INTRODUCTION
“The cost of a thing is the amount of what I will call life which is required to be exchanged for it, immediately or in the long run.”
Henry David Thoreau
Use of alcohol and other substances continues to be one of the most serious public health problems in both developed and developing countries. About four of the six leading causes of years lived with disability worldwide are due to neuropsychiatric disorders (depression, alcohol-use disorders, schizophrenia, and bipolar disorder) (WHO 2003).
Worldwide, at least 15.3 million persons are affected by disorders due to substance use. It was found that about 205,000 deaths worldwide in the year 2000 were attributed to illicit drug use (WHO 2002). Substance use affects various domains of life and results in significant morbidity and mortality (WHO 2006). They affect the development of the human and social capital, creating not only economic costs for society as a whole, including the health system, but also social costs in terms of injuries; violence, and crime. Substance use disorders also affect the well-being of future generations.
Illicit drugs include opium/heroin, coca/cocaine, cannabis, and Amphetamine-type stimulants. In terms of treatment, opiates remain the world's main problem drug (UNODC 2009).[1 rd among the current prevalence rate which was about 0.7% amounting to 2 million opiate users in the country (Ray 2004).[2
In general, economic consequences of substance use have been an under-researched area. Even among the available studies, most have been devoted to alcohol use as opposed to other substances and illicit drugs. Economics is concerned with the use and distribution of resources among the individuals making up a society, and how different ways of allocating resources impacts on their well-being. A common misconception is that economics is just about saving money. In fact, economics is about the optimal allocation of available or potentially available resources.
The WHO too has addressed the issue of financing the health-care delivery system with main objective of considering alternative ways in assuring health for all. Indeed, costing exercises could be an important tool for estimation and projection of budgetary demands. Cost-analysis can help hospital administrators and policy-makers to determine how well their institution meets this public need. As financial management technique, cost-analysis helps to furnish the necessary data for making more informed decision on operations and infrastructure investments.
Only a limited number of studies focus entirely or partially on the cost of treatment. Little is known about the economics of drug use in India, this study strived to conduct cost-analysis of heroin dependence.
Keeping this in mind, a cost analysis study to estimate the cost spent by heroin-dependent patients before and after availing treatment for substance use disorder in a defined study population at National Drug Dependence Treatment Center (NDDTC), Ghaziabad was conducted.
METHODOLOGY
A descriptive observational study was carried out in the outpatient department (OPD) of NDDTC, Ghaziabad on a sample size of 75 patients, after obtaining Ethical clearance from the ethics committee, AIIMS. Purposive (Sample of convenience) was utilized on the study population which comprised of male, heroin-dependent patients (International Classification of Diseases 10 Criteria) Registered within preceding 30 days of initiating the study in NDDTC OPD, Ghaziabad,
Whereas, patients dependent on substances other than heroin (except nicotine), patients with major medical illness and those with psychotic illness were excluded from the study.
The data was processed using SPSS for Windows, Version 15.0. Chicago, SPSS Inc. Demographic characteristics overall response rate, response to objective elements, and the composite parameters were determined. Data were represented with appropriate tables, charts, and diagrams. A schematic representation of the methodology of the study is represented in Figure 1 .
Figure 1: Schematic representation of methodology of the study
OBSERVATIONS
The observations of the study are described here under the following headings:
Time scale distribution of the patients recruited in the study
Sociodemographic profile
Brief-datcap (Drug abuse treatment cost analysis program [DATCAP]) client version – (Expenditure on treatment of substance use by patient).
Time scale distribution of the patients recruited in the study
A total of 81 patients were included in the study fulfilling the selection criteria.
As the information on cost were taken in period of 30 days prior to the first visit of the patient to NDTTC and after the first visit till the date of interview, there were difference between the two periods as thirty one patients (38.3%) were recruited in the study in 1st week of their registration, 11 patients (16.1%) in 2nd week, and 15 patients (18.4%) in 3rd week and rest in 4th week of their registration in NDDTC.
