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Avasthi A
Basu D
Subodh B N
Gupta PK
Malhotra N
Rani P
Sharma S
Substance use and dependence in the Union Territory of Chandigarh: Results of a household survey using a multistage stratified random sample
Ajit Avasthi1, Debasish Basu1, BN Subodh1, Pramod K Gupta2, Nidhi Malhotra1, Poonam Rani1, Sunil Sharma1
1 Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh, India
2 Department of Biostatistics, Postgraduate Institute of Medical Education and Research, Chandigarh, India
Date of Web Publication 6-Oct-2017
Background: Substance misuse is a global health and social problem with major adverse consequences. A number of regional studies on prevalence of substance use and dependence have been carried out in India; but methodologically robust data from Chandigarh are sparse.
Methodology: A house-to-house survey was carried out to estimate the prevalence of substance use and dependence in an adequate multistage-stratified random sample in the Union Territory (UT) of Chandigarh, using standardized instruments and predefined measures. Two thousand individuals (1000 each from urban and rural sites) from 743 households were interviewed.
Results: Lifetime use of any substance was reported in 21.26% households (8.01% of all respondents; 13.6% males and 1.01% females). Current use was reported in 6.55% of respondents. Prevalence rates of both lifetime and annual/current substance dependence were 2.96% (4.74% for males and 0.72% for females). Alcohol (6.72%) was the most common substance to be ever used by respondents, followed by tobacco (3.34%), opioids (0.17%), and hypnotics (0.04%). Lifetime dependence rates were found to be 1.76%, 2.28%, 0.04% and 0.17% for alcohol, tobacco, hypnotics, and opioids, respectively. None reported the use of cannabinoids, inhalants, or stimulants. Substance users were more likely to be married, employed, and in higher income group as compared to those who never used substance. Only 3.78% substance users had ever sought treatment for the same.
Conclusion: Substance use is prevalent in the UT of Chandigarh, with a higher prevalence in males. Substance users hardly ever seek treatment for substance use. This highlights the need of awareness and community-level services for the treatment of substance use disorders.
Keywords: Chandigarh, dependence, household survey, random sample, substance, substance use
Avasthi A, Basu D, Subodh B N, Gupta PK, Malhotra N, Rani P, Sharma S. Substance use and dependence in the Union Territory of Chandigarh: Results of a household survey using a multistage stratified random sample. Indian J Psychiatry 2017;59:275-83
Avasthi A, Basu D, Subodh B N, Gupta PK, Malhotra N, Rani P, Sharma S. Substance use and dependence in the Union Territory of Chandigarh: Results of a household survey using a multistage stratified random sample. Indian J Psychiatry [serial online] 2017 [cited 2020 Jan 19];59:275-83. Available from: http://www.indianjpsychiatry.org/text.asp?2017/59/3/275/216186
Substance misuse is a serious health problem affecting not only the individual but also the entire society. It is a matter of great concern given the fact that substance use has disruptive effects on physical and mental health as well as social and family relationships. The overall prevalence of substance use in India was reported to be 6.9 per 1000 in a meta-analysis done by Reddy and Chandrasekhar in 1998.[1] In the only multicomponent national level study done in our country, the current prevalence of substance use was found to be quite high, with that of alcohol being 21.4%, cannabis 3.0%, heroin 0.2%, opium 0.4%, and other opiates 0.1%.[2] However, the data for that study were collected in 2000–2001 and is now more than 15 years old. Various regional studies have been carried out all over India and the results are rather conflicting, thus, reflecting very high-regional variability in methodology as well as actual variability in substance use. Majority of the regional studies conducted talked about alcohol use and very few studies on other substances.[3]
In Chandigarh, data on substance use are very few and sparse. Varma et al., 1980,[4] reported the prevalence of current alcohol use to be 27.7% in Chandigarh. However, the study was conducted more than three decades ago and many changes have taken place in pattern of substance use since then with emergence of many new substances.[5] A community-based survey was carried out by Chavan et al., 2007,[6] about a decade back in Chandigarh, and the prevalence of substance dependence was found to be 6.88%. The results, however, cannot be generalized to the entire Union Territory (UT) of Chandigarh as it was done only in certain rural areas and urban slums of Chandigarh. In addition, these two studies had various methodological limitations. Varma et al., 1980,[4] had selected eight sectors using average plot size as the basis of sampling in case of urban area and selected three villages randomly for rural area, wherein they had further used systematic sampling. The study done by Chavan et al., 2007,[6] also employed systematic sampling and included every 10th household in five villages and five slum areas for survey. Both the studies thus did not have representative sample and robust methodology to yield a reliable estimate of substance use in the entire UT of Chandigarh. Conducting such a methodologically vigorous study is important because of the strategic importance of the UT of Chandigarh (Chandigarh being the capital of both the states of Punjab and Haryana) and because of the current concerns about substance use in both these neighboring states.
