Emerging from the opioid abyss

9 min read
14 Jul 2017
9 min read
3062 words
Opioid addiction is a hell that many Nepali addicts are trapped in. To get them out of it will require a concerted effort from all quarters

In the summer of 2008, Tsering Sherpa put his life and limb at risk by jumping between buildings. He was trying to escape confinement, and ultimately reality--by finding succour in a drug-induced haze. "The prospect of falling face first into an alleyway below the buildings seemed less painful than going into rehab," says Sherpa. His parents had learned that he'd become a drug addict, and they had locked him up in his room. They had planned to send him to rehab upon unlocking his room, and he was making a run for it.

Before he'd become a slave to narcotics--which he started abusing after he began bonding with a wrong crowd of school-seniors--Sherpa had been a well-liked student. By 16, Sherpa was hooked on cannabis, codeine-containing cough syrups and nitrazepam tablets. By 19, he was hooked on brown sugar--the adulterated version of street heroin. By 22, he had been in and out of rehab three times already. And yet, he couldn't keep himself from plunging deeper into addiction, and a few years later, he was shooting up as often  as eight times a day. He had also moved on from brown sugar to a concoction made up of norphin, benzodiazepines and antihistamines--famously known among drug abusers here as the 'South Asian Cocktail'. 

According to the Narcotics Control Bureau (NCB), the number of drug abusers in Nepal shows no signs of decreasing. And according to a national drug survey that was conducted in 2012 by the Central Bureau of Statistics, there were already 91,534 'hard drug users' in the country back then. The hard drugs of preference among Nepali addicts are opioids and the South Asian Cocktail. Although there is no clear data on the number of deaths caused by opioid overdoses in Nepal, there is no doubt that opioid addiction remains a scary problem: globally, an estimated 69,000 people die from opioid overdoses each year, according to a 2014 World Health Organization report. In Nepal, the majority of opioid addicts use illicitly cultivated and manufactured heroin, and with the abuse of prescription opioids also on the rise, the opioid problem is starting to become scarily complicated. 

What are opioids?

It's not surprising that Tsering Sherpa acted in such a foolhardy manner to get 'one last shot to heaven' (as he puts it) before entering rehab: The lure of opioids can be that strong. And prolonged use of opioids can derail the lives of even the best of us. Opioids are a class of drugs that are derived from the opium poppy plant or are synthesised in the laboratory. In the health sector, opioids are used as painkillers because they reduce pain by switching off pain receptors in the brain. Opioids do this by inhibiting our pain receptors' pain signals, which are transmitted along multiple pathways--the brain, spinal cord and the peripheral nervous system. Opioids cause sedation and can even decrease the emotional responses made by the brain. The drugs make for strong analgesics--that is, for treating acute pain--because they attack pain from every neurological aspect. 

Humans have known about the analgesic effects of opium for millennia--even though until the 1970s, we couldn't explain why we had opioid receptors in our bodies. Because of how opioids behave in our nervous system, they also have mood-altering effects. As it turns out, we have a built-in endogenous analgesic system that modulates pain signals. Our central nervous system naturally produces endorphins (a contraction of the term 'endogenous morphine') in response to pain, but their production can also be triggered by various human activities. And when we use opioids, they create artificial endorphins in the brain--producing the high that drug addicts so love. Over time opioids can trick the brain of drug users into stopping the creation of endorphins naturally. At this point, the only way an opioid addict can experience positive feelings is by using drugs--this is the reason why opioids are so addictive. When the body stops producing its own endorphins, a person feels 'sick' and depressed whenever they are not taking opioids. 

Opioid addiction in Nepal

According to Dr Sagun Ballav Pant, a consultant psychiatrist at TU Teaching Hospital, who runs the de-addiction services at the hospital's Department of Psychiatry and Mental Health, most opioid addicts have underlying alienation issues or develop them once they turn drug users. And the Narcotics Control Bureau has found that people in the 15-24 age group are most susceptible to becoming addicts. What all this means is that places such as schools--where youths spend most of their formative years--are where they usually pick up a drug habit. Sherpa, who used to attend a government school in Sindhupalchok, represents the sort of user who develops behaviour problems brought about by drug use. Bikens Nembang, on the other hand, is representative of users with already existing problems that might have led them to resort to drugs in the first place. Thirty now, Nembang started abusing drugs when she was 18. She started out with marijuana and the occasional pharmaceutical pill because she wanted to find some excitement and an escape from her troubled life. Nembang's mom passed away when she was little, and ever since, she has had a complicated relationship with her father. To find some solace, Nembang found herself turning to drugs. By the time she was 20, drugs had become her only refuge. "It had become my safe place where I could escape from problems and not confront day-to-day life," she says. 

