Patterns and prevalence of opium use in rural Punjab (India)

Sections

Abstract
Introduction
Method
Operational definitions
Results
TABLE 1 Patterns of opium use and craving (Figures in parentheses indicate percentages)
TABLE 2 - Male opium users according to patterns and quantity of opium consumed over a 30-day period (Figures in parentheses indicate percentages)
TABLE 3: Use of opium and combination of opium with other substances (Figures in parentheses indicate percentages)
TABLE 4 Age at initiation to opium use (Figures in parentheses indicate the number of opium users)
TABLE 5 Age and opium use (in percentage) (Figures in parentheses indicate the number of respondents)
TABLE 6 Opium use and occupation (Fifures in parentheses indicate the number of respondents)
TABLE 7 Reasons for opium use (Figures in parentheses indicate the number of respondents)
TABLE 8 Opium use and religion (Figures in parentheses indicate the number of respondents)
TABLE 9 - Opium use and marital status (Figures in parentheses indicate the number of respondents)
TABLE 10 Opium use and education (Figures in parentheses indicate the number of respondents)
TABLE 11 Opium use and per capita income (Figures in parentheses indicate the number of respondents)
Discussion
Bibliography

Details

Author: D. MOHAN, N.K. SHARMA, K.R. SUNDARAM
Pages: 45 to 56
Creation Date: 1979/01/01

Patterns and prevalence of opium use in rural Punjab (India)

D. , and

D. MOHAN
Associate Professor and Head, Department of Psychiatry, All India Institute of Medical Sciences, New Delhi, India N.K. SHARMA
Senior Research Officer, Department of Psychiatry, All India Institute of Medical Sciences, New Delhi, India K.R. SUNDARAM
Assistant Professor, Department of Biostatistics, All India Institute of Medical Sciences, New Delhi, India

Abstract

A household survey of opium use was carried out in three districts of Punjab. Of the 1,400 randomly selected households, 1,276 were covered by the study. All members above the age of 15 years were individually interviewed. The survey included 2,064 men and 1,536 women. The percentage prevalence rate of opium use was 5.76, much higher among men than women. Because of the small number of women involved in opium use (0.5 per cent), the data on socio-demographic variables were analysed only for men. The male opium users were classified as past, experimental, regular and seasonal users, with 3.4, 0.8, 3.6 and 1.8 percentage prevalence rates respectively. The relationships between opium use and variables such as age, occupation, religion, education, marital status and per capita income are discussed as well as their implication on drug abuse control policy.

Introduction

Since very early times people on the Indo-Pakistan sub-continent have been known to use opium both as a mind-altering drug and as an analgesic (Dwarkanath, 1965; Kohli, 1966). Its preparations are part of the traditional as well as of the allopathic systems of medicine. It has also been an item of trade for centuries. In tune with the growing international awareness of its potential to produce dependence and in compliance with treaty obligations poppy cultivation has now been controlled for several decades.

No recent systematic studies have been published on the extent of opium use, the characteristics of users and the social circumstances under which it occurs; some authors reported on patient characteristics (Ahmed, 1967). According to the Indian press, opium use is rising among the young urban population, a contention which, curiously enough, was not borne out by a series of prevalence studies, where use of opium ranged from between 0 to 1 per cent (Expert Committee Report, 1978).

The objective of the present paper is to describe the patterns and prevalence of opium use in a general rural population, along with some of its socio-demographic correlates.

Method

The data reported here are based on a prevalence survey carried out in three districts of Punjab. Methodological details are reported elsewhere (Mohart et al., 1978).

Sampling: The survey was conducted in three districts of Punjab (Amritsar, Gurdaspur and Ferozepur). Two community development blocks 1 (CDB's) were randomly selected in each district, 2 and four villages within each of these blocks were chosen on a random basis. The households formed the basic unit of the sample. All households were listed in each of the villages. They were selected by a systematic sampling with a random start. In this way 1,400 selected households constituted the sample of the study. In fact, only 1,276 of them were covered, as the rest of the homes were found locked, their occupants being away. In each household all members above the age of 15 were personally interviewed and their replies recorded in a set of schedules, structured and pre-tested for this purpose. Complete confidentiality of response was ensured. The sample does not represent a complete cross-sectional coverage of the State of Punjab, but permits adequate comments and observations about opium use.