Thus, it was felt imperative to generate reliable data regarding the prevalence of substance use and dependence in the UT of Chandigarh, using sound methodological techniques.
This study was carried out as a pilot project to find the feasibility, explore the field conditions, and to test the research instruments for the ICMR funded project "Epidemiology of substance use and dependence in the state of Punjab." Ethical clearance was obtained from Institute Ethics Committee and written informed consent was obtained from the participants. The study was carried out in rural and urban areas of the UT of Chandigarh. We carried out door-to-door household survey and rapid assessment survey for direct and indirect estimation of substance use in Chandigarh. Due to the complexity of the study design, the household survey is discussed in detail in this paper while details of the rapid assessment survey will be presented in a separate paper.
Calculation of sample size
Since a representative prevalence estimate for the entire Chandigarh is not available and limited recent studies were undertaken on this subject, several conservative assumptions had to be adopted in the design process. These assumptions were at least 6.88% prevalence of ICD-10-defined dependence (not simply use or harmful use)[6] with relative precision of 20% and the design effect of around 1.5. With 95% confidence interval, the needed sample size came out to be 1950 eligible respondents based on the inclusion criteria mentioned above.
Sampling procedure
Multistage-stratified sampling technique was used for collection of data. In the first stage, entire population of the UT of Chandigarh was stratified into two strata: urban and rural. In second stage, wards and sectors were selected for enumeration. Further stratification was done based on probability proportionate to size method. In third stage, enumeration blocks and households were selected based on simple random sampling and from each enumeration block, individual households were selected using systematic random sampling. In fourth and final stage, sample was stratified into male and female in a 2:1 ratio.
The individual households for the survey were selected according to the following criteria: (a) they must be listed in the households census 2011; (b) they must be currently "active," i.e., people living in that household; and (c) there must be at least two eligible respondents (age 11–60 years) available for interview per household.
In each household, individual respondents were considered eligible for the survey if they were between 11 and 60 years of age, willing to participate in the survey, and able to be engaged in meaningful communication.
The following instruments were used in the household survey:
Household form (Form A)
This questionnaire includes basic questions on housing information and household composition.
Individual lifetime substance use screen (Form B).
The individual lifetime substance use screen (Form B) was administered to all members in the household within the age bracket of 11–60. This questionnaire includes socioeconomic characteristics of the individual such as education level, employment status and type of employment, marital status, and the individuals' general social behavior. It also includes screening questions to identify whether the individual has ever used a substance in lifetime. Those who were screened positive for "ever" using substances (alcohol, tobacco, cannabinoids, hypnotics, opioids, inhalants, stimulants, and others) were administered the next questionnaire (substance use questionnaire for household survey; Form C).
Substance use questionnaire for household survey (Form C)
The substance use questionnaire for household survey (Form C) included questions on different themes such as substance misuse and behavior and drug using network. It also included questions on problems associated with drug use such as social functioning, physical and mental health, and crime and offending behavior. Injecting drug use and high-risk behavior, treatment, support, and care are also themes included in the questionnaire.
Forms A, B, and C were developed and finalized through a rigorous process of review, compilation, and consultation. In the process of questionnaire design, exhaustive search has already been done for similar studies conducted in India and different parts of the world. In particular, the pro forma used for the benchmark UNODC National Survey was consulted, and additional categories added (e.g., for inhalants which were not studied in that survey but now constitutes a major problem).
ICD-10 symptom checklist for mental disorders, psychoactive substance use syndromes module (Janca et al., 1994; Form D), to elicit specific dependence criteria [7]
WHO alcohol, smoking, and substance involvement screening test to generate three categories of substance use involvement such as mild, moderate, and severe risk (Form E). In conjunction with Form D, this can categorize respondents to various levels of need for intervention (WHO, 2011)[8]
Information and consent form.
