Situation of Homelessness and Substance Use in India and the Impact of COVID-19 Pandemic

INTRODUCTION

Availability of safe and comfortable shelter is one of the elementary human needs essential for both an individual’s survival as well as social development. However, even in the 21st century, about one fifth of the world’s population lives in inadequate housing conditions and more than 100 million are estimated to be homeless (United Nations Economic Commission for Europe (UNECE), 2021). Although a global phenomenon, most of the burden of homelessness is observed in densely populated urban areas of developing countries. India, the world’s second most populous country, has a sizeable number of homeless individuals estimated to be about 1.77 million (Census 2011, Government of India). However, some non-governmental organizations estimate the number to be much higher (Housing and Land Rights Network (HLRN), 2016). It is estimated that an additional 68 million people live in urban slums. There has been some improvement in the situation over the last 2 decades. Between 2001 and 2011, share of houseless population declined from 0.19% to 0.15% of the population (Census 2011, Government of India).

Homeless and slum populations constitute and extremely vulnerable group for a variety of adverse health conditions and social challenges. One of these adverse outcomes is the high vulnerability to substance use and addictions. Several studies and population surveys, conducted mostly in developed countries, have consistently demonstrated very high rates of substance use and substance use disorders among homeless populations (Rosenthal et al., 2008; North et al., 2010; Rhoades et al., 2011). Use of almost all categories of substances – Alcohol, Heroin, Cannabis, Cocaine and Methamphetamine – has been reported to be much higher among homeless population than in the general community. The increased prevalence of use, coupled with limited access to addiction treatment services, renders homeless individuals at a much higher risk of health and social consequences of addiction.

RELATIONSHIP BETWEEN SUBSTANCE USE AND HOMELESSNESS

A substantial body of work has directed its attention towards understanding the nature and direction of relationship between high prevalence of substance use disorders and homelessness. Studies have identified younger age of onset of substance use, addiction to alcohol and illicit drugs, poly-substance use, poverty and presence of a comorbid psychiatric condition as independent predictors of homelessness among patients with substance use disorders (Fountain et al., 2003; Early, 2004; Johnson and Chamberlain, 2008). Similarly, among homeless individuals, younger age, dropping out of school, long duration of homelessness, having a drug-using peer or sex-partner, negative coping practices, sex work and having comorbid depression have been found to be associated with increased risk of substance use (Lowe & Gibson, 2011; Torchalla et al., 2011; Upshur et al., 2017). These studies also point towards certain common underlying factors such as poverty, poor coping skills, etc. which can increase risk of both substance use and homelessness in a given individual. It appears that substance use and homelessness share a complex bidirectional relationship wherein certain risk factors increase risk for both the conditions while substance use and homelessness themselves increase the likelihood of each other.

Despite a large homeless population and the enormity of substance use problem, the issue of drug addiction and homelessness has garnered extremely limited research attention in India. There is only one unpublished scientific study on prevalence of substance use among homeless but the study was limited to one site (New Delhi), small sample size (100 individuals) and was conducted only among men (Ilam B, 2021). The study reported alcohol, cannabis and opioid use among homeless men to be 76%, 27% and 13% respectively which is about 3-5 times higher than in general population (27%, 5%, 4% respectively among males). It is difficult to extrapolate the findings of this study to the entire homeless population of a large and diverse country like India. Moreover, data on prevalence and pattern of substance use among homeless women is completely missing.

SERVICES FOR HOMELESS POPULATIONS IN INDIA

Considering the large population of homeless individuals in the country, a number of central and state supported schemes have been rolled out over the years. The flagship programme of the Government of India is called the Deen Dayal Antyodaya Yojna being implemented under the National Urban Livelihoods Mission (National portal of India, 2022). The scheme includes 5 key elements – a) employment through skill training and placement, b) social mobilization and institution development which includes formation of self-help groups for training members and hand holding, c) loans and interest subsidies to urban poor for setting up individual and group micro-enterprises, d) shelters homes for urban homeless, and e) special projects for the rag-pickers and differently-abled.

In urban areas, shelter services are available at designated shelter homes mostly managed by non-governmental organizations which provide free-of-charge night stay. However, most of these shelter homes do not have provision of either nutritional support or health services which are sometimes arranged by the NGOs themselves through linkages or donations. Despite an increase in availability of shelter services across the country due to these schemes, several challenges persist. A nation-wide review of shelter services conducted in 2019 revealed that only about 12% of urban homeless have access to a shelter home, around half of them do not have access to any health services, only 18% could avail subsidized ration through the public distribution system (Indo-Global Social Service Society (IGSSS) Survey, 2020).