Operational definitions

Prevalence: The prevalence rate of opium use is the number of current users, per 100 individuals, covered by the interview.

Frequency of use: The term indicates the number of times an individual has used opium over the past year, or at any point of time preceding it. They were further classified into:

  1. Past users: Persons who had used opium at least once during their lifetime, but had not used it during the year preceding the survey.

  2. Current users: Those who had used opium at least once during the past year. They were sub-divided into:

  3. Experimental users who used opium at intervals exceeding one week (seven days);

  4. Seasonal users who took opium for a specific period (mostly during the harvesting/sowing season), ranging from 15 days to 3 months; use is discontinued during the rest of the year;

  5. Regular users who used opium at least once a week or several times a week, or on a daily basis and more than once a day;

  6. Persons dependent on opium were those who either spontaneously or when asked expressed a craving for opium.

1. Sub-divisions within a district defined for developmental purposes.

2. An administrative unit, covering approximately 100,000 individuals in a geographically defined area.

Results

Prevalence and patterns of opium use (table 1). As it appears from table 1, there was a very large proportion of non-users (90.4 per cent of men and 99.47 per cent of women). Opium was used by 5.76 per cent of the population. The period prevalence rate was much higher among men (6.2 per cent) compared to women (0.5 per cent). Among men, 6.2 per cent were current users and 3.4 per cent past users. Since the number of female users was so small, they were excluded from further analysis and presentation. Among male current users 74 (3.6 per cent) were regularly using opium, while 38 (1.8 per cent) took it seasonally and 16 (0.8 per cent) experimentally. Craving and inability to do without opium was expressed by 71 (95.9 per cent) of regular users and by only one seasonal user and none of the experimental users. Of the past users 11 (15.3 per cent) were still experiencing a craving for opium, while the majority did not.

Quantity of opium used over a 30-day period (table 2). Nearly half of the opium users (49.8 per cent) consumed up to 49 g over a 30-day period, the average daily use being 1.6 g taken in one or two separate doses. Less than 10 g of opium was consumed by 20.1 per cent of users; an equal number of users consumed from 10 to 24 g over a 30-day period. Of the users 17.6 per cent consumed from 25 to 74 g, while 3.5 per cent of them used from 75 to 99 g of opium. One hundred grams and more were consumed by 2.0 per cent of the users. The majority of those consuming 50 g of opium or more were regular users, and the rest past users. However regular users were also consuming smaller quantities of opium; 47.5 per cent used from 10 to 24 g and 73.7 per cent from 25 to 49 g. Experimental users consumed less than 50 g, while the consumption by seasonal users did not exceed 25 g. More than half of the past users (56.3 per cent) and 25.8 per cent of current users could not state the exact quantity of opium consumed over a 30-day period.

Use of opium and combination of opium use with other substances (table 3). Of the total users 15.1 per cent consumed opium alone, while more than half (54.8 per cent) consumed both alcohol and opium. A similar pattern was observed in all categories: past, seasonal, experimental and regular users. The next most common combination was opium, alcohol and tobacco, which was used by 16.6 per cent. A combination of opium with tobacco was seen in only 2.0 per cent; 2.5 per cent used opium in combination with cannabis. Opium was also used in combination with other substances, mostly analgesics (9.0 per cent).