She has been in and out of detox six times altogether. "I had stopped loving myself by the age of 22," says Nembang. "And I was increasingly living only for the next fix." Luckily for her, Nembang's boyfriend, a former addict, intervened when she was hitting rock bottom. With her boyfriend's help and the special arrangements that he'd made, Nembang was sent to a rehab that usually took in only male drug users. "I consider myself fortunate that way," she says. "A close friend of mine, who was also a drug user, was in such a bad shape that she died from an untreated abscess." According to Nembang, many intravenous drug users are at increased risk of developing abscesses and other types of skin infections and inflammations. An abscess can lead to serious, potentially life-threatening complications if left untreated.

The rehab option

After long struggles, both Nembang and Sherpa have today emerged from their dark, destructive pasts of opioid addiction to lives that are fuller and more satisfying than the ones they had had before--they both run rehabs. Sherpa, who once needed opioids just to wake up in the morning, overcame his addiction after almost eight years of wrestling with the devil that is opioid addiction. "Opioid addicts are often treated by society as criminals and throwaways," says Sherpa, who is now the director for Aashraya Samuha, a drug and alcohol treatment centre in Sundarijal. To wean addicts at his rehab, he makes use of more effective methods than those employed by rehab centres in the past. The main reason he found recovery so difficult was that each rehabilitation programme he entered tried to rectify addiction-induced damage by relying only on an abstinence-based approach. "You can't just put an addict in a rehab and expect them to get over the addiction within a few days," he says. Sherpa suggests that rehab programmes should focus on rebuilding and restructuring the  abuser's entire self as they are healing. At Aashraya Samuha, under the supervision of Sherpa, in-patients are given proper care and attention to stabilise their conditions. A rehab stint typically lasts between three to six months. Sherpa promotes healthy living practices, together with counselling, to help the in-patients with recovery. The in-patients are encouraged to practice meditation and yoga every single day to counteract their negative, compulsive thoughts. Sherpa knows all too well how difficult the road to recovery can be--his body still quivers when he recalls the opioid-withdrawal symptoms he had to put up with. Opioid withdrawal symptoms can last anywhere from one week to one month. Users who've stopped using high doses of opioids can experience anxiety, insomnia and low-energy levels for a few months after they've quit. And there are also the bouts of agitation, muscle aches and sweating that they have to deal with.
Nembang, today, runs a rehab centre, the Grace Foundation, in Lalitpur, that takes in only female users. Both Sherpa and Nembang believe that rehabs, if run the right way, can help opioid users get back on their feet. 

Tsering Sherpa

Pharmaceutical opioids and other problems

According to the director of NCB, SSP Dhiru Basnyat, the use of pharmaceutical opioid drugs (which are mostly produced in India) has increased here in the past few years. Between 2016 through April 2017, the NCB seized many caches of pharmaceutical opioid drugs: 36,823 units of buprenorphine and 176,035 units of codeine. "The abuse of pharmaceutical opioids has emerged as a major problem in recent years," says Basnyat. "There is much to be done on the prescription-drug front." In Nepal, opioids such as codeine-based syrups, buprenorphine and morphine are supposed to be sold only with a prescription. But, says Basnyat, drug abusers can easily buy pharmaceutical opioids without a doctor's note. The NCB has found that many pharmacists are not even aware that certain opioids are being misused
as a drug. To combat this problem, the NCB has partnered with the Department of Drug Administration to improve pharmacovigilance: they routinely work with pharmacies to support drug-awareness and-control

According to the Narcotics Drug (Control) Act of 1976, no person is allowed to cultivate opium or produce opium in Nepal. However, says Basnyat, over the years, Nepal has slowly been emerging as a point of origin, with illicit cultivation being carried out in districts like Jhapa, Bara, Makwanpur, Dhading, Salyan and Jajarkot. Between 2011 to 2016, 53.5 kg of opium was seized in Nepal: That overall catch could have come from Nepali opium fields, Indian ones and those in the Golden Triangle (Thailand, Myanmar and Laos) and in the Golden Crescent (Afghanistan, Iran and Pakistan). India has been a source because of the porous Nepal-India border, and the triangles play a part because Nepal is a drug-transit country. Basnyat says various steps--strict surveillance, sensitisation and training of drug law enforcement--are being undertaken to enhance the enforcement capacity of the police to check drug smuggling. However, the cost of intelligence and the limited technical and human resources make it difficult for the NCB to check drug inflow into and distribution within Nepal. 

