Drug abuse is rampant in Manipur, and adults, particularly women, have little to look forward to after rehabilitation.

BEING poor is bad enough. To be a woman, destitute and caught in the midst of strong ethnic identities and some three dozen separatist movements, is even worse. That is the situation in which many women find themselves in parts of Manipur, which see frequent road blockades and have a large police and military presence. Caught in this unending vortex of poverty and violence, some of them become intravenous drug users and sex workers.

In a State with a high level of unemployment, the odds are especially high against women who are breadwinners and single mothers. With round-the-clock rehabilitation and detoxification measures either unavailable easily or expensive, many young men and women throng to the drop-in centres run by non-governmental organisations (NGOs). As complete abstinence is improbable, given the constant supply of drugs, NGOs and government departments now stress on harm reduction. It is estimated that at least 10 per cent of the new human immunodeficiency virus (HIV) infections are attributed to substance abuse through injections. Most drug prevention programmes have tended to address the risks to men, but with a growing population of young female drug users, increasing attention is now being paid to them.

Heroin, called Number 4 on the list of opiate derivatives, is apparently easily accessible in Manipur. The areas where it is normally available, peddled and used are called hot spots, where sex is also sold, often to pay for the substance. Located in congested residential and commercial areas, often in terribly insanitary and potentially unsafe conditions, these hot spots are known to everyone concerned. The drop-in centres are often located right in the midst of such spots, making it convenient for the users to avail themselves of clean disposable syringes and to access OST (Oral Substitution Therapy). These centres also offer counselling for those who want it. Interestingly, former substance users, called peer educators, rather than preachy NGO activists or government officials, encourage addicts either to join an OST programme or give up drug use completely.

A media visit organised by the Centre for Advocacy and Research revealed just how complicated the entire issue was. It cannot be resolved without a significant government intervention, backed by NGOs. Motivation alone is not enough for voluntary work; decent remuneration is also necessary. Most peer educators do not earn enough.

Some NGOs based in Imphal, such as Orchid, aver that the use of alcohol and drugs like opium and, to an extent, marijuana, is traditional in the region. Opium cultivation is not uncommon in certain areas. Illicit injections of morphine began in the 1970s. A founder member of Orchid recalled how her mother, formerly a nurse in a hospital, used to wonder how morphine ampoules and syringes regularly disappeared from the store. Heroin use exploded on the scene in the 1980s. One gram of heroin cost around $2. The shift from smoking and chasing to injecting began around this time and sharing, a common way of bonding among the youth, evolved gradually. Heroin became the most commonly injected drug. Not only did drug dependence become widespread but the frequency of usage also went up. Ingenious ways of using opium derivatives were explored.

Spasmoproxyvon (SP), an opioid used in caesarean deliveries in the form of an analgesic, was increasingly used in the liquid form by substance abusers. It was first dissolved in water and then injected by the users. Now banned only in Manipur, it is still very much in demand and available in the black market.

Intravenous drug users became the target for the collective frustration of almost every section of society, including some of the so-called underground groups. Those who have witnessed the early reactions to substance abusers said that there was a lot of vigilantism by so-called civil-society groups, which led to ostracism and public humiliation of and even physical attacks on the users. Caught in the quagmire of civil and ethnic conflict, there was little anyone could do for this growing category of drug users, who were young people.

Oral Substitution Therapy, or Opioid Substitution Therapy, is now being offered to many drug users, including women. Here the stress is on reducing the harm to the user and yet ensuring that the person leads a somewhat functional life. OST involves replacing the illicit drug with a drug that comprises prescribed medicines such as methadone or buprenorphine and is administered orally in supervised clinical settings. Psychosocial interventions are also part of the treatment package.

The reach of OST is limited as of now. According to documentation made available by the Centre For Advocacy and Research, only 8 per cent of the drug users have access to OST globally, and the access is skewed in favour of the developed bloc. Around 90 per cent of the drug users in the United Kingdom and 60 per cent in Australia receive OST; in India, the figure is around 3 per cent. OST was introduced in 2006 in Manipur and Nagaland through a private donor agency, but it was funded by the National Aids Control Organisation only in 2008. Though 40,000 injecting drug users were to be reached by 2011, current estimates indicate that only 10,000 have been covered under the programme.

Apart from the medical part of the treatment, which aims to wean the subjects off drug use completely, the organisations working among the affected population distribute syringes for safe injection and contraceptives. This is to contain the spread of acquired immune deficiency syndrome (AIDS) and other sexually transmitted diseases. But they are aware that this alone may not be enough to deal with the more systemic causes of the problem. Apart from an addict being identified and shunned by society and deemed unfit for any occupation, prolonged drug use through the intravenous route creates complications such as painful abscesses where the injections are taken.