TABLE 1 Patterns of opium use and craving (Figures in parentheses indicate percentages)

 

Pattern of use

 

Sex

Non user

Past user

Seasonal user

Experimental user

Regular user

Total

Men
1865 71 38 16 74 2064
  (90.4) (3.4) (1.8) (0.8) (3.6) (57.3)
Women
1528 1 1 3 3 1536
  (99.47) (0.07) (0.07) (0.19) (0.19) (42.7)
Total
3 393 72 39 19 77 3 600
  (94.3) (2.0) (1.1) (0.5) (2.1) (100.00)
Self assessed craving (males only) .
-
11 1
-
71 83
    (15.3) (2.6)   (95.9) (4.3)

TABLE 2 - Male opium users according to patterns and quantity of opium consumed over a 30-day period (Figures in parentheses indicate percentages)

 

Pattern of use

 

Quantity grams

Non user

Past user

Seasonal user

Experimental user

Regular user

Total

Less than 10
16 15 6 3 40  
  (40.0) (37.5) (15.0) (7.5) (20.1)  
10-24
7 12 2 19 40  
  (17.5) (30.0) (5.0) (47.5) (20.1)  
25-49
3
-
2 14 19  
  (15.8)   (10.5) (73.7) (9.6)  
50-74
3
-
-
13 16  
  (18.7)     (81.2) (8.0)  
75-99
1
-
-
6 7  
  (14.3)     (85.7) (3.5)  
100 and above
1
-
-
3 4  
  (25.0)     (75.0) (2.0)  
Quantity not
           
known
40 11 6 16 73  
  (56.3) (15.1) (8.2) (21.9) (36.6)  
Total
71 38 16 74 199  
  (35.7) (19.7) (8.0) (37.2) (100.0)  

TABLE 3: Use of opium and combination of opium with other substances (Figures in parentheses indicate percentages)

 

Pattern of use

 

Drug combination

Non user

Past user

Seasonal user

Experimental user

Regular user

Total

Opium alone
3 9 3 15 30  
  (4.2) (23.7) (18.7) (20.3) (15.1)  
Opium + alcohol
38 24 10 37 109  
  (53.6) (63.2) (62.6) (50.0) (54.8)  
Opium + tobacco
-
-
1 3 4  
      (6.2) (4.0) (2.0)  
Opium + tobacco
17 5
-
11 33  
  (23.9) (13.1)   (14.9) (16.6)  
Opium + cannabis
2
-
-
3 5  
  (2.8)     (4.1) (2.5)  
Opium + analgesics
11
-
2 5 18  
  (15.5)   (12.5) (6.7) (9.0)  
Total
71 38 16 74 199  
  (100.0) (100.0) (100.0) (100.0) (100.0)  

Age at initiation to opium use (table 4). A substantial number of users started taking opium between 15 and 24 years of age (26.2 per cent. Only 2.5 per cent started using it below the age of 15, and 5.5 per cent at the age of 40 years and above. Some persons (42.2 per cent) could not recall when they started opium use. About 10 per cent of the users had been using opium for over 30 years, about 25 per cent for more than 20 years, about 32 percent for more than 10 years and 56 per cent for more than 5 years.

Age and opium use (table 5). Opium use was significantly associated with age (P/0.001). The prevalence rate showed by and large a progressive rise with age in the total population of users. No significant differences were observed in seasonal and experimental users' prevalence rates between the three broad age groups. However, such differences were observed in past and regular users (P/0.001).

Opium use and occupation (table 6). Farmers and landless farm labourers constituted 64.5 per cent of opium users. Combined they accounted for 78.4 per cent of regular users, 89.5 per cent of seasonal users, 56.3 per cent of experimental users and 78.9 per cent of past users. The partitioned chi square test showed that prevalence rates of regular users (P/0.001) was significantly higher amongst farmers and farm labourers than in all other occupational groups.