Sociodemographic profile
Age
Majority of the patients in this study were between 30-50 years of age as represented in Figure 2 and Table 1 represents the distribution of age in sample population.
Figure 2: Distribution of age
Table 1: Distribution of age in sample population
Religion
Majority of the patients in this study were Hindus (86%) as represented in Figure 3 .
Figure 3: Distribution of religion
Marital Status
Majority of the patients in this study were married (61%).
Education
Educational status of the patients is represented in Table 2 and the distribution of educational status is depicted in Table 3 .
Table 2: Distribution of educational status
Table 3: Distribution of educational status in the sample population
Occupation
Current employment status (i.e. in last 30 days) is represented in Figure 4 and occupational distribution of study population is represented in Table 4 .
Figure 4: Distribution of current employment status
Table 4: Occupational distribution of study population
Source of family income
Almost 1/3rd of patients reported that their family was dependent on other sources of income apart from the patient's income, while near about 1/4th of patients reported that they were the only contributing member of the family and rest reported have contribution from others apart from their income for their family as represented in Tables 5 and 6 . The distribution of family income is represented in Figure 5 .
Figure 5: Distribution of family income
Table 5: Family income contributed by patients
Table 6: Family income contributed by other sources
Brief-datcap client version (expenditure on treatment of substance use by patient)
Number of past treatment attempts
Majority of the study population had never undergone past treatment as represented in Figure 6 .
Figure 6: Distribution of number of past treatment attempts
Distance travelled by the patients to come for the treatment in NDDTC from their residence (ONE WAY-round to the nearest whole km).
The patients in this study were coming for treatment from various places travelling distance of about 10 to 500 km with median of 100 and 50 km. On removing the outliers, the median comes to about 140 km as depicted in Tables 7 and 8 .
Table 7: Distance travelled by the patients to come for treatment in National Drug Dependence Treatment Center from their residence
Table 8: Distance travelled by the patients to come for treatment in National Drug Dependence Treatment Center from their residence (on removing outliers)
Time taken (in hours) for the patients to reach national drug-dependence treatment centre from their residence (one way)
The patients in this study take about an hour to a day depending upon the distance to reach NDDTC for the treatment with mean of about 7 h as tabulated in Table 9 .
Table 9: Time taken (h) for the patients to reach National Drug Dependence Treatment Centre from their residence (one-way)
Time spent (in hours) by the patients in treatment per visit (including travel time, waiting time, consultation time, etc.)
The patients in this study take about 3 h to 53 h depending upon the distance for the treatment per visit from their residence with mean of about 21 h as tabulated in Table 10 .
Table 10: Time spent (h) by the patients in treatment per visit
On removing the outlier 48 h and 53 h, the mean comes to about 20 h as represented in Table 11 .
Table 11: Time spent (h) by the patients in treatment per visit (on removing outliers)
Money spent by patients to travel to national drug-dependence treatment center and return home, per visit (including all transportation costs)
The patients coming for the treatment on an average spent around Rs. 264 which includes all the cost spent by the patient for one visit to NDDTC as represented in Table 12 .
Table 12: Money spent by patients to travel to National Drug Dependence Treatment Center and return home, per visit (including all transportation costs)
On removing the outliers Rs. 4 and Rs. 30, the mean cost comes to about Rs. 273 as tabulated in Table 13 .
Table 13: Money spent by patients to travel to National Drug Dependence Treatment Center and return home, per visit (on removing outliers)
Money spent by patients in buying prescribed medications in last 30 days
About 40 of the 81 patients reported that they spent money on buying the prescribed medications in private pharmacies. The amount they had spent is tabulated in Table 14 .
Table 14: Money spent by patients in buying prescribed medications in last 30 days
Total amount spent (lost productivity + expenses in visiting the treatment)
On calculating the total amount spent by the patient for treatment considering the lost productivity because of absence in the work while coming for treatment and all expenses the patient spent while coming for the treatment, median amount spent by per patient was Rs. 610 and Rs. 810, respectively, for those reported 2 visits and 3 visits to NDDTC till the date of interview which is depicted in Table 15 .
