In the absence of a comprehensive strategy, Uttar Pradesh could face a Punjab like crisis.
There are tell tale signs that injecting drug use has crept into cities and villages of Uttar Pradesh.
A privately owned ber orchard, tucked away in Attrauli tehsil in Aligarh district, western Uttar Pradesh, has needle syringes and paraphernalia lying around. Apart from the fruiting season in winter, the orchard would be desolate and neglected.
It soon became a hotspot for drug users in the area.
To prevent this, the orchard owner and family members have now made it a part of their daily routine to take a quick round of their land.
"I have beat people up. I have hit them with sticks. It's an everyday affair. You can see them in the afternoons or the evenings. When they see us, they run away. We can't keep a look out on the entire area," says Ajmat, a resident of Attrauli.
A kilometer away, 40-year-old Deepak Nagaich, the son of a farmer, is one of the faces of injecting drug use. He began injecting pharmaceutical drugs nearly 15 years ago. Along with other users he went to hotspots or to agricultural fields nearby to escape notice.
His mother Savitri says Mr Deepak started using drugs when he failed to get into the police force like his brothers. She said, "He was obsessed by his failure. He secretly started using drugs. Someone told him it would cure him of his insomnia."
Mr Deepak is clean of drugs for over a year now and is employed as a driver. But it has been a difficult journey. His life was out of control. He was losing weight, and was in poor health. At home, he was stealing anything he could lay his hands on to feed his addiction.
A little away from the busy Ramghat street in Aligarh district is another hotspot for drug users.
24-year-old Kuldeep, who got married a month ago, suffered a relapse today after staying clean for three months.
"I do want to get de-addicted, but if the town doesn't have de-addiction centres what can I do?" Mr Kuldeep said.
According to him, there are nearly a thousand drug users in this area. The numbers had increased.
It is no coincidence that the hotspot is close to chemist stores.
"There is illegal sale of pharmaceutical drugs. If you or I go, the chemists will not sell the drugs to us. But regulars face no problem," Mr Deepak said.
A number of injecting drug users share needle syringes, leading to the spread of HIV. According to the latest NACO data, injecting drug users are the principal drivers of the HIV epidemic.The HIV prevalence at the national level was 9.9 per cent among injecting drug users compared to 4.3 per cent among men who have sex with men, another high risk group.
Injecting drug users in Uttar Pradesh need the skills, means and information to prevent HIV transmission.
40-year-old Munish Chand, who is a tailor, has been injecting drugs for over a decade. He wants to access government treatment services but none exist in Aligarh. There are only a handful of government treatment centres in the entire state. Mr Munish cannot afford the nearly Rs one lakh required at private treatment centres in Lucknow and Delhi. Drugs has taken a heavy toll on his family. His wife and young children work in a factory to sustain their lives.
A visit to Uchan mohalla, a working class neighbourhood in the district, exposes a terrible secret. Injecting drug use over the last decade has brought death and destruction in its wake.
40-year-old Mukesh, worked as a cook in a sweet shop. He died nine years ago, leaving behind three children.
"He would spend whatever I earned. My employer would give me clothes to wear. He would not even spare my clothes and would sell them," his wife Saroj Devi said.
30-year-old Saroj Devi was married for five years and had three children. Her husband was just 24 when he died. According to her, he injected, used smack and bhaang. He abused drugs all day and did not work.
She works as an agricultural labourer now and says her family often goes to bed hungry.
"Sometimes you get work for 10 days in a month, sometimes for eight days. You have to live on the earnings for the entire month," she said.
Then there are mothers like Kashmiri Singh, who lost her 32-year-old son, who was a vendor, to drug abuse.
Ms Meena's husband is a rickshaw-puller. She has seen how injecting drug use led to two deaths in her family. First her brother in law and then her 20-year-old son.
The tragedy is that there is no support system for the families of victims. None of the widows are getting a widow's pension from the state government. These deaths have not been investigated and no one knows whether they were caused by HIV, Hepatitis C, or drug overdose.
While there is no comprehensive survey of drug use in Uttar Pradesh, an independent study conducted by YRG Centre, AIIMS and John Hopkins University has shown alarming trends. People who injected drugs at a site in a medium sized city like Kanpur had an HIV prevalence of 31 per cent. Access to needle syringe exchange and opioid substitution treatment were extremely low in Kanpur, and the rate of HIV testing was the lowest of all sites surveyed.
In Aligarh, the state government hospitals have yet to respond to the crisis. There is no dedicated deaddiction clinic and no harm reduction services.
Dr Arup Kumar Roy, Chief Medical Officer in Aligarh, said, "We don't have a psychiatric department. Physician have to handle these cases. We have a shortage of doctors. There should be data collection. In my opinion, drug addiction is increasing among the youth these days."
There is also no serious move to curb the illegal sale of pharmaceutical drugs by chemists. In the absence of a comprehensive strategy, Uttar Pradesh could face a Punjab like crisis.
In Punjab, politicians, activists, experts and filmmakers have spoken about Punjab's drug problem. Now, schoolchildren in Lopoke in rural Amritsar tell us what they see in their village.
