Addicted to substitute drugs: the unexpected turn in the opioid crisis for India

Balkar Singh, a 35 year old farmer in Jalandhar, Punjab, takes his buprenorphine-naloxone tablet every day at 8 am. Taken sublingually, the prescription pill delivers 2 mg of synthetic opium, ensuring that Singh—whose name has been changed to protect his privacy—doesn’t feel like injecting himself with heroin, the opioid he was addicted to for more than four years.

Singh hasn’t taken heroin for five years. He gets his buprenorphine free from the nearest state run outpatient opioid assisted treatment clinic. Punjab has 529 such clinics, as well as 36 addiction treatment centres and 19 rehab centres, to tackle opioid abuse.

In 2022, 21% of the 681 deaths in India1 from drug overdose happened in Punjab. The north western state also has some of the highest rates of opioid use and dependency in India. Whereas the national average is 2.06%, in Punjab 9.69% of the population use opioids while the number of people with opioid dependence is 1.28%.2 (The government differentiates between people using opioids and those who are harmfully using opioids, with the latter considered dependent on the substance.)

Since the state introduced buprenorphine opioid substitution therapy through outpatient clinics in 2017, more and more of those who were previously addicted, like Singh, have been able to resume their lives.

But the easy availability of buprenorphine is a double edged sword. Punjab is also seeing an increasing number of people misusing the drug.

“In the past few years we’ve seen more people with an addiction to opioids who are dependent on buprenorphine,” Neeru Bala, professor and head of the department of psychiatry at Government Medical College, Amritsar, told The BMJ. “While this is an expected outcome of the …