TABLE 4 Age at initiation to opium use (Figures in parentheses indicate the number of opium users)

 

Pattern of use

 

At the time of the interview

Less then 10

10-14

15-19

20-24

25-30

30-39

Unknown

Total

15-19
-
-
25.0
-
-
-
-
75 2.0
                  (4)
20-29
2.8
-
25.0 27.8 8.4
-
-
36.0 18.1
                  (36)
30-39
-
-
5.7 17.1 17.1 11.4
-
48.7 17.6
                  (35)
40-49
2.8 2.8 5.7 11.4 5.7 28.6 8.6 34.4 17.6
                  (35)
50-59
-
-
2.6 21.1 10.5 18.4 2.6 44.8 19.1
                  (38)
60 & above
-
4.1 10.2 8.2 10.2 12.2 14.3 40.8 24.6
                  (49)
Unknown
-
-
-
-
-
-
-
100.0 1.0
                  (2)
Total
1.0 1.5 10.1 16.1 10.1 13.6 5.5 42.2
100%
  (2) (3) (20) (32) (20) (27) (11) (84) (199)

TABLE 5 Age and opium use (in percentage) (Figures in parentheses indicate the number of respondents)

 

Pattern of use

 

Age at time of interview

Non user

Past user

Seasonal user

Experimental user

Regular user

Total

15-19
98.5 0.7
-
0.4 0.4 13.6
            (281)
20-29
93.1 1.7 2.1 1.1 1.9 25.6
            (528)
30-39
90.6 2.7 1.9 0.5 4.3 17.9
            (3171)
40-49
88.0 3.8 2.0
-
6.2 14.1
            (291)
50-59
84.4 5.7 2.9 0.8 6.1 11.8
            (244)
60 and above
84.5 7.9 1.6 1.6 4.4 15.4
            (317)
Unknown
93.8
-
6.2
-
-
1.5
            (32)
Total
90.4 3.4 1.8 0.8 3.6 100.0
  (1865) (71) (38) (16) (74) (2064)

X [ 2] = 58.23; d.f. = 8; P = 0.001.

TABLE 6 Opium use and occupation (Fifures in parentheses indicate the number of respondents)

 

Pattern of use

 

Occupation

Non user

Past user

Seasonal user

Experimental user

Regular user

Total

Farmers
87.0 4.8 2.3 0.3 5.6 40.8
            (841)
Landless farm labourer
90.2 3.3 3.1 1.2 2.2 23.7
            (488)
Craftsmen
93.6 2.4
-
2.4 1.6 6.1
            (126)
Blue collar worker
88.4 2.3 2.3 2.3 4.7 2.1
            (43)
Clerk/Health workers
96.0
-
2.0
-
2.0 2.4
            (49)
Shopkeeper
93.7 1.8 0.9 1.9 2.7 5.3
            (110)
Ex-servicemen
94.6 3.6 1.8
-
-
2.7
            (56)
Dependants
89.3 5.4
-
1.3 4.0 3.6
            (75)
Others
98.4 1.1
-
-
0.5 8.8
            (182)
Unknown
93.6 1.1
-
1.1 4.2 4.5
            (94)
Total
(1865) (71) (38) (16) (74) (2064)

Regular use was however not confined only to men working as farmers amongst whom it was highest (5.6 per cent). Amongst blue collar workers there were 4.7 per cent and among dependants 4.0 per cent of regular users. The lowest percentage of regular use was seen in craftsmen (1.6 per cent).

Reason for use of opium (table 7). The commonest reason stated for use of opium was strain in agricultural work, especially harvesting and sowing (38.2 per cent). The second commonest reason was "inability to work" without opium (16.0 per cent). The other reasons varied between 2.0 per cent (family and social problems) and 9.0 per cent (to relieve physical fatigue). Those who did not give any specific reasons were 8.5 per cent and 12.5 per cent did not respond to this question. Among seasonal users, use was confined to the period of agricultural activity.

The most common reasons stated by regular users were "inability to work without opium" (37.8 per cent) and "to relieve fatigue" (18.9 per cent). Among experimental users health problems and inability to do normal work without opium were the most common reasons.

Opium use and religion (table 8). Religion was significantly associated with opium use (P/0.001). On applying the partitioned chi square test seasonal users and religion showed no significant association between Sikhs and other religions. Among regular and past users rates of use were significantly higher among Sikhs compared to other religions.

