Gujrat and Rajasthan (Charles et al., 2005). Otherwise, opium use is generally lower among Hindus and most groups, and is generally regionally bound (Chaturvedi & Mahanta, 2004). This shows that local customs, caste, religious rituals and traditions play a major role in promoting use of various substances or restricting its use in India (Sharma, 1996).


             Besides religion, there are a range of regional, economic and political factors that have determined the prevalence of substance use in India. At macro level, economic divide of the urban-rural regions and the various drug policies and measures have defined the various substance use sub cultures within India. Urban spaces in India have become highly westernized and the overall higher socio economic status in cities has meant that substance use patterns have become similar to other metros in the world with use of stimulants, methamphetamines, psychedelics, synthetic substances, etc. (Ambekar et al., 2019; Sharma, 1996). In urban places, there are more kinds of substances available, and most imported substances are also available in cities first. Despite restrictions in place, the use of substances has only increased over the years, and the uptake of substances among youths is a concerning aspect of the drug problem in India (Iqbal, 2020; Sunitha & Gururaj, 2014). There is also significant gender disparity in substance use with males making up most of the users, although the number of female users is also gradually increasing. This gender disparity also reflects the patriarchal systems that have defined most Indian communities as women are disadvantaged in education, occupation and public life (Lal et al., 2015). While substance use may be common across most communities in India, the type and nature of the substances might differ. For example, cannabis is mostly grown in the northern parts of the country, and the Northeast and Northwest borders are also the closest points for opium import. Not surprisingly, cannabis and opium use is higher among the Northern states than the Southern ones (Charles, 2001). Thus, other than religious factors, there are a host of regional, economic, political and sociocultural factors that determine use of various substances.




          Besides the socio cultural factors that lead to use of various substances, the same socio cultural factors also determine how substance use or addiction is perceived and treated. There is still a huge stigma towards ‘the addict’, or an individual dependent on substances. Scientific based treatments for substance use is still rare in India, and lack of general awareness about drugs has also meant that substance dependents are negatively perceived and discriminated in society (Panda et al., 2020; Sreenivasan et al., 2022). Traditional healing practices are still largely prevalent in treating addictions and families often play a huge role in treatment. For the lucky ones who do receive formal treatment, reasons related to family and community play a huge role compared to just personal reasons for quitting alcohol (Mehta et al., 2020). India is generally considered collectivistic and the huge significant role of family and community can have both helpful and detrimental effects in substance progression and treatment (Sarkar et al., 2016). The negative health consequences of substance use are still the most common reasons for approaching treatment; however, most treatment or rehabilitation facilities are limited to urban spaces (Patel et al., 2020). There is a huge treatment gap for substance use and it reflects the overall gap in medical infrastructure in the country where large parts of the rural areas are still outside coverage.


           The substance use problem in India is an endearing one and has a myriad of influences and contributing factors. It affects more than 300 million Indians and is probably the single most significant health behaviour contributing to tremendous economic, health and social costs every year. As described above, the issue is not a simple one, and the representations of substances at various religious, historical, traditional, medicinal and spiritual levels for Indians means that controlling its use is a tough task for the state. The Indian Government enacted the most stringent set of laws prohibiting most narcotics in 1985 with the Narcotic Drugs and Psychotropic Substances Act (NDPS); however since then, there have been no major efforts at curtailing the steadily growing rates of substance use. There are hardly any nationwide epidemiological studies on various substances, and the funding for scientific research on substance use is also abysmally poor. Subsequently, the treatment structure for substance use is also fragmented and out of reach for most citizens. Substance use remains a pressing public health issue in India, and one that warrants immediate and decisive steps. An obvious first step would be to systematically examine the various sociocultural influences to substance use in India and understand the roots better.

  

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