Table 15: Total amount spent (lost productivity + expenses in visiting the treatment)
Comparison on various parameters, before and after the onset of treatment at national drug dependence treatment center
An attempt has been made to compare the expenditure before and after seeking treatment. For this all parameters on which data are available have been added and the same calculations have been repeated taking both – The median values as well as the mean values.
As shown in the table below, the expenditure per day incurred by the patients on almost all parameters reduced substantially after seeking treatment at NDDTC. This includes the median expenditure on procuring all the substances used (including prescribed medicines), expenditure on transport (for procuring as well as for visiting NDDTC), and loss of productivity (due to drug use as well as due to treatment-seeking).
Therefore, the median of total expenditure on all the substances (i.e. median of total expenditure on all the substances in Rs. per day + median of expenditure on transport for procuring the substances used in Rs. per day + Median of loss of productivity in Rs. per day) was Rs. 527.
While the median of total expenditure on all the substances per patient per day after visit at NDDTC (i.e. (money spent on procuring all substances and money spent on buying the prescribed medicines + money spent on transport in procuring all substances + money spent on transport in coming for treatment + loss of productivity due to absence in work + loss of productivity due to absence in work due to time spent on treatment)) was Rs. 34.
Comparison of Median of Total Expenditure on all the substances Pre & Post Treatment in Rs per day is represented in Table 16 .
Table 16: Comparison of median of total expenditure on all the substances pre and posttreatment in Rs per day
Therefore, money saved by patient after starting treatment = Total Patient Expenditure (TPE) (Pretreatment) −TPE (Post) (in Rs.).
=526.67 − 34.05
=492.62.
Treatment Expenditure (TrE) = total money spent by NDDTC on substance use treatment for the fiscal year per patient per day was (in Rs.).
=47.59.
Money saved with consideration of NDDTC expenditure on patient (in Rs.).
= TPE (Pretreatment) − (TPE [Post] + TrE)
=526.67−(34.05 + 47.59)
= Rs. 445.04.
Similar calculations have also been done taking the mean values. Here also, it was quite apparent that there was marked reduction in expenditure before and after seeking treatment, even when the expenditure incurred by the NDDTC is taken into account, as tabulated below in Table 17 .
Table 17: Marked reduction in expenditure before and after seeking treatment, even when the expenditure incurred by the NDDTC is taken into account
Money saved by patient after starting treatment = Patient's Total Expenditure (PTE) (Pretreatment)–PTE (Post) (in Rs.).
=386.36 − 70.10
=316.26.
RESULTS
(The values here have been rounded to the nearest whole number).
Mean age of patients recruited in the study was 37 years; a large majority of them were Hindu by religion. A large proportion of the patients was educated between 6 and 12th standard, while some (13 patients) were illiterate. More than half of the patients were married (61%).
Almost half of the patients belonged to nuclear family and a quarter each belonged to extended-nuclear and joint family. Almost a third of patients were unskilled workers/laborers by occupation followed by skilled workers (20%), agriculture and farming (16%), businessman and industrialists (14%), and transport workers (7%). Majority of the patients reported having at least one earning member in the family, there family size – In some cases – Being as large as 15 members. About a third of patients were the sole contributors to the family income, another reported some other member of the family as the major contributor while for the rest, the major contribution for family income was coming from other sources.
Majority of the patients reported that they were coming for treatment first time for their substance use. The patients in this study were coming for treatment from various places travelling distance of about 10 to 500 km with median of 300 km, using more than one mode of transport to reach NDDTC (primarily train) and reported spending about 7 h (range 1 h to 1 day) and about Rs. 264 per visit on the transport.
The median amount spent by the patient till the time of interview on buying the prescribed medications in pharmacies was Rs. 110.
The median of total expenditure incurred by patients on substance use (considering procurement of substance, transport, and lost productivity) before coming to treatment was Rs. 527/day.
The median of total expenditure incurred by patients after initiating treatment at NDDTC (considering continued substance, transport to NDDTC, lost productivity, and purchasing medicines from outside) was Rs. 34/day.