Changes in outlook

The Government of Nepal has ratified the two UN Conventions related to narcotic drugs, namely, the Single Convention on Narcotic Drugs, 1961 (as amended by the 1972 Protocol) and the United Nations Convention against Illicit Traffic in Narcotic Drugs and Psychotropic Substances, 1988. Similarly, the United Nations office on Drugs and Crime (UNODC) with the Government of Nepal implements a comprehensive package of services for drug users and HIV-positive drug users. As a part of these services, it supports organisations that provide clean syringes to users. "Drug trafficking is a crime, but drug addiction is not a criminal problem," says Basnyat. He says drug addiction is a victimless crime. In a country where drug addiction used to be viewed through the lens of criminal justice, such a change in outlook represents a sea change in how the police are starting to regard drug use and addiction. Basnyat says the most preferable intervention option would be to reduce demand by providing treatments like opioid-substitution therapy (OST). 

Nepal's OST programmes have been led by the Government of Nepal and Nepali civil society organisations, with support from international development partners. OST entails providing for users a medically safe, long-acting agonist licit medication--to wean them away from illicit drugs. The safer substitutions--such as methadone and buprenorphine--are prescribed by a medical doctor and administered under the supervision of a trained nurse or pharmacist. Dr Pant of Teaching Hospital also believes in the efficacy of OST. He further believes that OST  also reduces crimes associated with opioid use, besides their assisting opioid users in efficiently combating withdrawal symptoms.

DIGP Dhiru Basnyat

Drug addiction as a health problem

"In our society, addiction is still regarded as a criminal problem. It is still not viewed as a public-health problem," says Dr Pant. According to him, young individuals resort to drugs because they lack suitable emotional outlets and because they don't have counselling options available. "Individuals with impulsive borderline personality are more susceptible to falling into the trap of addiction," he adds. "People who suffer from borderline personality disorder have often experienced childhood trauma. And owing to the personalities they've developed as a consequence, they can easily get into the drug trap."

"Addiction is a complex process of the central nervous system that results from recurring drug intoxication and is moderated by genetic, developmental, experiential, psychological and environmental factors," says Dr Pant. "Because addiction often co-occurs with other psychological disorders, treatments need to be multidimensional too. Opioid addiction, in particular, is extremely difficult to overcome."

Dr. Sagun Ballav Pant

"When it comes to addiction, the focus now is still only on individual recovery," says Dr Pant. "However, it's time we started talking about social recovery too. The opposite of addiction is not merely sobriety:
it's also connection." Dr Pant says society and institutions have a role to play as well in ensuring that opioid addicts reintegrate into society.  

"Addiction is not only about chemical hooks; it is also about an individual's not being able to adapt to their environment," says Dr Pant. "We punish the drug abusers by shaming them or by disregarding their existence," says Dr Pant. "This further pushes the abusers to fall into the seemingly bottomless abyss of opioid addiction. Opioid addiction is treatable. But we all need to do our part to help addicts recover."

And recovery is attainable, say ex-users Sherpa and Nembang. But the best course of action, they concur, is to not try opioids in the first place. 

The severest stigma

According to The Formative Years: Pathways to Substance Abuse and The Mature Woman (1998), a study published by The National Center on Addiction and Substance Abuse at Columbia University, girls differ from boys regarding how they obtain drugs and regarding the offers they receive to use these substances. Girls are likelier to be offered drugs by a female acquaintance, a young female relative or a boyfriend. That finding holds true in Nepal too. "Many women are introduced to drugs by their boyfriends, spouse or other significant relationships, and drugs become a way to cement the connection," says Bikens Nembang. 

Of more than 91,000 drug users in the country, 6,330 are women, according to the Central Bureau of Statistics, Government of Nepal. But the number of women addicts is rising fast and has doubled since 2007. Even so, of the 163 rehab centres all over Nepal, there are only a few that are specifically targeted for female abusers. Most rehabilitation centres are largely developed around the needs of men. 

Nembang says rehab programmes must address the specific risks and consequences that women face when abusing drugs. Many women feel great hostility towards treatment, and they express shame and guilt about seeking rehab services. "Many families hide their daughter's addiction problem for fear of scaring off potential husbands for their daughters," says Nembang. Female addicts are also likely to have multiple sex partners--for there is a great risk of drug use overlapping with sex work. "There are drug abusers who are sex workers, and sex workers who abuse drugs," says Nembang. These women face increased risk of getting infected by diseases, including HIV and viral hepatitis. Barriers to accessing services are particularly pronounced for this population because of the stigma surrounding both drug use and sex work. Having faced all these problems herself, Nembang decided to open a rehabilitation centre for women in 2013. "My friends would have been alive if there had been enough rehabilitation centres for female addicts," she says. As of today, the Grace Foundation, the rehab opened by Nembang, has treated more than 200 female addicts.