Dr R.K. Lenin Singh, an Assistant Professor of Psychiatry at the Regional Institute of Medical Sciences, Imphal, explained how OST was successful in some parts of the State. Very few doctors are interested in substance abuse and treatment of dependence. Now medical science has proved that it is not a social problem but more a medical one and can be treated as such, he said. As OST is being made available as a medical treatment option, it is considered safer and purity-controlled and its side effects are minimal. But the target population is a large one. In the next one year, Project Orchid plans to target 6,400 intravenous drug users (IDUs) with the help of 11 NGO partners in seven of the nine districts in the State.

What is needed is greater government intervention in providing well-equipped facilities such as drop-in centres and alternative livelihood mechanisms to ensure that substance abuse as a whole comes down and that there is little or no relapse among the section undergoing treatment for social or other reasons. There are only a few drop-in centres now. Though many of them are located in commercial and residential areas, there is still a social stigma attached to them. At the moment, there is some tolerance towards this problem as wider sections of the community have come forward with more humane responses to the issue. But livelihood concerns dominate every discussion.

At the drop-in centre and shelter at Churachandpur district managed by the Society for HIV/AIDS and Lifeline Operations in Manipur, women drug users said they were desperately in need of livelihood options. The drop-in centres sometimes double as a night shelter for these women who have nowhere to go. But with limited resources, these centres are unable to offer them sustained livelihood opportunities and regular nutritional support. We give them tea and snacks, and counselling too, said Lalrualpuii Pachuan, the director of the organisation. She explained how many of the women were forced to take to sex work. There are only a few cases where women drug users are completely rehabilitated. Socially ostracised, harassed by almost every section of society, including sometimes the law enforcers and underground elements, these women live precariously.

The physical and sexual abuse of these women is very high. They've been thrown out by their families. We can't turn them away. Many of them have children too and they worry about them. The children are kept with their families, she said. Interestingly, the women themselves were able to articulate clearly what they wanted. Kim (name changed), a 34-year-old drug user, said how she got drawn into drugs through peer pressure. It began with smoking, chasing, drinking and then stealing to sustain my habit. I got overdosed and was hospitalised. It was then that my family got to know about it. I ran away to Imphal as they restricted my movements. I tested negative for HIV. It was then that I decided to do something with my life, and with some help, now I run a little shop, she said.

Another former drug user narrated how she took to sex work. After her husband died, she opened a liquor store to support her children. Gradually, she got addicted to drinking. She was thrown out by her family and began living on the streets. We cannot do hard labour any more. We would like to run some grocery stores collectively if possible. The government should help us in this, said one of the women at the Churachandpur shelter, and the others agreed. Puii said that while men were accepted by their families after rehabilitation, it was not easy for women to be accepted back. I shouldn't be saying this but they are like damaged goods, she said. Their needs are the same as that of male drug users. And like their male counterparts, most female IDUs are poor and so are their families. The average cost of detoxification is Rs.3,000 a month, which most drug users cannot afford. Petty crimes, therefore, are common.

Similar problems were echoed by the Social Awareness and Service Organisation located at Imphal. Run by a former group of drug users, SASO has emerged as one of the nodal points for those who want to give up drugs. Orphaned children and drug users, male and female, are part of the targeted interventions of this organisation.

But as it has emerged, it is easier said than done. There have been many cases of overdosing too, and naloxone, the life-saving drug to treat overdosing, is not available through any government programme. The enabling environment that involves access to treatment for hepatitis C or overdose cases, nutritional needs and even a sympathetic approach by the service providers is still absent, said SASO staff members. Drug users, some of whom were on OST, explained how the long economic blockade had affected livelihood opportunities.

There are other health issues. Dengue, malaria and tuberculosis are commonly occurring diseases. Young people have scant cheer in their lives, what with limited recreation and employment opportunities and the never-ending cycle of bandhs and blockades. Occasional breaks like the annual cultural Sangai festival (named after the endangered brow-antlered deer, unique only to Manipur), which was held recently, are welcomed wholeheartedly with all-round participation by the dominant ethnic groups in the State. However, a low intensity blast marred the last day of the festival, on November 30, on the eve of the Prime Minister's visit. Any semblance of normalcy is not quite allowed to last for long, and tranquillity, if any, is a transient feature.