Thus amount saved by the patients after starting treatment was Rs. 492.62/day. Even after considering the expenses incurred by the NDDTC in treatment, amount saved is Rs. 445.04/day.
DISCUSSION
Substance use leads to a substantial impact on different aspects of the individual life as well as the society as a whole. Economic analysis provides a mean of quantifying the effects of substance use on users themselves and the society. The cost estimate of drug abuse also provides insight about the baseline measures before determining the policies and programmes. Only few developing countries have taken steps to estimates the economic cost of drug abuse such as Columbia (Perez-Gomez et al . 2000).
There has been a wide variation in methodology used to estimate cost in different components (Rice et al . 1990). Among the approaches to cost estimation, one of the most widely used program-level instruments is the DATCAP (French 2002). The DATCAP and the Addiction Severity Index (ASI) are the most frequently used cost and clinical instruments among addiction researchers. Each has proven reliable and valid in numerous treatment and research settings (French et al . 1997; Salome and French 2001).
Although economic studies in the area of substance use are conspicuous by their rarity in the literature from India, such analysis has been conducted in other areas of health care in India. For instance, a recent study in India which aimed to conduct composite economic analysis of HIV prevention interventions to inform efficient utilization of resources in India conducted the economic analysis of HIV prevention interventions in Andhra Pradesh (Dandona L 2009). In this study, authors obtained output and economic cost data for the 2005–2006 fiscal year from a representative sample of 128 public-funded HIV prevention programmes of 14 types in Andhra Pradesh state of India. Using data from various sources, they developed a model to estimate the number of HIV infections averted. Then, they estimated the additional HIV infections that could be averted if each intervention reached optimal coverage and the associated cost. On the basis of their calculations authors concluded that Scaling-up HIV prevention interventions to the optimal level would require US$38.8 million annually.
Subash Soren had studied the core economic costs of opioid dependence among two different groups of male patients-seeking treatment in de-addiction center, AIIMS-before and after treatment period of 3 months-by using a semi-structured questionnaire (Soren 2001). Another study was conducted by Shashi Bhusan (2003) i n which he estimated the economic burden of Opioid dependence in relation with severity in a community clinic setting. As far as we know, this is the first study in India on Cost Analysis of Heroin Dependence Syndrome conducted using the DATCAP and the ASI.
In this study, the semi-structured pro forma used in the previous study (Soren 2001) was adapted for getting information on sociodemographic profile and cost spent on procuring the substances. Client DATCAP-Outpatient module of the Brief DATCAP has been used for collecting data on cost spent by patient for coming to treatment, and finally, ASI 5th edition has been used for getting information on severity of the dependence.
This study was completed over short period with limited target and objectives. However, the findings of this study provide insight into this area where there is a paucity of statistical data especially in the context of India so in developing world.
CONCLUSION
Little is known about the economic consequences of substance use especially in developing countries like India. This study successfully demonstrated that:
It is feasible to conduct a cost analysis exercise in a setting like ours (albeit with certain limitations)
Data from two different sources – Patients and service providers – Can be collected and compared against each other
A considerable cost – Representing a significant proportion of their income – Is borne by the patients in maintaining their heroin dependence
Even seeking help from a treatment center which provides most services at no-charge, also involves considerable expenditure to the patients
Even after adding the expenditure by the NDDTC to the expenditure by the patients on the treatment, treatment at NDDTC does result in a considerable reduction of overall costs. This is an indirect pointer toward cost-benefit of drug treatment.
Recommendations
As stated earlier, this study was conducted with certain limitations. In the future studies, certain methodological refinements could be brought about:
Longitudinal study design on the cost analysis of substance use by patient and comparing the costs at different periods after starting treatment
Studies on cost effectiveness among the different modalities of treatment, including pharmacological and nonpharmacological modalities
Cost analysis studies on drug dependence and its treatment in different settings (Institute, community settings, District hospital)
More detailed analysis of economics of illicit drug market (in the community/field setting).
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