Definitions of study parameters
The key terms used in our study to characterize substance consumption patterns are as follows:
Lifetime use: Any use, even if only once, of a particular substance (not necessarily problematic use, harmful use, or dependence)
Annual use: Use in last 12 months
Current use: Use in last 30 days
Lifetime dependence: Dependence (as per ICD-10 criteria) on any substance in lifetime
Annual dependence: Dependence in last 12 months.
List of house numbers to be recruited was generated using multistage-stratified sampling technique and residents of households were contacted in a systematic manner. In each household, maximum of three respondents were recruited. Overall, residents were contacted in 852 households, of which consent to participate in the study was not provided by residents of 81 households. In such a case, next household number in the sampling list was contacted. Among the remaining 771 households, 39 households were found to be locked on first visit. On visiting the locked house again for maximum two more occasions, interviews could be conducted in 11 households. Twenty-eight households were declared locked after three visits, and in such a case, the next household in the sampling list was contacted. Thus, a total of 2000 respondents were recruited from 743 households. The details of the sample collection are shown in a flowchart [Figure 1].
Figure 1: Sample selection for the study according to Population Census 2011
To ensure quality, interviews were reconducted in 10% households by a separate team. Apart from those who had already reported substance use, only two more respondents reported lifetime use of alcohol during this resurvey. The margin of error was calculated for each parameter.
Two thousand respondents were enumerated in 743 households, 1000 each from rural and urban locality with male:female ratio being 1.9:1. Mean age of the respondents was 35.86 years with about 11% of the respondents belonging to the age group of 11–18 years. Most of the respondents were married (69.60%) and around half of them were employed.
Prevalence rates of substance use and dependence
Lifetime use of any substance was reported to be present in 21.26% households of the UT of Chandigarh and among 8.01% of the respondents with current use being present in 6.55% of respondents. The prevalence rates of lifetime and annual dependence on any substance were both found to be 2.96%. [Table 1] and [Figure 2]. The prevalence of lifetime use of substance was somewhat higher in urban areas (10.5%) as compared to rural areas (8%), but the difference was not statistically significant. The rates of substance dependence were almost equal in rural (3.2%) and urban areas (3.5%).
Table 1: Prevalence and pattern of any substance use and dependence in the union territory of chandigarh
Figure 2: Prevalence of substance use and dependence in the Union Territory of Chandigarh
[Table 2] shows the prevalence of use and dependence on specific substances. Alcohol (6.72%) was the most common substance to be ever used by respondents followed by tobacco (3.34%). The current use of alcohol was reported in 5.02% of respondents and tobacco in 3.21% respondents. Lifetime use of sedative-hypnotics and opioids was reported by 0.04% and 0.17% respondents, respectively, and the use was reported to be continuing in the last month too. Lifetime dependence rates were found to be 1.76%, 2.28%, 0.04% and 0.17% for alcohol, tobacco, hypnotics, and opioids, respectively. Annual dependence rates were almost similar to the lifetime dependence rates for the respective substances. None reported the use of cannabinoids, inhalants, or stimulants [Figure 3]. Among the total 4 opioid users, 2 reported use of injectable buprenorphine. Use of bhukki (poppy husk/poppy straw) and smack (street heroin) was reported by one respondent each.
Table 2: Prevalence and pattern of specific substance use and dependence in the union territory of chandigarh
Figure 3: Distribution of lifetime substance use and dependence according to substance type
As demonstrated in [Figure 4], the prevalence rate of ever use of any substance in male and female population was 13.60% and 1.01%, respectively. The prevalence of ever use of any substance was highest in the males belonging to the age group of 19–60 years (13.53%) and only one male reported the use of substance in the adolescent age group. Alcohol use was reported by 11.62% males and 0.57% females; alcohol dependence was present in 2.98% of males and 0.14% of females. About 13% of males in the age group of 19–60 years reported to have used alcohol, while none in the age group of 11–18 years reported to have used alcohol. For tobacco use, 5.43% males answered in affirmative and 3.52% were dependent on tobacco. In females, tobacco use was present in 0.72% and dependence was present in 0.72% respondents.
Figure 4: Distribution of lifetime substance use and dependence according to gender
Correlates of substance use
Age of substance users was significantly higher and they were more likely to be married, employed, and in higher income group as compared to those who never used substance. Mean years of education were significantly lower in substance users; no association was found between substance use and locality [Table 3]. In females, substance use was more common in older females in higher income group. When we compared the sociodemographic profile of male and female substance users, no significant difference was observed. The most common reason for starting substance use was reported to be fun (67.03%) followed by curiosity (52.43%). The substance users reported to be spending on average Rs. 239 on substance use and most of them reported to be spending their own money on substances. The most common source of illicit substance was reported to be a dealer (79.46%).