Opium use and marital status (table 9). A significant association was observed between marital status and opium use (P/0.001). Prevalence rates were highest among widowed and divorced persons in all categories except experimental users. Amongst the latter group the rate of use was higher among the married than the single persons. Regular and past user rates however differed significantly between unmarried and married men and unmarried and widowed.

TABLE 7 Reasons for opium use (Figures in parentheses indicate the number of respondents)

 

Pattern of use

 

Reasons

Past user

Seasonal user

Experimental user

Regular user

Total

1.
Harvesting and sowing
12.5 100 6 4.0 38.2
2.
For company's sake
11.8
--
6.3 2.7 5.5
3.
For health reasons
5.6
--
31.3 9.5 8.0
4.
Fatigue
4.2
--
6.37 18.9 9.0
5.
Unable to do normal work
2.0
--
12.5 37.8 16.0
6.
Family and social problems
1.4
--
--
4.0 2.0
7.
No specific reasons
9.9
--
12.5 10.8 8.5
8.
Unknown
18.8
--
18.8 12.2 12.5
 
Total
100.0 100.0 100.0 100.0 100.0
    (71) (38) (16) (74) (199)

TABLE 8 Opium use and religion (Figures in parentheses indicate the number of respondents)

 

Pattern of use

 

Religion

Non user

Past user

Seasonal user

Experimental user

Regular user

Total

Sikh
88.3 4.3 1.9 1.0 4.4 71.0
            (1466)
Hindu
94.7 1.3 2.1 1.0 1.7 22.5
            (464)
Others
98.1 1.9
--
--
--
5.2
            (108)
Unknown
96.2
--
--
--
3.8 1.3
            (26)
Total
90.4 3.4 1.8 0.8 3.6 100.0
  (1865) (71) (38) (16) (74) (2064)

X 2 = 26.53; 4 d.f., P = 0.001.

TABLE 9 - Opium use and marital status (Figures in parentheses indicate the number of respondents)

 

Pattern of use

 

Material status

Non user

Past user

Seasonal user

Experimental user

Regular user

Total

Unmarried
96.6 1.4 0.8 0.4 0.8 24.3
            (503)
Married
88.3 4.1 2.2 1.0 4.4 66.9
            (1 380)
Widowed/Divorced
86.3 6.4 2.7
--
4.6 5.3
            (109)
Unknown
91.7 1.4 1.4
--
5.5 3.5
            (72)
Total
90.4 3.4 1.8 0.8 3.6 100.0
  (1865) (71) (38) (16) (74) (2064)

X 2 = 34.35; 8 d.f.; P = 0.001.

Opium use and education (table 10). Education was significantly associated with opium use (P/0.001). Seasonal and regular user rates were lower in the literate, primary/middle school educated user groups than in the illiterate persons user group; in the matric and above group also use was significantly lower than in the illiterate group. In experimental users the rate of opium use was lower in the illiterate group compared with literate, primary and middle school educated groups.

Per capita income (PCI) and opium use (table 11). Prevalence rates of opium use were higher in the higher per capita income groups, but significantly so only in the past user group.

TABLE 10 Opium use and education (Figures in parentheses indicate the number of respondents)

 

Pattern of use

 

Education level

Non user

Past user

Seasonal user

Experimental user

Regular user

Total

Illiterate
87.5 4.3 2.3 0.5 4.9 51.3
            (1058)
Literate
88.4 4.3 1.2 2.4 3.7 7.9
            (164)
Primary
93.0 3.5 0.8 0.8 1.9 12.6
            (260)
Middle
95.3 1.7 0.4 1.3 1.3 11.2
            (231)
Matric and above
95.9 1.5 1.1 0.4 1.1 13.1
            (270)
Unknown
91.4 1.2
-
1.2 6.2 3.9
            (81)
Total
90.4 3.4 1.8 0.8 3.6 100.0
  (1865) (71) (38) (16) (74) (2064)

X 2 = 37.77; 8 d.f.; P = 0.001.