Unsurprisingly, the schemes for homeless populations place no emphasis on mental health and substance use disorders which are common among this population. In New Delhi, All India Institute of Medical Sciences (AIIMS) is implementing a model project in an underserved area of the city since 2017. Under this project, the National Drug Dependence Treatment Centre (NDDTC) of AIIMS is offering free treatment services for substance use disorders for homeless drug users from a shelter home facility being managed by an NGO and supported by the Government of Delhi. This collaboration between a central academic institution, civil society and state government is harnessing existing resources to provide evidence-based treatment, shelter, nutritional support and outreach services to a vulnerable and hard-to-reach population and has enrolled more than 1600 homeless drug users so far. To address the barriers in treatment seeking faced by street drug users, NDDTC (AIIMS) started the Mobile Methadone Dispensing Clinic in 2019, a first of its kind initiative in Asia. The mobile clinic van has designated halt points along a route which takes about 4 hours every day. A team of a nurse, counsellor and social worker provides free-of-charge clinical assessment and dispenses methadone to patients with opioid dependence. The van was extremely crucial in maintain continuity of care to street populations during the lockdowns imposed due to the COVID-19 pandemic.

IMPACT OF COVID-19 PANDEMIC ON HOMELESSNESS AND POVERTY

Over the last 2 years, the world has been in the grip of the COVID-19 pandemic which has adversely impacted almost all aspects of our lives. In India, the more than 40 million individuals have been infected during the pandemic and more than 500,000 lives have been lost. The harsh lockdown measures taken to combat the epidemic have led to economic hardship for a large proportion of the population across the world. However, the poorer sections of the society have been disproportionally affected by these measures as lockdown brought immense economic distress causing many migrant workers to lose livelihood and shelter.

During the pandemic, a number of initiatives were taken by the government to support homeless populations which included – a) opening emergency temporary night shelters in public service and community buildings and unoccupied residential facilities, b) screening for COVID in shelter homes, c) provision of ration for poor families. However, despite best efforts, a number of challenges were faced with regards to adequate spacing and social distancing, privacy, managing special needs of women and children and ventilation. While it was an extremely difficult period for the poorer sections of the country, the covid relief package of Government of India which included free rations through the public distribution system seemed to have made a significant impact as the prevalence of extreme poverty in India remained at a low level of less than 1% in 2020 (Bhalla et al, 2022).

IMPACT OF COVID-19 PANDEMIC ON SUBSTANCE USE AND ACCESS TO TREATMENT

Globally, the impact of the pandemic on availability and use of substances is unclear. According to the World Drug Report, 2020, some countries have seen an increase in the use of illicit drugs over the course the pandemic (UNODC, 2020). However, a systematic review of scientific studies found the findings to be heterogenous (Roberts et al., 2021). Another study conducted in 7 European countries using waste-water analysis which examined impact of stay-at-home orders on stimulant and cannabis use could not identify a clear pattern of change (European Monitoring Centre for Drugs and Drug Addiction (EMCDDA), 2022). The International Society of Addiction Medicine carried out global online surveys among addiction professionals regarding the availability, use pattern and treatment access for alcohol and illicit drugs during the pandemic(Farhoudian et al., 2021). The overall impression of the professionals was that there has been a substantial reduction in availability of illicit drugs during the pandemic and a consequent increase in use of alcohol, prescription opioids and cannabis. The professionals also reported disruptions and in some cases discontinuation of addiction treatment and hard reduction services during the pandemic and issues in availability of medications for treatment of substance use disorders.

In India, nation-wide lockdowns were imposed during the pandemic which included shutting down of liquor shops, pubs, bars and restaurants which in effect resulted in a sudden imposition of a state of prohibition across the entire country. However, soon the supply of alcohol got restored through illicit channels which resulted in increase in prices and transition towards high concentration alcoholic beverages. Although it was expected that the trafficking of heroin into India, which happens mainly through the country's western borders, would slow down due to travel restrictions, the illicit drug markets operated largely as before and opioids were available almost at the same prices as before (Pandit et al., 2020). The impact of these changes in availability and price of substances on prevalence and patterns of alcohol and drug use are yet unclear.

During the pandemic, difficulties in accessing addiction treatment services started being reported due to the travel restrictions imposed by the government. In response, the Government revised the treatment guidelines for substance use disorders and dispensing procedures for psychotropic medicines and permitted longer duration of take-away dosages and less-frequent need for follow-up at the clinics. A reduction in threshold for entry into treatment was also allowed and some of the medications were also permitted to be prescribed through tele-consultations (Ambekar et al., 2021). However, it is likely that despite these measures, many patients faced substantial difficulties in seeking treatment primarily on account of the travel restrictions imposed during the initial period of the pandemic.

CONCLUSION

Homelessness is a significant social, developmental and health challenge in a rapidly urbanizing country like India. Homeless populations are extremely vulnerable to variety of adverse health conditions particularly substance use disorders and often lack access to quality treatment. During the last 2 years, the COVID-19 pandemic has only worsened this vulnerability due to its disproportionate economic impact on poorer sections within the society. Although, support and relief measures have been directed towards the homeless populations, much more needs to be done to truly mitigate the impact of the pandemic. While the impact of the pandemic on the availability of psychoactive substances is unclear at the moment, there have been changes in the pattern of substance use in the community. These changes in the nature and extent of substance use and treatment access due to the pandemic are poorly understood and need further scientific exploration.