Table 3: Comparison of sociodemographic profile of substance users versus nonusers
Other important findings of the study
Mean age of start of substance
Mean age of start of any substance and tobacco was significantly higher in females; however, no difference was observed in mean age of start of alcohol between the two genders [Table 4].
Table 4: Mean age of start of substance use
Each substance user reported to know around 7 people who consumed some substance and 6 people who consumed similar substance. Number of males and females known by a person who consumed any substance were around 6 and 0.09, respectively. Further, details of network size of males and females are illustrated in [Figure 5].
Figure 5: Network size of substance users
Support seeking
Of those using alcohol, 11.53% had attempted to stop alcohol at some point of time; 8.97% had sought some kind of support. For tobacco users, these figures were 28.94% and 22.36%, respectively. Overall, only 7 (3.78%) respondents had actually sought treatment and only 2 respondents reported to have ever been admitted to a hospital for treatment of substance use.
In the present survey, lifetime substance use was present in 8.01% respondents while 6.55% respondents reported current use of substance. Although less than the national figures of National Survey on the extent, patterns, and trends of drug use in India,[1] these figures are in the range reported by regional studies done on epidemiology of substance use of India.[2] The prevalence rates are, however, much lower when compared with those reported from the neighboring state of Punjab.[9],[10],[11],[12] This may be explained by the difference in cultural, sociooccupational, secular, and normative backgrounds. However, more importantly, lifetime use of substance was reported to be present in as high as 21% of the households of Chandigarh.
The most commonly used substance as per the present survey was alcohol (6.72%) followed by tobacco (3.34%). A closer look at the prevalence figures reveals that 11.62% males reported to have used alcohol, and the prevalence of the same was even higher (13.34%) in males in age group of 19–60 years. The reported rates in Chandigarh are lower than the national level rates of alcohol use in men reported in NFHS-2 (17%) and NFHS-3 (less than one-third of men).[13],[14] However, since the regional variability is so high, it may be difficult to compare the figures with national average. The prevalence rate of alcohol use/abuse ranged from 167/1000–370/1000 in different regions according to a review.[3] High rates of alcohol use (27.7%) have been reported in a previous study done in Chandigarh, but the same was done nearly three decades back.[4] The difference in methodologies of two studies may have played a role in different results. In our survey, we have used multistage-stratified sampling and systematic sampling was done on the basis of probability proportion to population size. Therefore, it is possible that the prevalence rates of alcohol use in the current study reflect an actual low prevalence of alcohol use in Chandigarh. However, as known in such studies, the possibility of underreporting cannot be ruled out.
Opioids were reported to be used by 0.17% respondents in the current study. Although slightly less, these figures are comparable with the national figures.[1] Among the total 4 opioid users, 2 reported use of injectable buprenorphine. Use of bhukki and smack was reported by one respondent each. Interestingly, all the opioid users reported to have been taking the substance in dependent manner. Similar rate of dependence on opioids was also reported in the previous study in Chandigarh.[6]
In the present survey, no respondent reported the use of cannabinoids, inhalants, or stimulants in the present survey. Stigma associated with substance use might have played a role in the same.
The prevalence of substance dependence in our survey was 2.96%, with that in rural and urban areas being 3.20% and 3.50%, respectively. The prevalence in rural areas in our study is comparable to prevalence rate of 3.12% reported previously in rural areas in Chandigarh.[6] The same study had reported the overall prevalence of substance used to be 6.88% and that in urban slums to be 10.7%.[6] This difference in prevalence rates can be explained by the fact that the population studied was different for the two studies. Dependence rates for alcohol and tobacco were found to be 1.76% and 2.28%, respectively, in the present survey in the entire population, and 3.06% and 3.52% specifically in males for the respective substances. The difference in methodology in the two studies might also have contributed to the difference in rates of substance dependence.[5],[6]
One interesting finding noted in our study is the emergence of substance use in females in Chandigarh. To the best of our knowledge, this is the first general population study to show the use of substance in females in Chandigarh. The prevalence of substance use in females was 1.01% and 0.72% of females were dependent on substance. As expected, the prevalence rates were lower in females as compared to males, which are in keeping with the previous studies.[13],[14],[15] Given the huge stigma attached with female substance use, it is imperative that special case finding strategies are used in the future studies.