TABLE 11 Opium use and per capita income (Figures in parentheses indicate the number of respondents)

 

Pattern of use

 

Per capita income in Rs.

Non user

Past user

Seasonal user

Experimental user

Regular user

Total

Less than 20
82.8 3.4 3.4 6.9 3.4 1.4
            (29)
20-39
92.9 4.9 0.9
-
1.3 10.9
            (226)
40-99
91.3 2.3 1.8 0.6 4.0 46.4
            (957)
100-199
90.0 4.3 1.9 0.6 3.2 25.7
            (530)
200 and above
83.8 6.9 3.7 1.9 3.7 7.8
            (160)
Unknown
90.2 1.8 1.2 1.2 5.6 7.8
            (162)
Total
90.4 3.4 1.8 0.8 3.6
-
  (1865) (71) (38) (16) (74) (2064)

X 2 = 22.34; 12 d.f.; P = 0.05.

Opium use and family structure. No associations were observed between family structure and opium use.

Discussion

No comparable general population surveys have been published on the various parameters of opium use in India. The Narcotics Commissioner's estimates on the magnitude of the problem, contained in the Expert Committee's Report on Drug Abuse in India, are the only data available. But even according to the same source the problem was grossly underestimated (Expert Committee Report, 1978). Taking into account the limitations of the present survey, the total number of opium users estimated for Punjab at the time of the interviews was 38,566. This figure corresponds to almost half the total number of officially registered addicts indicated in the report for 1975. Likewise it should be noted that only six of all the current users covered by the survey were officially registered addicts.

Two points emerge in connexion with prevalence estimates: ( a) a fairly large proportion of individuals who are now past users must have given up opium use without any medical intervention; ( b) opium users may broadly be divided into regular, seasonal and experimental users. Seasonal users take opium only during a specific period for a specific purpose. This pattern of use has, to our knowledge, so far not been reported elsewhere.

The quantity of opium used had been stated to be 30 to 90 mg/day (Chopra and Chopra, 1965), or up to 240 mg/day for men in the age group 45-50, whose virility was on the wane. For individuals who presented themselves for treatment in Assam the quantity was stated to range from 2.5 g to 1.5 g/day (Ahmed, 1967). The average quantity found in this survey differed, and the data were interesting in as far as they threw a light on the correlation between quantity, tolerance and craving. Seasonal users took almost constant dosages and thus did not seem to develop tolerance. In fact, nearly half the current users consumed 1.6 g of opium per day on the average, and their dosage remained constant. Constant dosages were even observed in a considerable number of the regular users. There did seem to be a correlation between dosage and tolerance in a small number of those regular users (4.0 per cent) who took 100 g or more over a 30-day period. The fact that "self assessed" craving was reported by almost all the regular users at lower dosage levels suggests dependence of a psychological nature.

The balance of evidence would indicate that there is a tendency in rural populations to maintain reasonably constant dose levels. Whether cultural control mechanisms are involved or whether this tendency is due to the fact that raw plant material is used, rather than synthetic substances, remains a matter of speculation. Some authors support the cultural hypothesis (Chopra and Chopra, 1965).

Among regular and past users there was a significant association between age and opium consumption. Use progressively increased with age. This dovetails with the observation that a considerable number of opium users started taking it between 15 and 24 years of age. There were very few who started taking opium below the age of 15, and an even smaller number who started their opium use at 40 and above.

This interpretation has also to be viewed in the context of occupation together with reasons for use. Use was highest among farmers and landless farm labourers who work in the fields. The reasons most commonly given related in different ways to fatigue and the wish to increase working efficiency, especially during the harvesting and sowing seasons. It was the age group 15 to 24 years who, after Patterns and prevalence of opium use in rural Punjab 55 some education, carried out this kind of work. Use hence seemed to be closely related to the kind of work involved (i.e. heavy physical labour) and related issues, such as rains and other factors of agrarian life. The recreational aspect of opium use seemed to be much less pronounced, and the most common other reason seemed to be related to medical needs, where opium was probably used in conjunction with other analgesics. This would also account for the fact that some individuals started using opium at 40 or above.