17-year-old Amritpal, a student of Shaheed Bhagat Singh Memorial School, said, "Our village, Lailpur, has 18, 19-year-olds using smack."
His classmate Manish adds, "They use drugs and sell them as well. We have seen them sell while serving in the gurdwara. A new user is supplied drugs without payment for the first 15 days. This is how they get them addicted."
According to Pavandeep, "Using drugs is a fashion now. So many people are getting into it. When politicians come asking for votes, they offer drugs in return."
Like these schoolchildren, Sonu was 17 when he started using smack. He is now 30 and is still using drugs.
"I thank God that I am still alive. I know many 17 year olds who have died after using drugs for a year or two. About 20 per cent of drug users are dying every year. We are compelled to inject. If it costs Rs 1,000 to chase heroin, you can inject for Rs 200," he said.
At Kazi Kot in Tarn Taran district, we get a glimpse of a village ravaged by drugs. There are 100 odd users here, of them nearly 40 are still hidden. This group do not mind being identified. One of the members of the group is a woman named Satnam Malhotra. "I want to warn women to stay off drugs. You are rejected by everyone, even those close to you," she said.
Sucha Singh, who works as daily wage labourer, said, "I used to inject norphine. I did not use heroin as it was expensive while injections were cheap. Earlier I would get the injections for Rs 35 and now they cost about Rs 400."
A former shopkeeper, Mehanga Singh, said, "The government should shutdown the drug business. Its a major problem in Punjab."
Unable to afford heroin and its painful withdrawal symptoms, these injecting drug users opted for opioid substitution therapy or OST, provided at the Tarn Taran civil hospital a few kilometres away.
It is a harm reduction strategy as clients keep off injecting drugs, reducing the risk of blood borne diseases like HIV and Hepatitis C, of abscesses and drug overdose. Tablets of buprenorphine are crushed and placed under the tongue as a once daily dose. The dose is supervised as clients could divert the tablets and inject them.
Dr Rana Ranbir Singh, consultant psychiatrist at the Tarn Taran civil hospital, said, "We are providing them with patient friendly services. They watch TV and play cards. They also get group counselling on a number of topics like tobacco use, HIV, HCV, safer sexual practices, safer injecting practices."
He says the optimal dose of OST or buprenorphine is important to curb any cravings.
Many people gradually reduce the dose and go off drugs. Others stay on buprenorphine long-term, but may not inject.
Balra Pal Sahib, a resident of Kazi Kot village, said, "They should open more OST centres. I tell them that if I can leave drugs at my age, so can they. I have improved my life and have got remarried as well."
Anecdotal evidence suggests that over the past year heroin has become expensive and difficult to source, indicating better policing of Punjab's borders.
The government has been effective in cutting off heroin supply. Yet experts warn of a danger of the possibility of users shifting to injecting pharmaceutical drugs. To counter this, the government has to scale up services and increase the number of supervised sites.
People who use drugs want more OST centres and that services be extended to those who take opioids orally.
Currently OST sevices are provided by the National Aids Control Organisation only for people who inject drugs.
There are about 28 OST centres in 15 districts. 600 clients visit the centre at Tarn Taran everyday.
There is need to create more awareness about these services. And for those clients who are unable to come daily, the centres should introduce a takeway dose of buprenorphine combined with another medicine naloxone. This combination reduces the risk of diversion by the client as it gives the effects of a withdrawal if injected.
"The government should start OST in a big way because this is the only successful treatment. It's done with the help of buprenorphine, which is a partial agonist, and the help of methadone, which is a full agonist of opium. These should be given in all the centers," says Dr Garg, Head of the Department of Psychiatry and Swami Vivekananda De-addiction Centre in Amritsar.
Dr Garg says the situation is worrying as about 40 per cent of injecting drug users are infected with Hepatitis C.
There is presently a dichotomy between the Centrally run OST centres and the Punjab Government's deaddiction and rehabilitation centres.
Harm reduction and rehabilitation are complementary strategies, and should be offered as a comprehensive package of services under the same roof. But this does not happen.
People who use drugs need multiple options. And they need different options at different times.
Some clients require vocational skills that make them employable.
Having a job helps to prevent relapses. Some need outpatient facilities so that they can continue to go to work.
The Punjab Government has created infrastructure by setting up rehabilitation centres in each district, but it has failed to connect to the needs of people using drugs. There are also reports of shortage of trained staff.
The centres look good. There is a prayer room, a library, a gym, yoga trainers and a tiled courtyard fit for a game of volleyball. The expenses are minimal, just Rs 50 a day.
Yet the 100 bedded rehabilitation centre in Amritsar has just one client. In Tarn Taran the 50 bedded centre has 20 clients. Most of these centers are either empty or have low occupancy. The Punjab government has invested crores of rupees in setting up brand new, shiny rehabilitation centers for drug users. But clearly, the programs offered by them will have to be tweaked because they have failed to attract the average drug user.
For now the rehabilitation centres seem to be empty monuments, built to placate voters.