Each substance user reported that they knew around 7 people who consumed some substance and 6 people who consumed similar substance. Number of males and females known by a person who consumed any substance were around 6 and 0.09, respectively. As expected, network size of females was lower (4.6) as compared to males (7.28). However, interestingly, females tended to know more females (0.8) who used substance as compared to males who reported to know only 0.09 females with substance use. To the best of our knowledge, previous studies have not looked into this aspect.
Mean age of first use of substance in our survey was 21.1 (standard deviation: 4.10) years. This is comparable to other studies.[3],[6] Furthermore, it was seen in our survey that mean age of start of any substance was higher in females compared to males and it was statistically significant (t = 2.790; P = 0.006). The age of onset of tobacco use too was significantly higher in females compared to males (t = 3.340; P = 0.001). Previously also a higher age of onset has been reported in females.[3],[16],[17] The age of onset of substance in females was less compared to previous hospital-based studies.[16],[17] This indicates that the age of onset of substance use in females might be coming down over the years. However, this finding needs to be replicated in future studies.[3]
Another important finding in our study is that age of onset of alcohol is earlier compared to tobacco in females. This finding may be due to increased awareness about harmful effects of tobacco, or it may reflect more liberal views about drinking alcohol. This finding too needs to be replicated in the future studies.
There was not much difference in the age of onset of alcohol in males and females in our study. This may be an isolated finding and future studies are needed for generalization of the results.
In the present survey, sociodemographic factors had some significant associations with substance use. Substance users were more likely to be married, employed, and in higher income group as compared to those who never used substance. However, mean years of education were found to be lower in substance users. Sociodemographic factors have been found to be important in substance use epidemiology previously as well.[18] Medhi et al.[19] reported low levels of education in substance users in tea industry of Assam. Varshney et al.[20] recently reported that the odds of substance use decreases with increasing education. In line with our survey, Chaturvedi et al.[18] also reported that substance use is higher in employed and married individuals. Significantly higher relapse episodes have also been associated with increasing age, married individuals, poor literacy, and current unemployment.[21] An association between substance use and occupation and income has been reported by other studies as well.[22],[23],[24],[25] The commonly cited reasons for starting substance use were for fun, curiosity, and peer pressure. Some of these factors have been found to be associated with start of substance use in earlier studies as well.[26],[27]
It was disappointing to learn that only around 4% of substance users had sought treatment for the problem of substance use. It highlights the importance of initiatives to raise awareness of problems associated with substance use and the availability of effective treatments.
The survey had a few limitations. The methodology used was that of a house-to-house survey. This methodology has inherent problems in estimating the rates of a stigmatizing condition like substance use although maximal efforts were spent to ensure privacy and anonymity of the respondents. More than the use of licit substances (alcohol and tobacco), there are high chances of underreporting use of illicit substances in such household survey design. Moreover, the type of households and localities selected could have influenced the estimated prevalence rates although due care was taken to make the sample as randomly representative of the population as possible, as detailed in the methodology section. In addition, hidden populations such as street children, prisoners, and those not on the census (e.g., the homeless) were not assessed by this method. Thus, there is a need for a companion study using a supplementary methodology for hidden population, such as respondent-driven sampling. This is addressed in the companion paper.[29]
As per the current study findings, 21% households of the UT of Chandigarh have at least one substance user. Lifetime substance use was present in 8.01% and current use in 6.55% residents of Chandigarh. Almost 3% residents of Chandigarh use substances in a dependent pattern, the dependence rates being 4.74% in males and 0.72% in females. The mean age of first experiment with substances (most commonly alcohol) is around 21 years despite the legal drinking age being 25 in the Chandigarh UT.[28] Most commonly used substances in Chandigarh are alcohol and tobacco though sedative-hypnotics and opioids are also being used. Substance users are more likely to be married, employed, and in higher income group as compared to those who do not use substance.
Despite the availability of healthcare facilities for treatment of substance use in Chandigarh, only about 4% substance users had ever sought treatment for the same. This highlights the need of awareness and community-level services for the treatment of substance use.
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Avasthi A, Basu D, Subodh BN, Gupta PK, Malhotra N, Rani P, et al. Patternand prevalence of substance use and dependence in the Union Territory of Chandigarh: Results of a rapid assessment survey. Indian J Psychiatry 2017;59:284-92.
[Full text]
Debasish Basu
Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh
DOI: 10.4103/psychiatry.IndianJPsychiatry_326_16
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