Other significant associations of opium use were seen with variables such as religion, marital status, education and per capita income. Most of these were inter-related and some of them were independent of opium use. Sikhs formed the largest segment of the population and hence prevalence amongst them was high in all categories of users. As a religious group they are not supposed to smoke; hence use of other psychoactive substances is comparatively high, the most popular being alcohol, followed by opium. In fact they do not mind mixing alcohol with opium to get potentiating effects. With regard to marital status use was obviously higher among widowed/divorced persons when compared to other groups, suggesting again that the family exercises a restraining influence on drug use, irrespective of the type of family structure.

Education and per capita income have to be viewed as part of broader social changes taking place in India. More youngsters attend school nowadays than did in the past; as a consequence there tend to be more users also among persons educated up to varying levels; some of them leave school prematurely and take up work. The only negative aspect of the association with education is that in spite of education use has persisted. Similarly rise in per capita income is a general phenomenon in Punjab.

In conclusion there seems to be a higher prevalence of opium use in rural areas than officially estimated, although the percentage of non-users is fairly high amongst men and women. Use seems to be related to occupation as well as to some extent to the state of health. Use is mostly confined to men in the younger age groups. These broad observations are in agreement with what had earlier been reported by other authors (Chopra, 1972; Kohli, 1966) who claimed that due to adequate control in India of opium poppy cultivation, the number of addicts was limited. The present study however suggests that, though control measures may be adequate, considerable amounts of opium are still available-from cultivating areas or through illicit traffic. This point needs careful attention.

On the speculative level this survey raises a number of points which might be relevant when planning demand reduction through limiting supplies. The first issue which it highlights is the fact that even though crop cultivation control may be effective, leakage may and does exist. Leakage may be just enough to supply the illicit demand in India. Furthermore, though an agricultural revolution may be in progress in Punjab, as is witnessed by the rise in per capita income, the demand for opium does not automatically cease; but perhaps it is being reduced. The danger lies in its substitution by other, socially more prestigious substances such as alcohol. The last point deserving attention is the fact that even though health care and delivery systems may be available, as is the case in Punjab, it does take time for the general population to trust "modern medicine" as opposed to the traditional healing methods, of which opium still forms a part. All these points are relevant when planning treatment programmes. Cognitive issues are not the only ones which determine programme end products; a host of other socio-cultural variables intervene which need to be taken into account.

Bibliography

Ahmed, R.Z. The characteristics of opium users studied at the treatment centre in Lekhpani and North Lakhimpur Assam, India. Bulletin on Narcotics, XXIX:2, 45-49, 1967.

Chopra, R.N. and Chopra, I.C. "Drug addiction with special reference to India", C.S.I.R. Raft Marg, New Delhi. 183, 1965.

Chopra, G.S. Sociological and economic aspects of drug dependence in India. The International Journal of Addictions, 7 (1) 57-63, 1972.

Dwarkanath, C. Use of opium and cannabis in the traditional systems of medicine in India, Bulletin on Narcotics, XXVII:I, 15-19, 1965.

Drug abuse in India, Expert Committee Report, Ministry of Health and Family Welfare, 1978.

Kohli, D.N. The study of narcotic control in India , Bulletin on Narcotics, XVIII:3, 3-12, 1976.

Mohan, D. Ed. "Pattern and prevalence of rural drug use in Punjab". Monograph, Department of Psychiatry, AIIMS. New Delhi, 1978.

Mohan, D. and Tongue, E. Eds. Drug abuse, an Overview, Proceeding of the Seminar, 1-7. Department of Psychiatry, AIIMS, New Delhi, 1979.